A new study suggests that a range of medications, including antidepressants and antipsychotics, could serve as effective alternatives to powerful opioids for pain relief in emergency departments. The review, published by researchers at the University of California, San Francisco (UCSF), examined non-opioid medications available at San Francisco General Hospital and evaluated existing medical literature to identify which ones might provide pain relief without the addictive properties of opioids.
The Opioid Crisis and Need for Alternatives
Opioids have a strong track record of effectively reducing pain, but loose prescriptions and insufficient attention to their addictive potential contributed to the first wave of the US opioid crisis, which began in the 1990s. Akash Shanmugam, a medical student at UCSF and first author of the study, stated that the goal was to “create a very targeted list for specific pain conditions” to expand the “toolboxes” physicians use to treat patients.
Study Recommendations for Common Pain Types
The study provides recommendations for the most common types of pain experienced in emergency departments: abdominal pain, back pain, chest pain, fracture pain, and headache. Common pain medications like acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen showed potential to relieve all types of pain examined. However, other drugs had more targeted applications:
- Ketamine, a common anaesthetic, showed promise for chest pain.
- Serotonin norepinephrine reuptake inhibitor (SNRI) antidepressants showed promise for back pain.
- Several types of antipsychotics showed promise for headache and abdominal pain.
Mechanisms of Action
Psychotropic medications have long been used for pain relief as well as psychiatric symptoms. Shanmugam noted that gabapentin was initially approved as a mediocre drug for epilepsy but is now widely used for neuropathic pain management. The mechanisms behind these medications' effectiveness for pain are complex and not fully understood, but Shanmugam explained that “neural circuits that create the sensation of pain are also involved in the emotional experience of pain, and the distress that pain produces for human beings.”
Neurotransmitters like dopamine, serotonin, norepinephrine, and glutamate, which regulate mood, also play a role in pain sensation. Gabapentin alters neurotransmitter release through its effect on calcium channels, while antidepressants and antipsychotics regulate them more directly. These medications help maintain the nervous system at a more even keel by altering how neurotransmitters send signals within the brain. Dr. Kathy LeSaint, an associate professor of emergency medicine at UCSF and co-author, added, “In chronic pain conditions, the nervous system can become highly sensitive, and it’s thought that antidepressants and antipsychotics can maybe reduce this heightened sensitivity in the brain.”
Addressing Pain Holistically
Drugs that improve mood can also help the body deal with pain. “Chronic pain is often linked to things like poor sleep, depression, anxiety, fatigue,” according to LeSaint. Medications that improve sleep and reduce anxiety might make pain easier to manage both physically and mentally.
Opioids Still Have a Place
Both Shanmugam and LeSaint agree that opioids still have a role in medicine. “The desire to reduce opioids shouldn’t come at the expense of under-treating pain,” Shanmugam said. However, alternatives are important as physicians become more aware of long-term consequences. LeSaint pointed out that beyond concerns about addiction and overdose, having a variety of pain medications is crucial because what works best varies from person to person, often due to genetic differences in metabolizing enzymes.
When prescribing psychiatric medications for pain, doctors must ensure patients understand that this does not mean the pain is psychological. Shanmugam noted that many clinicians use a basic science approach to explain the overlap between pain mechanisms and emotional understanding of pain, which helps reassure patients.
