Amitriptyline (tricyclic antidepressants)

Does it work? Better for some people than others. Unless your doctor says it would be a problem for you, it's probably worth a shot to find out if you're one of those people it works well for.

What is it? Amitriptyline (also sold under the brand name Elavil) is a prescription-only drug (at least in the UK) known as a tricyclic antidepressant. The reason it's known as a tricyclic antidepressant is that it was first developed for people with depression and only later discovered to be effective for other conditions including chronic pain. Its effects include simply reducing the level of pain experienced by people with neuropathic pain and fibromyalgia. It also relaxes the muscles and improves sleep. I find that it both helps me go to sleep and helps me stay asleep (although the flip side of that is it also makes me need more sleep). It is not a medicine that has an instant impact. You have to take it regularly for it to have its effect. Some websites say you only need to take it for 1-7 days for it to have an effect, others say 2-6 weeks. My own experience is that I begin to feel the side effects within a week, but that painkilling effects can take 2-4 weeks. Also, my experience is that once I have got through the initial period, I can feel a difference about 20-30 minutes after taking the tablet each day. In my case, I feel my muscles relaxing and the pain falling away from them - not always 100% but a clear improvement over before I took the tablet. In fact, I often notice I have forgotten to take the tablet because I'm wondering why my pain's so bad tonight. I am not a medical professional, so please check with a doctor whether they consider this advice a suitable guide for you, but my advice to me when I first went on it based on what I know now would be:

• You need to take it every day for it to work and you won't necessarily notice a difference for 2-6 weeks or after taking each pill (taking it only "as required" when you're in pain is likely to do little more than give you a taste of the side effects).
• Try it for at least 6 weeks before deciding whether it works or not, unless the side effects are really bad.
• If the side effects are bad but not dangerous, try and live with them for 3 weeks if you can before making a decision about whether to carry on, as often side effects lessen over time (they can carry on improving after 3 weeks, but that's about my cut-off point for tolerance of waiting for bad side effects to improve). If the side effects are beyond what you can cope with and it is making your life miserable, then feel free to decide earlier that this drug is not for you, go back to your doctor and find out how to come off it without withdrawal symptoms. If you're undecided about whether the side effects are worth it, I recommend setting a date in your diary to reassess the situation after 6 months.
• Start on a low dose and be prepared to move up to a higher dose if the effects on the pain aren't strong enough or down to a lower one if the side effects are too high. For me the key decision as to whether to take a non-life saving drug (and working out the best dose) is one of whether the side effects and risks outweigh the benefits or vice versa.
• Set your phone alarm to tell you when to take it so you don't forget. This drug is incredibly likely to make you sleepy - but your sleepiest hours won't necessarily be immediately after taking it. Start by taking it three hours before bedtime and get earlier if you're finding it excessively hard to wake up in the morning, and later if you're finding it hard to stay awake until bedtime. Keep adjusting it until you've found the optimum balance between staying awake till bedtime and waking up in the morning. Mine is 3.5 hours before bedtime. You may also have to adjust your bedtime or getting up time if a side effect for you is that you need more sleep.
• If the amitriptyline starts to feel less effective, talk to your doctor about if there's room to increase the dose.

Who does it work for? People with:

• neuropathic pain
• fibromyalgia
• pain from tight/tense, unrelaxed muscles
• overactive bladder (for instance, it can significantly reduce the number of times you need to pee at night)
• irritable bowels (this is another problem that often comes with HMS and I've noticed that mine have been a lot less painful in the years since I've been on tricyclic antidepressants, although until researching this post, I didn't realise that might be why. The NHS doesn't recommend amitriptyline as your first choice of treatment, but does mention it if antispasmodic meds don't work)
• migraines or headaches  
• temperomandibular joint dysfunction
•  atypical facial pain 

Who doesn't it work for? Researchers don't seem entirely certain which sorts of chronic pain it doesn't work for (and goodness knows my pain doesn't always behave like medical theory says it's supposed to), so my feeling is that unless your doctor says there's a reason why it would be a problem for you, it would be worth giving it a 6 week trial to see if the benefits outweigh the downsides for you.

