What are psychiatric pain relievers?

From the Guidelines

Psychiatric pain relievers, such as duloxetine, are the most effective treatment options for patients experiencing pain with psychiatric components, due to their ability to address both pain and underlying psychiatric conditions simultaneously, as evidenced by the most recent study 1.

Key Considerations

• The medication duloxetine (Cymbalta) is recommended as the first-line treatment, starting at 30mg daily for one week, then increasing to 60mg daily if tolerated, as it has shown consistent efficacy in treating neuropathic pain and has a simple dosing regimen 1.
• Alternative options include amitriptyline (starting at 10-25mg at bedtime) or venlafaxine (starting at 37.5mg daily), which have also demonstrated effectiveness in treating neuropathic pain, but may have more side effects and require more cautious dosing 1.
• It is essential to start with lower doses and gradually increase to minimize side effects like nausea, dizziness, or dry mouth, and to maintain therapeutic levels, patients should take these medications consistently, even when pain-free 1.
• Non-medication approaches like cognitive behavioral therapy should be used alongside medication for optimal results, as they can help address underlying psychiatric conditions and improve overall quality of life 1.

Mechanism of Action

• These medications work differently from traditional pain relievers by addressing the neurochemical pathways involved in both pain perception and mood regulation, making them particularly effective for conditions like fibromyalgia, chronic back pain, or pain associated with depression or anxiety 1.
• Duloxetine, for example, inhibits the reuptake of serotonin and norepinephrine, which helps regulate pain signals and mood, making it an effective treatment option for patients with psychiatric components to their pain 1.

Important Considerations

• The use of any opioids for management of chronic neuropathic pain carries the risk of addiction and should be avoided, as stated in the most recent study 1.
• Tricyclic antidepressants, such as amitriptyline, may have anticholinergic side effects that can be dose-limiting and restrict use in individuals ≥65 years of age, highlighting the need for careful consideration and monitoring when prescribing these medications 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Psychiatric Pain Relievers

Psychiatric pain relievers, also known as antidepressants, are used to treat chronic pain in adults. These medications work by increasing the levels of certain neurotransmitters, such as serotonin and norepinephrine, in the brain, which can help to reduce pain perception.

Types of Psychiatric Pain Relievers

• SNRIs (Serotonin and Norepinephrine Reuptake Inhibitors): These medications, such as venlafaxine, milnacipran, and duloxetine, block the reuptake of both serotonin and norepinephrine, and are effective in treating chronic pain associated with and independent of depression 2, 3, 4.
• SSRIs (Selective Serotonin Reuptake Inhibitors): These medications, such as fluoxetine and sertraline, block the reuptake of serotonin only, and their effectiveness in treating chronic pain is inconclusive 5.

Efficacy of Psychiatric Pain Relievers

• Duloxetine: This SNRI has been shown to be effective in treating painful diabetic neuropathy, fibromyalgia, and chronic pain in adults, with a moderate to high certainty of evidence 3, 6.
• Milnacipran: This SNRI has also been shown to be effective in treating chronic pain, although the certainty of evidence is lower than that of duloxetine 3, 4.
• Other Antidepressants: The evidence for the efficacy of other antidepressants, such as SSRIs, in treating chronic pain is limited and inconclusive 5.

Safety of Psychiatric Pain Relievers

• Common Adverse Events: Psychiatric pain relievers can cause common adverse events, such as nausea, headache, and dizziness, although these are often mild and temporary 2, 3, 6.
• Serious Adverse Events: Serious adverse events, such as suicidal thoughts and behaviors, are rare but can occur, especially in people with a history of mental health conditions 3, 6.