The single most useful medications in treating pain problems are antidepressant medications — some but not all. Most people are first tried on SNRIs like Cymbalta or Savella. Another highly effective pain medication is the family of “tricyclic antidepressants.” Sometimes tricyclics can be difficult to use, especially when you first start them. Patients may say they don’t understand how they work, what they’re supposed to do, or how to take them. So here’s information on tricyclic antidepressants, how to use them, and why they’re so important in treating pain symptoms.

I’m not depressed. Why do you want me to take a medicine for something I don’t have?
Tricyclic antidepressants are far and away the best medication for treating chronic pain, whether or not you’re depressed. The dose required for treating pain is about 50-75 mg per day, about half what you need to treat depression.

I’m not crazy! Don’t give me psychiatric medications!
Medical practice is full of drugs which were originally developed for one reason, but which turn out to be useful for all kinds of other problems. Aspirin started out just to treat pain, but it has many other uses, like helping to prevent strokes and heart attacks. Tricyclic antidepressants are proven in laboratory experiments to treat and prevent real physical pain. And they’re among the more useful agents for those having trouble sleeping or severe fatigue.

What are tricyclic antidepressants?
This group of medications was first introduced to medical practice in about 1960. They are generally extremely safe. But they don’t work like many drugs you’ve used in the past. Once you get used to them, however, you may discover that they are the best treatment yet.

Here are the five medications commonly used, listed by trade name and then generic name, in order by most sedating first and most stimulating last:

  • Sinequan (doxepin)
  • Elavil (amitriptyline)
  • Tofranil (imipramine)
  • Pamelor (nortriptyline)
  • Norpramin (desipramine)

I don’t want to become dependent on any drugs. Shouldn’t I worry about taking antidepressants?
Taking antidepressants for pain are not addicting in the slightest. You couldn’t become addicted to them if you wanted to. They are not dope or speed. They are not happy pills. They don’t make you high or low, happy or sad. The aim of using them is so that you’ll feel normal. That’s it.

In fact, the way that you know that these medications are working properly is that every time you take a pill or capsule, you ask yourself, “I feel great! Why do I have to take this stuff?”

With addicting drugs like Valium or Vicodin, it can be murder to get people to stop taking them. But with the tricyclic antidepressants, it can be hard to get them to start them.

What’s so hard about starting tricyclic antidepressants?
With some drugs, you get the best results the first time you take them. The longer you’re on them, the less well they work, and the more side effects you have.

Tricyclic antidepressants are completely the opposite—when you first start taking them, you get side effects and little benefit. As you continue on them the side effects go away and the benefit increases. The longer you take them, the better they work.

Once you understand how they work, taking tricyclic antidepressants is not difficult. You start at a low dose, wait until side effects go away, and then gradually increase the dose until the benefits kick in. It may take a few weeks before you notice the maximum improvement.

What kind of side effects are we talking about?
Mostly people notice dry mouth and constipation. Also, some of these medications cause drowsiness, which is why they are useful to help you sleep. Some of them cause certain people to be more awake or alert or to have difficulty sleeping. Occasionally, patients notice slightly increased heart rate or sweating. Rarely, for the first few days people feel slightly tired and achy, like the day before you come down with a cold. None of these side effects is serious; they are merely pesky or possibly annoying.

Each drug in this family is different. As a rule, doxepin and amitriptyline are more apt to make you groggy. Nortriptyline and imipramine may make you sleepy for eight to ten hours, then give you more energy thereafter. Desipramine tends to be stimulating and may at first make some people feel anxious.

Each person is completely different in the type and severity of the side effects they experience, particularly whether they wake you up or make you sleepy or both. Often, these medications make you sleepy for a few hours and then give you more energy. So if you take them in the evening, you’ll sleep better and be more refreshed in the morning.

Quite a few of our patients have been on so many medications that they develop severe side effects to sugar pills (placebos)! So if you get a headache, an upset stomach, more depression, or more stress, these side effects are not caused by tricyclic antidepressants.

Are there any serious side effects?
Certain people with heart rhythm problems should not take tricyclic antidepressants, since they may make the heartbeat even more irregular. (Unless you have heart disease, your risk of heart rhythm problems is quite low.) Occasionally, older men with existing prostate disease may find tricyclic antidepressants make it even more difficult or impossible to empty their bladders. If you have glaucoma or epilepsy, talk with your doctor before taking tricyclics.

Like any drug, you should keep these medications out of the reach of small children.

Will tricyclic antidepressants injure my kidneys or liver or heart or brain?

No (except for the very rare idiosyncratic reaction you can get with virtually any medication, approximately 1 patient in 100,000).

What benefits can I expect from their use?
Many people experience one or more of the following:

  • Less pain—on occasion, the pain completely goes away.
  • Improved sleep.
  • More energy.
  • Improved memory and concentration.
  • Fewer problems with jaw joint pain or irritable bowel syndrome.
  • Improved moods. If present, your depression just seems to clear up.
  • Less irritable. It takes a lot more stress before you become upset, cranky or overwhelmed.

How long do I need to take it?
Most people can take tricyclic antidepressants safely as long as they need them. Often, people do best if they use the initial period of pain relief to exercise and stretch and regain their ability to cope. Just becoming physically fit and flexible can relieve many people’s pain for good. Then sometimes you can reduce the dose of medication or perhaps stop it entirely.

Unfortunately, many people decide to stop this medication as soon as they feel better, and then their symptoms return with a vengeance.

How do I use this medication?
We’ll discuss the specifics during our appointment. Here are some general principles:

  • This medication doesn’t work if you take it only when needed, when you feel the pain. You need to take it on a regular basis every day.
  • Remember, the only way you’ll get any help from antidepressants is if you give it a chance to work! The most common reason for failure of this medication to help is not taking a sufficient dose for long enough, or stopping as soon as you feel better.
  • Start with a low dose, wait until any possible side effects go away, increase the dose, wait, and so forth, slowly increasing the amount you take until you get the benefits you want.
  • Whatever you do, don’t stop this without talking with me, unless a single dose produces overwhelming side effects. For example, sometimes people take one pill and feel nothing. They increase to two pills, and still not much. But taking three pills causes side effects and so they quit and say the medicine doesn’t work. Wrong—you should cut back to the dose you could tolerate, two pills a day, until your body adapts.
  • The most important principle is everybody responds differently to this medication. We’ll work together to help you modify the dose to get the best results. You may have to take the medicine all at once in the evening, all at once in the morning, or spread out through the day. Change the time of day you take it to minimize side effects.
  • Once patients figure out how this medication works for them, we find they are great at deciding for themselves how much they need and what time of day they should take it.
  • Sometimes patients do very well on a low dose for weeks or months, and then it seems like it just stops working. This generally means your body has become used to the amount you were taking, and you need to increase the dose slightly.

Here’s additional information on tricyclic antidepressants. But Cymbalta and Savella have fewer side effects. They often work just as well as a tricyclic and have fewer side effects. Note that for most patients, SRI-type antidepressants do not help pain, though sometimes I’ll add an SRI when a patient is still depressed despite taking an adequate dose of another antidepressant.