Taking Elavil for Chronic Back Pain

Amitriptyline

Elavil (amitryptyline) is a medication with several uses. It has long been used for the treatment of depression but is sometimes given as an adjuvant ("along with") pain medication to people with chronic back pain.  

What exactly is amitryptylline, how effective is it for pain, what are the common side effects, and what drug interactions may occur with this drug?

1
What Is Amitriptyline?

Diagram of an amitriptyline molecule.
What do you need to know about using Elavil (amitryptyline) for back pain?. Laguna Design/Science Photo Library/Getty Images.

Elavil (amitriptyline) is an antidepressant medication which is sometimes prescribed off-label to manage chronic back pain. It is one of the drugs in a class of drugs known as tricyclic antidepressants.

Elavil is most often used along with other medications. Medications that are used in this way are referred to as adjuvant pain medications. It is not usually used as a first line treatment, but instead after more conservative treatments for back pain, such as Advil (ibuprofen) and Tylenol (acetominphen) have been ineffective for relieving the pain.

Elavil is not a narcotic (opioid) drug, and there is not usually an addiction risk with the medication.

2
What Type of Back Pain Does Amitriptyline Treat?

A gowned woman sits at the end of an examining table in a doctor's office.
Elavil is particularly effective for the type of pain known as neuropathic pain. H. Armstrong Roberts/Classic Stock Archive Photos/Getty Images

Elavil appears to be most effective for neuropathic type of chronic back pain. For spine pain sufferers, this usually means your pain radiates down an arm or leg. You may also have tingling or a pin prick sensation in your arm or leg.

Although Elavil's pain relieving abilities are independent of its antidepressant effect, the drug works by increasing the amount of certain brain chemicals necessary for mental balance.

Amitriptyline is also used to treat fibromyalgia, which is a condition marked by widespread pain and tender points.

3
Is Amitriptyline Effective?

Doctor with Stethoscope is Reading Package Insert
Elavil may reduce chronic back pain and also the disability caused by that pain. Tomas Rodriguez / Getty Images

Amitriptyline is the most studied of all the tricyclic antidepressants. It has been in use since the 1960s.

According to Dr. Kathleen Fink, Director of Pain Services at the National Rehabilitation Hospital in Washington D.C., this medication is underutilized due to the development of newer tricyclic antidepressants.

Fink says doctors are not comfortable prescribing amitriptyline for chronic spine pain because the side effects can make you feel hung over in the morning. "But in reality," she says, "amitriptyline is an effective and inexpensive medication for managing chronic back pain, especially if you are also having problems sleeping."

A 2014 study published in the Journal of Neurological Science compared amitriptyline with Lyrica or pregabalin (another drug given for neuropathic pain) for reducing pain, as well as physical disability.  The researchers found that while both were effective pain relievers, only amitriptyline significantly reduced disability, as well.

4
Amitriptyline Dosage

Close up of oval white pill
The dose of amitryptyline used for pain is usually different than that used for depression. GIPhotoStock / Getty Images

When Elavil is used for managing back or neck pain, the dose is lower (approximately half, although this will vary) than when it is taken for depression.

Your doctor will likely start you at a very low dose and then increase upwards a little each week until your pain is relieved and/or the side effects become too much for you.

Positive effects often occur more speedily when this drug is taken for chronic back pain as compared to when it is used for managing depression.

5
Amitriptyline Side Effects

Woman holding medication
Side effects on Elavil can be mild such as a dry mouth or serious, such as an increased risk of suicide. LEA PATERSON/SCIENCE PHOTO LIBRARY / Getty Images

It's important to be aware of the possible side effects of amitryptyline before beginning this drug.

Because amitriptyline is approved by the FDA to treat depression, it can affect mental status, including increasing the risk for suicide. But on the scale of things, amitriptyline likely has a relatively low risk of suicide.

For example, 2015 cohort study published in the British Medical Journal found that in people with depression, the absolute risk of suicide for amitriptyline over one year was 0.02 percent. Certainly people living with depression have an elevated risk of suicide even without this medication. If anyone in your family has bipolar disorder or suicide, your doctor may recommend not using this medication.

If you are pregnant or breastfeeding, it's best to stay away from amitriptyline or Elavil, because the drug could possibly be passed on to your child.

Elavil can cause problems for people who have arrhythmias (abnormal heart rhythms) and other forms of heart disease, and it is not generally given to people over the age of 60. (The newer antidepressants may be a better choice for this age group.)

A few less serious Elavil side effects include dry mouth and drowsiness.

6
Amitriptyline and Drug Interactions

Prescriptions and drugs with water.
There are several medications which can interact with Elavil. Gerard Fritz / Getty Images

There are a number of drugs which interact with amitryptyline.

Interactions between Elavil and some other drugs can increase the amount of amitriptyline in your blood. In turn, this may increase side effects of the medication. Interactions may also increase the toxicity (or decrease the efficacy) of the drugs you are taking along with Elavil.

It is important to tell your doctor everything you are taking, whether recreational, over-the-counter or prescribed. For example, the herbal preparation St. John's Wort should not be used with amitryptyline.

Important interactions may occur between Elavil and some muscle relaxants, antidepressants, drugs for abnormal heart rhythms, drugs for high blood pressure, thyroid medications, birth control pills, and more. It is a good idea to talk to your pharmacist as well if you are prescribed Elavil.

7
When to Avoid Amitriptyline: Contraindications

Doctor and patient conversation
Doctor and patient conversation. Dan Dalton/Caiaimage/Getty Images

There are some instances in which it is best to avoid taking amitriptyline altogether. These instances are referred to as "contraindications."

For example, if you are taking a monoamine oxidase inhibitor (MAO for depression or the heartburn medications cisapride (no longer available in the United States) you should not take amitryptyline.

Since Elavil may increase or decrease the level of other drugs you take, always talk to your doctor before discontinuing your medication.

Bottom Line on the Use of Elavil (Amitryptyline) For Back Pain

The antidepressant medication amitryptyline may be effective as an adjuvant treatment for the relief of chronic back pain. It appears to work particularly well for neuropathic pain, pain that may radiate down your leg and cause numbness, tingling, or pin-prick sensations: neuropathic pain tends to be one of the more difficult types of pain to treat. It's not certain exactly how Elavil works, but the mechanism appears to be different than how it works for depression. A smaller dose is usually used as well.

There are both mild and serious side effects with amitryptyline and it's important to talk to your doctor about these. In addition, there are several drugs which can interact with amitryptyline, and your doctor should have a comprehensive list of your prescription, over-the-counter, and herbal medications before prescribing this drug.

Sources:

Fink, K., M.D. Telephone Interview. National Rehabilitation Hospital. May 2011.

Kasper, Dennis L.., Anthony S. Fauci, and Stephen L.. Hauser. Harrison's Principles of Internal Medicine. New York: Mc Graw Hill education, 2015. Print.

Urquhart, D., Wluka, A., Sim, M. et al. Is Low-Dose Amitryptyline Effective in the Management of Chronic Low Back Pain? Study Protocol for a Randomised Controlled Trial. Trials. 2016. 17(1):514.

van den Driest, J., Bierma-Zeinstra, S., Bindels, P., and D. Schiphof. Amitrytyline for Musculoskeletal Complaints: Systematic Review. Family Practice. 2017. 34(2):138-146.

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