Tricyclics

Tricyclics aren’t really meant to be sleeping tablets – i.e. they aren’t meant to sedate you or get you to sleep. Their action is more to restore a natural restful sleep pattern through their action on neurotransmitters (which is why they also take time, as in weeks, to work). This may be useful especially when you consider that in fibromyalgia (for instance) lack of some type of restful/restorative sleep state is implicated. They did make changes for me in this area, I started dreaming like mad again (not something I like – we don’t go in for the pleasant variety) – and I think I felt a lot better in the day for it – maybe. But didn’t touch the pain or muscle tension.

But for non-specific pain (like what we got) they are generally just prescribed to ease the pain and muscle tension. They tend to say take them at night because some do have an associated sedative action, but what they generally mean by this is that they tend to make you groggy, which is where, as you say, AT is one of the least bad. But in some patients, they actually have a wake you up action (including with me – couldn’t get to sleep at night, groggy and late to work in the morning). I found that taking the AT spread through the day or by latest after the evening meal, was best. And watch it, they can also cause restless leg syndrome, which doesn’t help with getting to sleep.

Bear in mind however, that 10-20mg doses prescribed for pain are way below the anti-depressant normal doses of up to, I think, 100+ mg per day – so anything reported on them will tend to apply to the latter use. In fact, in the UK, when I last checked a few months ago, they aren’t licenced for use for anything else but depression, and we are therefore, in effect, still a trial. Certainly not listed in Mims or the BNF for pain and you’ll find that most pharmacists don’t know about the pain use. If you have problems getting to sleep there’s nothing wrong with asking the doctor to prescribe you an actual sleeping tablet, perhaps short acting, and taking that as well. Different mode of action entirely.

I wouldn’t recommend taking two different tricyclics, and can’t really see the point, not for sedative action – (better with an old style anti-histamine if you don’t want an actual sleeping tablet) but there are reports that different ones do have differing effects on people and whilst most might not work on pain/muscle tension (OK, they don’t know how it works either), there might be one that does. But they all have their different side effects, one in particular (I think nortryptilline) associated with weight gain (stuff that!) – I think again that’s why they tend to go for AT first.

Comment 1: Tricyclics have a sedative effect. Even amitryptiline does. I am aware that 10-15mg is well below the level at which a tricyclic is normally effective as an antidepressant, and that almost always a higher dose would be prescribed were the relief of depression an aim. I know that the lower doses are used for the treatment of persistent pain. My York GP told me they work particularly well, for reasons unclear, when taken in combination with an “ordinary” painkiller such as aspirin or paracetamol. (I also know that tricyclics take time to work as antidepressants. I was not clear to me given the accounts I had that (and still is not) that their other effects would take as long to emerge. Their sedative and anti-sedative effects certainly do not.) It is not uncommon for patients to be prescribed different tricyclics in succession, and the dose to be titrated, until the required result is obtained.

*My point is that the tricyclics vary.* If you consult the literature you will find that ideally, anyway, different tricyclics are prescribed for different kinds of depression. It was my assumption, I admit, given in lower doses they would vary as they do in higher doses and that a small dose of amitryptiline would have the same kind of effect, not the same effect, please note, as a higher dose. (Etc. for other tricyclics.) What you say is not as strange as it appears at first sight: amitryptiline both sedates and stimulates, in large doses and even a fairly conventional “depression dose”: I will not take it (or any other tricylic) in that dose now. The tricyclics are very good and very safe drugs and I regret their supersession and am glad there are doctors who still prescribe them for depression, but, they do in doses appropriate for depression affect the heart, and can do so adversely. Actually I got specific pain as well, so do a number of people on this list; I have so-called acute RSI. I have De Quervain’s tenosynovitis. So I have topical non-diffuse RSI and experience acute localized pain as well as the more diffuse dragging- down type pain of which you speak.

