Taking Elavil for Chronic Back Pain

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 (meaning "along with") pain medication to people with chronic back pain. A tricyclic antidepressant, amitryptyline is very effective for pain, but it does come with some side effects and drug interactions.

What Is Amitriptyline?

Diagram of an amitriptyline molecule.
Laguna Design/Science Photo Library/Getty Images.

Elavil (amitriptyline) is an antidepressant medication that 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 (acetaminophen) have been found ineffective for relieving the pain.

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

Uses

Elavil appears to be most effective for neuropathic (relating to nerves) 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 pinprick sensation in your arm or leg.

Although Elavil's pain-relieving abilities are independent of its antidepressant effect, the drug works by increasing the number 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.

Effectiveness

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 hungover in the morning. "But in reality, amitriptyline is an effective and inexpensive medication for managing chronic back pain, especially if you are also having problems sleeping," she notes.

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.

Amitriptyline Dosage

The way antidepressants relieve back pain is independent from the anti-depressant effect, so the dosing is different. 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.

Elavil also works in patients who are not depressed. 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.

Side Effects

It's important to be aware of the possible side effects of amitryptyline before beginning this drug. Some of the most common side effects are sleepiness, headache, and tremors.

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

For example, a 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.

Drug Interactions

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 the 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.

Contraindications

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 (MAOI) for depression or the heartburn medication cisapride (no longer available in the United States) you should not take amitryptyline. Also, do not take Elavil within 14 days of using MAOI.

You should not use Elavil if you have a history of QTc prolongation, arrhythmias, recent myocardial infarction, or heart failure. Since Elavil may increase or decrease the level of other drugs you take, always talk to your doctor before discontinuing your medication.

A Word From Verywell

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.

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.

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Additional Reading
  • Fink K. Telephone Interview. National Rehabilitation Hospital. May 2011.

  • Kasper DL, Fauci AS, Hauser SL. Harrison's Principles of Internal Medicine. New York: Mc Graw Hill education, 2015. Print.

  • van den Driest J, Bierma-Zeinstra S, Bindels P, Schiphof D. Amitriptyline for musculoskeletal complaints: a systematic review. Family Practice. 2017. 34(2):138-146.