A University of Sydney study has uncovered a concerning gap between clinical practice and scientific evidence in the treatment of pain for older adults. The research, published in the British Journal of Clinical Pharmacology, shows that international guidelines recommending antidepressants for chronic pain management in people over 65 are based on limited data.
Dr. Sujita Narayan, lead author and Research Fellow at the University’s Institute for Musculoskeletal Health, found that in the past four decades, only 15 trials worldwide have focused on the benefits of antidepressants for pain in older people. This scarcity of targeted research raises questions about the efficacy and safety of these medications for this age group.
“If I am a busy clinician and want to look at the guidelines for quick reference, I will probably have time to look at only the key points regarding management of chronic pain, some of which advise the use of antidepressants,” said Dr. Narayan, from the Faculty of Medicine and Health.
Lack of Evidence for Antidepressant Use in Older Adults
Associate Professor Christina Abdel Shaheed, senior author of the study, emphasized that no trials examined the growing use of antidepressants for acute pain, such as that experienced by those with shingles or muscular pain. “These medicines are being prescribed to remedy patients’ pain, despite the lack of evidence to adequately inform their use,” she stated.
Potential Risks and Harms Associated with Antidepressant Use
The research found that people taking antidepressants experienced more negative effects, including falls, dizziness, and injuries, compared to control groups. These adverse effects led to higher discontinuation rates among those taking antidepressants than those in placebo groups or groups using other pain management drugs.
Dr. Narayan cautioned against abrupt cessation of antidepressants: “Withdrawal from antidepressants can be as bad as withdrawal from opioids. I would recommend that anyone considering discontinuing their medication to not stop taking their antidepressants immediately, but to consult with their clinician and devise a tapering plan, as necessary.”
Duloxetine for Knee Osteoarthritis: A Potential Exception
The study did find one exception to the overall trend. The SNRI duloxetine showed some efficacy in relieving knee osteoarthritis pain in older adults during the intermediate term (2-4 months). However, its effects were not significant in the short term (up to 2 weeks), and no data was available for use beyond 12 months.
“For clinicians and patients who might be using or considering duloxetine for knee osteoarthritis, the message is clear: benefits may be seen with a little persistence, but the effects may be small and need to be weighed up against the risk,” Dr. Narayan explained.
The Need for a Multidimensional Approach to Pain Management
The research underscores the need to update guidelines and rethink the clinical practice of prescribing antidepressants for pain in older adults. It supports recommendations for a multidimensional approach to managing chronic non-cancer pain in older people, emphasizing non-pharmacological strategies such as physical exercise and cognitive behavior therapy.
Dr. Narayan stressed the importance of age-specific research: “The key point is that we shouldn’t rely on findings from studies with younger people and apply them to older adults because they are different. Older people’s bodies undergo changes that alter how they respond to medications. This can lead to different effects in older people compared to younger people.”
Moving Forward: The Need for More Targeted Research
As the population ages and chronic pain remains a significant health issue, this study highlights the urgent need for more robust, targeted research to inform safe and effective pain management strategies for older adults. The findings underscore the importance of consulting healthcare professionals about pain management and carefully considering potential risks and benefits of different treatment options, especially for older individuals.
This study provides a valuable contribution to the ongoing conversation about the appropriate use of antidepressants in older adults. By calling for more research and a more cautious approach to prescribing these medications, it aims to protect the health and well-being of an increasingly vulnerable population.
