A placebo-controlled randomized clinical trial of... : PAIN (original) (raw)

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A placebo-controlled randomized clinical trial of nortriptyline for chronic low back pain

Atkinson, Hampton J.a,e,*; Slater, Mark Ab,e; Williams, Rebecca Ac; Zisook, Sidneya,e; Patterson, Thomas La,e; Grant, Igora,e; Wahlgren, Dennis Rc,g; Abramson, Ianh; Garfin, Steven Rd,f

a_Department of Psychiatry, San Diego VA Healthcare System, San Diego, CA 92161, USA_

b_Department of Psychology, San Diego VA Healthcare System, San Diego, CA 92161, USA_

c_Department of Research, San Diego VA Healthcare System, San Diego, CA 92161, USA_

d_Surgery Services, San Diego VA Healthcare System, San Diego, CA 92161, USA_

e_Department of Psychiatry, University of California San Diego, La Jolla, CA 92093, USA_

f_Department of Orthopedic Surgery, School of Medicine, University of California San Diego, La Jolla, CA 92093, USA_

g_Center for Behavioral Epidemiology and Community Health, Graduate School of Public Health, San Diego State University, San Diego, CA 92182, USA_

h_Department of Mathematics, University of California San Diego, La Jolla, CA 92093, USA_

*Corresponding author. Department of Psychiatry (0603), School of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093–0603, USA. Tel.: +1 619 5346714; fax: +1 619 8220524; e-mail: [email protected]

Submitted July 14, 1997; revised February 23, 1998; accepted March 2, 1998.

Abstract

To assess the efficacy of nortriptyline, a tricyclic antidepressant, as an analgesic in chronic back pain without depression, we conducted a randomized, double-blind, placebo-controlled, 8-week trial in 78 men recruited from primary care and general orthopedic settings, who had chronic low back pain (pain at T-6 or below on a daily basis for 6 months or longer). Of these 57 completed the trial; of the 21 who did not complete, four were withdrawn because of adverse effects. The intervention consisted of inert placebo or nortriptyline titrated to within the therapeutic range for treating major depression (50–150 ng/ml). The main outcome endpoints were pain (Descriptor Differential Scale), disability (Sickness Impact Profile), health-related quality of life (Quality of Well-Being Scale), mood (Beck Depression Inventory, Spielberger State Anxiety Inventory, Hamilton Anxiety/Depression Rating Scales), and physician rated outcome (Clinical Global Impression). Reduction in pain intensity scores was significantly greater for participants randomized to nortriptyline (difference in mean change 1.68, 95% −0.001, CI −3.36, _P_=0.050), with a reduction of pain by 22% compared to 9% on placebo. Reduction in disability marginally favored nortriptyline (_P_=0.055), but health-related quality of life, mood, and physician ratings of overall outcome did not differ significantly between treatments. Subgroup analyses of study completers supported the intent-to-treat analysis. Also, completers with radicular pain on nortriptyline (_n_=5) had significantly (P<0.05) better analgesia and overall outcome than did those on placebo (_n_=6). The results suggest noradrenergic mechanisms are relevant to analgesia in back pain. This modest reduction in pain intensity suggests that physicians should carefully weigh the risks and benefits of nortriptyline in chronic back pain without depression.