The treatment of neuropathic pain: Antidepressants and opioids

Objective: The objective of this article was to review the positive scientific data on antidepressants and opioids, which are largely confined to randomized controlled trials in two neuropathic pain conditions that have proved to be good models for clinical investigation. These two disorders are postherpetic neuralgia and painful diabetic neuropathy. Design: This is a review of the literature using MEDLINE, CINAHL, and the Cochrane Database. Results: There is extensive literature supporting the use of the older antidepressants such as amitriptyline in neuropathic pain. Newer randomized controlled trials support the use of opioids. Conclusions: First-line therapy for neuropathic pain may be either an older generation antidepressant such as amitriptyline or nortriptyline or the anticonvulsant gabapentin. For refractory cases, chronic opioid therapy may be the only avenue of relief, and evidence is accumulating that this approach is safe if proper guidelines are observed.