Antidepressants and antipsychotics could serve as alternatives to opioids, study finds

A range of other medications could serve as alternatives to powerful opioids for pain relief in emergency departments, according to a new study.

The review paper examined non-opioid medications available in the emergency department at San Francisco general hospital and examined existing medical literature to figure out which ones might provide pain relief.

Opioids have a strong track record of reducing pain effectively, but loose prescriptions with insufficient care towards their addictive properties led to the first wave of the US opioid crisis, which began in the 90s.

Akash Shanmugam, a medical student at the University of California, San Francisco (UCSF) and first author on the study, said the goal of the study was to “create a very targeted list for specific pain conditions”, to help add to the “toolboxes” physicians use to treat patients.

The study provides recommendations for the most common types of pain that patients experience in emergency departments; abdominal pain, back pain, chest pain, fracture pain and headache.

Shanmugam and Dr Kathy LeSaint, an associate professor of emergency medicine at UCSF and another of the paper’s authors, agree that opioids still have a place in medicine. “The desire to reduce opioids shouldn’t come at the expense of under-treating pain,” Shanmugam said.

However, alternatives can also have an important role as physicians have become increasingly aware of possible long-term consequences. LeSaint also pointed out that beyond concerns about opioid addiction and overdose, it’s important to have a variety of medications for pain available because what will work best varies from person to person. This variation is often genetic; for example “the enzymes that are responsible for metabolizing opioids can have different strengths in people”, LeSaint explained.

The type of pain that a patient is experiencing can also determine what medications work best.

In the study, common pain medications like acetaminophen and non-steroidal anti-inflammatory drugs like ibuprofen showed the potential to relieve every type of pain examined. But other drugs in the study had more targeted applications; ketamine, a common anaesthetic, showed promise for chest pain; a serotonin norepinephrine reuptake inhibitor (SNRI) antidepressant showed promise for back pain, and several types of antipsychotics showed promise for headache and abdominal pain.

Psychotropic medications have long been used for pain relief as well as psychiatric symptoms. Shanmugam pointed out that gabapentin was first approved as “a really mediocre” drug for epilepsy, but “now it’s used a lot for the management of neuropathic pain”.