Hospitals stock antidepressants and antipsychotics for psychiatric emergencies, and they stock opioids for pain emergencies, but the same neurotransmitters, dopamine, serotonin, norepinephrine, glutamate, regulate both mood and pain sensation [1]. Until now, no one had created a systematic map matching which psychiatric medications, already sitting on emergency department formularies, work for which common pain conditions. Akash Shanmugam, a medical student at the University of California, San Francisco, and Dr. Kathy LeSaint, an associate professor of emergency medicine at UCSF, reviewed what was already available at San Francisco General Hospital and built that map [1][2].
The study provides recommendations for five types of pain physicians see every shift: abdominal pain, back pain, chest pain, fracture pain, and headache [1][3]. Non-steroidal anti-inflammatory drugs like ibuprofen showed potential across all five categories [1]. But the specificity goes further than that. A serotonin norepinephrine reuptake inhibitor, an SNRI antidepressant, showed promise for back pain [1][2]. Several types of antipsychotics showed promise for headache and abdominal pain [1][4]. Ketamine, already stocked as a common anesthetic, showed promise for chest pain [1][3]. The goal was not to discover new drugs but to create a targeted list physicians could actually use in the moment, adding options to the treatment toolbox rather than replacing what already works [1][4].
The neurotransmitter overlap is not incidental. Neural circuits that create the sensation of pain are also involved in the emotional experience of pain [1]. In chronic pain conditions, the nervous system can become highly sensitive, and antidepressants and antipsychotics are thought to reduce that heightened sensitivity [1][5]. Gabapentin, now used for the management of neuropathic pain, is thought to alter neurotransmitter release through its effect on calcium channels [1]. Antidepressants and antipsychotics regulate neurotransmitters more directly [1]. The same chemical messengers that modulate mood also modulate the body's pain response, which means the artificial boundary between psychiatric and physical pain has kept effective treatments in separate drawers for years.
Chronic pain is often linked to poor sleep, depression, anxiety, and fatigue, the same conditions these medications treat [1][4]. Psychotropic medications have long been used for both pain relief and psychiatric symptoms, but informally, without systematic guidance for emergency settings [1]. The study formalizes what has been scattered practice, giving emergency physicians a structured reference for conditions they encounter constantly. The specificity matters because opioids work on everything; these alternatives work on particular pain types, which means a physician treating back pain now has a different recommendation than one treating a headache, rather than reaching for the same blunt-force solution in both cases.
The need for this map traces back to the first wave of the U.S. opioid crisis, which began in the 1990s with loose prescriptions and insufficient attention to addictive properties [1][5]. Physicians became more cautious, more aware of the long-term consequences of opioid use [1]. But caution without alternatives leaves a gap, and emergency departments, where pain arrives acutely and decisions are made quickly, have been working without a clear playbook for non-opioid options tailored to the setting. The drugs were already there, already approved, already stocked. The map just had to be drawn.
Both Shanmugam and LeSaint agree that opioids still have a place in medicine [1][4]. This is not replacement; it is addition. Enzymes responsible for metabolizing opioids can have different strengths in different people, which means some patients will not respond to alternatives the same way [1][5]. The study does not argue for eliminating opioids from emergency departments but for giving physicians more tools to match treatment to the patient and the pain type in front of them. The formulary was already sitting there. Someone just had to write down which drug works for which pain.
The result is a reference that does not require new approvals, new funding, or new infrastructure, just a shift in how existing resources are deployed. Emergency departments can now treat pain with precision rather than volume, turning a crisis of overprescription into an opportunity for targeted care. What was once improvisation is now protocol.