Where can I get it? Through a prescription from your doctor.

How much does it cost? As a prescription drug, in the UK it is free if you are entitled to free prescriptions or buy a prescription prepayment certificate (well worth it if you get regular prescriptions) or it costs the standard prescription charge, or 2 p to 4 p per tablet plus postage from an online pharmacy. Given that UK GPs usually prescribe it in packs of 28 you are better off buying it at that price than for the prescription charge if you can or getting a prepayment certificate if you have a lot of prescriptions. The medicine has been off-patent for many years, so the cost to the NHS is minimal. Here are some prices for the US.
 

Is there any evidence for it? Yes. Clinical trials show it works for various types of pain, including neuropathic pain (postherpetic neuralgia, diabetic neuropathy), irritable bowel syndrome, temperomandibular joint dysfunction, atypical facial pain and fibromyalgia.

What about other tricyclic antidepressants? For years I've heard doctors recommending amitriptyline for chronic pain. It seems to be the go-to choice. When I complained loads about the horribly dry mouth it gave me (which I now know only happens for me on 10 mg a day when I also take codeine, but happens every night on 25 mg), my doctor said I could try doxepin (she also said amitriptyline is known for giving people a dry mouth and doxepin is known for causing weight gain) and I said I'd rather get fat. I spent about 2 years on doxepin and put on about 1-1.5 stone (14-21 lb/6.3-9.5 kg) and found the pain relief pretty good (possibly even better than amitriptyline, although it's always hard to really pin down which factor is making you better or worse). Unfortunately someone then discovered that doxepin was a risk for people with long QT syndrome that could result in death. I don't have a diagnosis of long QT syndrome, but this was still considered an unnecessary risk, so I was taken off it (and immediately lost about a stone without really trying in less than 2 weeks). I've also tried lofepramine, but didn't last very long on it. As far as I remember, the reason I stopped taking it was that it had very little impact on my pain. I haven't tried any other tricyclic antidepressants, but theoretically others could work. Amitriptyline is, however, very much the well known one for chronic pain and the one that a lot of people take for it.

Are there any downsides? Hell yes. Like any med it has a load of possible side effects. I get the common side effects: it makes my mouth dry (in my case it makes it horribly dry if I take it at the same time as codeine or beta blockers, and I wake up with more dryness in the morning on 25 mg than I did on 10 mg, but most of the time it's OK so long as I don't take codeine or beta blockers). It makes me really tired/sleepy in the 12-15 hours after I've taken it and more tired than I would be without it the rest of the time (this is the one that's the biggest problem for me). It makes me quite a lot hungrier (which in my case equates either to weight gain or evenings spent feeling really really hungry, although I don't find it as bad as doxepin for that and my BMI is still less than 25). Also, they warn you on the info leaflet to avoid alcohol on the basis that you will be more affected and get more tired. I choose to interpret that as still drinking alcohol, but not as much as those around me - for instance choosing lower alcohol options or having only a couple of alcoholic drinks in an evening and the rest alcohol-free. Several of the meds I'm on increase the effects of alcohol, which in my case means I wouldn't dare drive after any amount of alcohol at all and anything more than two glasses of wine is likely to result in me falling asleep in my chair (and also two glasses of wine for me is equivalent to about a bottle or two of wine for a hardened drinker). If my pain were less bad, I might choose not to take amitrptyline at all, but as it is, I find the far from perfect level of pain relief it provides increases my quality of life by more than the side effects worsen it.

Are there any other upsides? Yes, I used to have to get up a lot to go to the toilet in the night (often as much as 6 times). Now I generally only get up between 0 and 2 times a night (most often 0). Also, given that it can help with irritable bowels, it may also be what's behind the improvement in the irritable bowel pain I get. Also, it improves my ability to go to sleep and stay asleep. I can also sleep through more pain than I can without it.

Was it worth the money/side effects? Yes. To me it was.

Do you use amitriptyline or another tricyclic anti-depressant for chronic pain? How does it affect you?