Some doctors prescribe them in spread doses and I would say amitryptiline probably is best prescribed that way. As you will know, the idea of giving one evening dose is that daytime drowsiness is avoided, but that can be outweighed by the stimulating effect of some. You are not experiencing a paradoxical reaction to amitryptiline, simply one that some patients do and any patient could. They are however really quite widely used, I believe. I didn’t know they weren’t so licensed, that explains the widespread ignorance (or what seems like ignorance) of their character among doctors who prescribe them for RSI. I exclude my York doctor, who knew all about their use. (My database is the RSI-UK List; I have not found doctors I know to lack such knowledge.) One problem seems to be a misunderstanding of the term “nerves”. “If you have problems getting to sleep there’s nothing wrong with asking the doctor to prescribe you an actual sleeping tablet, perhaps short acting, and taking that as well”. – I agree entirely. People take rather a lofty attitude to sleeping pills. I had in mind the substitution of a different tricyclic.

Comment 2: My GP did say he didn’t know why they worked better in combination with “usual” painkillers – if I asked him about a slightly unusual treatment he didn’t simply say yes or no, he gave me as much information as he had. Quite often people in clinical practice will do things that work when they don’t know quite how; aspirin came along because they observed it relieved pain (long story cut short), and they noticed short-acting tranquillisers were more “addictive” than long-acting ones before clinical research showed it. The best way for a patient to cope is to know enough to be able to question doctors and choose doctors who don’t mind answering the question and have friends who know about medicine. Your point (and mine) about tricyclics varying: I think we were both saying the same thing – on reflection – yes.

I wasn’t getting at you or anyone else when I said this, I just wanted to point out that there are people on RSI-UK, of whom I happen to be one, who have either “localized scream pain, or both kinds. It is a help to me and I know it is. This List has confirmed how lucky I was. A student told me what I had and told me to run to my GP: I told him the symptoms and mumbled “er RSI?”. He said, “It certainly sounds like it but I’d better examine you”. One <ouch> later and I had my diagnosis. People can’t wish that away or say it’s psychological. – I don’t think knowing what you have is a benefit that’s “just psychology”, I think you have good reason to want to know – after all, I also know what I haven’t got! The other pains came later as the condition progressed. As it does for almost everybody, it seems. (You don’t want De Q’s. It’s impossible to treat – unless it’s treated properly very early on; I don’t know what that proper early treatment is – except by an op that is tricky and best avoided. Physio can’t do anything for it.)

I haven’t seen the product literature for them — it is some while since I was prescribed them – a lot of what I know comes from a very good book by Peter Parish, The Penguin Book of Medicines. (And asking doctors or having doctors who told me things anyway. I remember now, a doctor first told me about the adrenaline-effect.) I was told all of the side effects depending on the drug of choice. I have referred people to the Parish book because he says all of that. I know people get put on anti-depressants with little or no warning. That’s bad, very. This List is my source for their not working! I did wonder whether people here were being given the right kind or the right dose?

I mean that people use “nerves” for the actual nerves in our body and also for “nervousness”. Some people on this List have been told tricyclics will “help their nerves”, and been unclear, reasonably so given the prescribing of large doses of tricyclics, on occasion, for RSI, what was being said. (I came across this myself quite recently when a doctor who visited me said “You suffer from nerves?” I didn’t think medics said that any more.) “By the way, have you come across any suggested mechanisms of action as to why they’re being used for pain and RSI” – Pain, yes. I don’t know of an RSI-specific use. I have an account of the exact mechanism (I got it from a man in the US whose family are all medics). I’ll try to find it. As I recall, it blocks transmission of pain from the nerves (hence, you see, nerves!) to the brain. (Like one or two other painkillers.) But I’d best check.

“Also – do you know anything about how long before the effects start to wear off after you stop taking the stuff, given their delayed onset?” – I don’t actually know anything about this but I’d say from two weeks to a month, as drugs that conflict with them can’t be given before two weeks after they’re stopped. “I’m trying to see if they have done anything or not – I don’t think they have but there has been a mild improvement in things lately – could be down to a lot of stuff since I’ve been very busy trying out many new things,” That is the problem — sorry to get frivolous, but I know what you mean. It’s really difficult to work out what is having what effect. “and the only way I’m going to find out is to hold the rest constant and come off the AT”- Yes. Well, it’s easy to stop taking, that’s one good thing to be said about it! Yes it is the only way to find that out.


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