Treatment Option and Pain

Tricyclic antidepressant use to mitigate chronic low back pain has been investigated by researchers as a form of treatment for decades. Some articles go as far back as 1986. The types of antidepressants tested for efficacy in treatment of chronic low back pain have been either tricyclic or tetracyclic. Systematic reviews from twelve years ago noted antidepressants treat pain via inhibition of norepinephrine reuptake (Staiger, Gaster, Sullivan, & A Deyo, 2003. Antidepressants that failed to inhibit norepinephrine reuptake did not provide any benefit in pain relief.

New modalities of treatment with antidepressants use not just one, but a combination of tricyclic antidepressants like Pregabalin and Amitriptyline. Pregabalin, otherwise known as Lyrica, is a nerve pain medication. Uses for the drug include treatment of seizures, fibromyalgia and nerve and muscle pain. Amitripyline (Elavil), is a standard treatment for depression and works as a never pain medication. Some medical practitioners have also prescribed the drug for insomnia (Atkinson & Sullivan, 2013). These drugs have been reviewed as treatment separately or together.

Drugs that treat nerve pain are important because chronic lower back pain consists of mainly neuropathic or nerve pain like sciatica or lumbar radiculopathy (Jacobson et al., 2015). If drugs like Pregabalin and Amitriptyline can be used to diminish nerve pain, this would be the most likely treatment option for chronic lower back pain. The strategies focus on seeing if Pregabalin or Amitriptyline work as a main treatment option for chronic lower back pain or if Pregabalin and Amitriptyline work best together.

The search strategy uses Pregabalin and Amitriptyline as main keywords, allowing search results to produce current (less than five years old) articles that show efficacy of either or, and dual treatment options. Along with the use of these two, main keywords, antidepressants and chronic low back pain were also used to highlight previous and current use of antidepressants for the treatment of chronic lower back pain. The first article covers antidepressant use in those that suffer from lower back pain among other treatment options.

Interestingly the treatment option of antidepressants was not used primarily for pain management. Instead, the common reason for prescription of antidepressants was used in chronic low back pain sufferers because they suffered from anxiety and depression. ". because older patients with chronic LBP are commonly associated with depression or anxiety, it is not uncommon for them to take antidepressants or benzodiazepines" (Wong, Karppinen, & Samartzis, 2017, p. 7). It is important to include a review like this because it shows what the common treatment options are for chronic lower back pain (LBP).

The researchers state the main aim for conventional pain management of geriatric patients that present with nonmalignant pain is maintaining a steady concentration of analgesic (for example, acetaminophen) in the blood stream. If this treatment option does not work, convention methods suggest non-steroidal anti-inflammatory drugs (NSAIDS). "In addition, the guideline also suggests that if acetaminophen cannot control pain, non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., COX-2 therapy or non-acetylated salicylates) may be used as adjunct therapy" (Wong, Karppinen, & Samartzis, 2017, p. 4).

Such use of drugs can lead to adverse effects in patients. The article notes use of Tramadol can increase potential seizure activity in vulnerable populations. Moreover, NSAIDS can cause stomach problems and exacerbate peptic ulcers and gastrointestinal bleeding. The article demonstrates a need for better treatment options that are not only more effective, but also provide less side effects. The next article attempts to determine the efficacy of Pregabalin or Amitriptyline in the treatment of chronic LBP.

The article shows that prior research has never tackled a head-on comparison of both drugs in relieving pain and disability. The study included patients with chronic LBP or chronic lower back ache (CLBA). Patients were between the ages of 15 and 65 years old (Kalita, Kohat, Misra, & Bhoi, 2014). The main outcome for the study was pain relief with the secondary outcome being reduction in Oswestery Disability Index (ODI). From the 200 patients used in the study 103 were given Amitriptyline and 97, Pregabalin.

"The VAS score and ODI improved significantly following AMT and PG at 6 and 14 weeks compared to baseline. The improvement in pain (57.3% Vs 39.2%; P = 0.01) and disability (65% Vs 49.5%; P = 0.03) however was more in AMT group. The composite side effects were similar in both groups" (Kalita, Kohat, Misra, & Bhoi, 2014, p. 127). While both medications improved pain and disability, it was Amitriptyline that performed better. Amitriptyline minimized disability and pain significantly compared to Pregabalin.

Because Amitriptyline is a tricyclic antidepressant, it shows the efficacy of tricyclic antidepressants for the treatment of chronic LBP and CLBA. The article not only demonstrated the efficacy of Amitriptyline alone, it also demonstrated the need to do comparative studies showing the efficacy of certain medications. Although treatment options may include the use of multiple medications, if a positive outcome can be derived from only one medication, this option should be explored further. The study revealed a gap in literature regarding tricyclic antidepressant use for chronic LBP and CLBA.

It also showed the efficacy of Amitriptyline as a standalone form of treatment. The last article shows efficacy of treatment for chronic LBP using Pregabalin and Amitriptyline. The study sought to see if the combination of Pregbalin and Amitriptyline reduced chronic LBP. ". longitudinal prospective observational study was conducted at pain clinic of a public tertiary care hospital. Adult patients suffering from low back pain for >3 months, and who received pregabalin (75-150 mg/day) and amitriptyline (10/25 mg/day) were included in the study" (Kanukula, Bansal, & Ghai, 2014, p. A224).

The requirements for chronic LBP was only greater than three months, because chronic LBP is classified as such when the pain persists for more than six weeks or three months. The type of pain that the patients endured came from several causes. Some patients experience disc herniation, disc bulging, other problems, and spondylosis. The results showed major reduction of pain was seen in terms of VAS score post 6-month follow up. Although pain reduce, the medications did not indicate improved quality of life.

Results also included adverse events such as postural hypotension. VAS&MODQ baseline median (IQR) scores found to be 75(60-90) & 52(40-60), and after 6 months 35(20-50)&41(24-53), no improvement in quality of life found p=0.08. Dry mouth is being the commonest adverse event [in 80 (40.4)]. Other adverse events reported are headache, constipation, dizziness and postural hypotension" (Kanukula, Bansal, & Ghai, 2014, p. A224). Although both medications used together produced significant reduction in pain, the adverse events such as dizziness and constipation may spell problems for long-term use of both medications.

More research must be dedicated to the adverse effects of medications used together to see if patients can manage long-term use of these medications. The overall themes across the studies indicate antidepressant drugs have been considered as a treatment option for chronic LBP. Furthermore, Drugs like Amitriptyline may be used more frequently in the future as a standard treatment option for pain management of chronic LBP. The interest in these drugs and its potential efficacy have been highlighted in all three articles.

In terms of my own practice, the use of tricyclic antidepressants is uncommon. Many take NSAIDS and often share potential problems of stomach upset and increased activity of peptic ulcers. Most doctors typically prescribe NSAIDS with some prescribing opioids in the treatment of chronic LBP. Should the use of tricyclic antidepressants reach doctors and nurses as a preferred treatment, it would be easy to do regarding change of practice. All doctors and nurse practitioners should do is prescribe the antidepressant.

Some potential barriers to change is simply the acceptance of standard of care. Many medical practitioners do not wish to deviate and try something else. The.