Tricyclic antidepressants are probably the most commonly used adjuvant analgesics in the management of chronic pain. An adjuvant analgesic is a medication that is used to control pain despite that it is not designed for pain management. The tertiary amines (amitriptyline, imipramine, doxepin, and clomipramine) and the secondary amines (nortriptyline and desipramine) both have analgesic properties.

Amitriptyline is the prototype antidepressants used in this context. Clinical efficacy of tricyclics for neuropathic pain has been demonstrated by numerous well-controlled double blind clinical studies for both neuropathic and somatic pain. Clinical experiences, as well as the results from uncontrolled trials, generally support the analgesic effect and use in neuropathic pain syndromes. Clinicians have to be familiar with the possible side effects of amitriptyline, especially in elderly patients. These adverse effects include sedation, dry mouth, constipation, urinary retention, glaucoma, orthostatic hypotension and cardiac arrhythmias. Patients should be warned about the side effects before they start the medication. Amitriptyline should be avoided in patients with a history of heart disease (conduction disorders, arrhythmias or heart failure) and closed-angle glaucoma. Amitriptyline should be started at a relatively low dose (10 mg) at bedtime and slowly titrate up as tolerated. Most patients report improved sleep after taking amitriptyline. The onset of pain relief may precede the anticipated onset of antidepressant effects. In general, pain relief may be expected in 7 to 14 days. The dosage required for pain management is usually lower than for depression; 75 to 100mg at bedtime is often effective. If the patient cannot tolerate this dose, or is not a good candidate for amitriptyline, other tricyclics such as nortriptyline or desipramine may be considered. These secondary amines generally have less anticholinergic effects and, therefore, are better tolerated than the tertiary amines. However, their clinical efficacy is not as well established as that for amitriptyline.

The main advantage of the selective serotonin reuptake inhibitors is the favorable side-effect profile. However, selective serotonin reuptake inhibitors are clearly less effective than tricyclic antidepressants NNT (Number Needed to Treat to reach 50% pain relief): 6.7 vs. 2.4). Venlafaxine is a selective serotonin/noradrenaline reuptake inhibitor. Randomized controlled trials show good pain relief for painful polyneuropathy and also for neuropathic pain following treatment of breast cancer. Duloxetine, a newer selective serotonin/noradrenaline reuptake inhibitor, has also been demonstrated to have some analgesic effects in neuropathic pain. Bupropion, a noradrenergic compound, also has analgesic effects in neuropathic pain and often is activating. The latter effect can be particularly helpful in the hypoactive, depressed, sedated, or fatigued patients. However, bupropion is not significantly better than the placebo in the treatment of patients with non-neuropathic chronic low back pain. Trazodone (a serotonin-reuptake inhibitor as well as a postsynaptic serotonin receptor antagonist) does not appear to be effective for the treatment of chronic pain. Evidence for the efficacy of trazodone in treating insomnia is also very limited. The table below presents the tricyclic antidepressants most commonly used for pain management.

Meet the FLPNR Team

  • Richard Adkins, MD
  • Hoang (Wayne) T. Vu, D.O.
  • Lourdes Varela–Batista, M.D.
  • Vinh-Loc Nguyen, P.A.
  • Irene Aponte Moreno, N.P.
  • Sunny Park, N.P.
Anesthesiology Specialist in Ocala, FL Doctor of Osteopathic Medicine in Ocala, FL Physician in Ocala, FL Physician in Ocala, FL Nurse Practitioner in Ocala, FL Nurse Practitioner in Ocala, FL
Anesthesiology Specialist in Ocala, FL

Richard Adkins, MD

Anesthesiology Specialist

Dr. Richard Adkins has been in practice for more than 30 years. His specialty is in anesthesiology and pain medicine.

Doctor of Osteopathic Medicine in Ocala, FL

Hoang (Wayne) T. Vu, D.O.

Dr. Hoang (Wayne) T. Vu is board certified by both the American Board of Pain Medicine and the American Board of Physical Medicine and Rehabilitation. Dr. Vu earned his degree of Doctor of Osteopathic Medicine from Touro University College of Osteopathic Medicine in California in 2003.

Physician in Ocala, FL

Lourdes Varela–Batista, M.D.

Dr. Varela is a fellowship trained pain specialist and board certified PMR expert. Her specialities include physical medicine and rehabilitation and interventional pain medicine. She received her undergraduate degree from University of Puerto Rico and completed her medical degree from New York Medica College. Dr. Varela completed her physical medicine and rehabilitation residency at University of Texas Health Science Center San Antonio.

Physician in Ocala, FL

Vinh-Loc Nguyen, P.A.

Vinh-Loc Nguyen is a NCCPA certified physician assistant and is licensed by the State of Florida Department of Health. He received his Bachelor of Science degree in microbiology and Bachelor of Arts Degree in economics from University of Florida in 1994. He had a successful career in the financial industry before returning to his true passion for medicine.

Nurse Practitioner in Ocala, FL

Irene Aponte Moreno, N.P.

Ms. Irene Aponte Moreno is an Adult-Gerontology certified Nurse Practitioner and licensed by the State of Florida Department of Health. In 2014, she received her Master of Science degree in Nursing from the University of South Alabama. She completed her Bachelor of Science degree in Nursing from Jacksonville State University in December of 2006. In 2003, she received an Associates of Arts degree from Southwestern Michigan College. She also completed an Associate degree in Informatics from the University Institute Antonio Jose de Sucre located in Lara State, Venezuela.

Nurse Practitioner in Ocala, FL

Sunny Park, N.P.

Ms. Sunny Park is an AANP and ANCC certified Advanced Registered Nurse Practitioner, licensed by the State of Florida Department of Health. She graduated with Summa Cum Laude with Bachelor of Arts in Drawing from Southern Illinois University in 1999. She pursued nursing career and graduated with Associate of Science in Nursing in 2007 and started working as a registered nurse in Cardiovascular ICU in St.Luke’s Medical Center. She continued with her education and graduated with Magna Cum Laude obtaining Bachelor of Science in Nursing in 2010 from Cardinal Stritch University. During her nursing education, she was awarded multiple scholarships including the Lamplight scholarship by Milwaukee Nurses Association.


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