Treating pain: Conventional medical care
Medications can play an important role in managing pain. In fact, medications are the most common treatment for both acute and chronic pain. When used properly, medications help relieve pain, treat conditions that can accompany pain — such as anxiety or sleep problems — and improve quality of life.
In addition to the potential relief they provide, all pain medications carry the risk of side effects. Here's what you need to know about the most common types of prescription pain medications.
Some of the medications you buy over the counter for pain relief, such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve), are also available in more powerful, prescription-strength formulas. All of these medications fall in the nonsteroidal anti-inflammatory drug (NSAID) category. NSAIDs relieve pain by preventing the body's cyclooxygenase (COX) enzymes from working. COX enzymes make hormone-like substances called prostaglandins, which contribute to pain and inflammation. NSAIDs are most often prescribed for arthritis and for the pain resulting from muscle sprains, strains, back and neck injuries, and menstrual cramps.
Another type of NSAID, called a COX-2 inhibitor, works slightly different from traditional NSAIDs. A COX-2 inhibitor blocks only the COX-2 enzyme — the one that's more likely to cause pain and inflammation. The COX-2 inhibitor celecoxib (Celebrex) is most often prescribed for people with rheumatoid arthritis, osteoarthritis, menstrual cramps and injury-related pain.
Side effects: If you take more than the recommended dose (and sometimes even the recommended dose) of NSAIDs, side effects can include nausea, stomach pain, bleeding and ulcers. NSAIDs also increase your risk of cardiovascular problems, such as heart attack and stroke — and they can interact with drugs prescribed to treat heart disease, such as blood thinners, antihypertensive drugs and aspirin. Large doses of NSAIDs can also lead to kidney problems, fluid retention and high blood pressure. The older you are, the higher your risk of developing these conditions.
Another concern with NSAIDs is the "ceiling effect" — meaning there's a limit to how much pain they can control. Beyond a certain dosage, NSAIDs won't deliver any additional pain-relieving benefit. For this reason, even prescription NSAIDs might not be powerful enough to relieve moderate to severe pain.
Opioid medications (also called narcotics) are currently the most commonly prescribed medications in the United States. But a physician must have a special license to prescribe opioids, which are regulated as controlled substances by the U.S. Drug Enforcement Administration.
Because opioids are powerful drugs, they are often used to relieve pain from cancer, terminal illness, severe injury or surgery. Individuals with severe osteoarthritis or rheumatoid arthritis, low back pain, or neuropathic pain also can be prescribed opioids.
Opioids fall into two categories:
- Agonists. These include codeine, drugs containing hydrocodone (Vicodin, Norco, others), morphine (MS Contin, Kadian, others) and drugs containing oxycodone (Oxycontin, Percocet, others).
- Mixed agonists and antagonists. These include drugs containing buprenorphine (Butrans, Buprenex, others), butorphanol and levorphanol.
Both types of opioids provide powerful pain relief that's difficult to match using other methods. But this strength comes with some serious risks.
Side effects: Opioid side effects can include dizziness, nausea and vomiting, gastrointestinal issues, cardiovascular issues, sexual dysfunction, fatigue, mental cloudiness, unclear thinking,
and mood changes. These side effects can make it difficult to function normally — preventing driving a car, operating machinery or even returning to work. In some cases, opioids can even cause changes in the nervous system, amplifying your perception of pain and making you feel more uncomfortable (hyperalgesia).
Opioids are highly addictive, which can lead to misuse and abuse. Trends in the United States reflect this problem. Prescriptions for opioid pain relievers have quadrupled since 1999. During the same period, the rate of opioid overdose has tripled. In fact, prescription opioid addiction, overdose and deaths are at an all-time high in the United States.
Given these statistics, the use of opioid analgesics can be controversial. In some cases, the risks of opioid use outweigh their benefits. Other NSAIDs, such as analgesics, should be considered first. And when opioids are prescribed, the lowest effective dose should be given for the shortest amount of time.
Other pain-related medications
Because pain is complicated and involves many aspects of your body, mind and life circumstances, traditional pain relievers might not provide enough relief. Your health care professional can prescribe other medications for pain relief or help manage the side effects of existing medications.
Tramadol (Ultram, Ultram ER, ConZip) interferes with the way pain sends signals and decreases your perception of pain by affecting certain brain chemicals. Tramadol primarily is used to relieve mild to moderate pain.
Side effects: Although the risk of dependence and addiction is significantly less than with opioids, common side effects can include dizziness, drowsiness, headache, nausea, constipation and seizures.
In addition to relieving symptoms of depression, some antidepressants can also contribute to pain relief. There may be two reasons for this: First, by helping to manage depression, they boost energy and improve mood, which makes pain feel more tolerable. Second, antidepressants can also directly relieve pain by changing the way pain signals are transmitted within the central nervous system.
Antidepressants that might help with pain relief include:
- Tricyclic antidepressants, such as amitriptyline and clomipramine (Anafranil)
- Serotonin and norepinephrine re-uptake inhibitors, such as duloxetine (Cymbalta) and milnacipran (Savella)
Side effects: Side effects of different antidepressants vary, but can include drowsiness, dry mouth, blurred vision, constipation, insomnia, nausea, fatigue, weight gain, blood pressure changes, confusion and dizziness. They also can interfere with the way the heart produces electrical impulses (cardiac conduction). As a result, antidepressants are not usually recommended for individuals with heart disease.
Although these medications were initially developed to control or reduce epileptic seizures, they were later found to help manage pain — particularly the shooting pain that results from nerve damage. It's believed that anti-seizure medications work by "quieting" damaged nerves to slow or prevent uncontrolled pain signals. These medications include gabapentin (Gralise, Neurontin) and pregabalin (Lyrica).
Side effects: Side effects can include dizziness, drowsiness, nausea, short-term memory disturbance, weight gain, and lack of balance and coordination. More severe but less common side effects include blood, skin and liver disorders.
Adjuvants are medications commonly prescribed in conjunction with pain medications. They are intended to:
- Help control side effects, such as nausea or fatigue
- Manage other pain-related symptoms, such as insomnia or anxiety
- Boost pain-relieving power
Adjuvants include topical analgesics that help relieve joint or muscle pain. Muscle relaxants, which help reduce painful muscle spasms, also fall into this category.
Pain is complex and so is treating it. You may find that you benefit from multiple strategies and resources to eliminate or minimize your pain. Work with your health care professional to find the treatment approach that's right for you.
July 26, 2016
- Vowles K, et al. Rates of opioid misuse, abuse, and addiction in chronic pain: A systematic review and data synthesis. Pain. 2015;156:569.
- Frenk S, et al. Prescription opioid analgesic use among adults: United States, 1999-2012. National Center for Health Statistics. http://www.cdc.gov/nchs/data/databriefs/db189.htm. Accessed Jan. 25, 2016.
- Brown C, et al. Colorectal surgery patients' pain status, activities, satisfaction, and beliefs about pain and pain management. Pain Management Nursing. 2013;14:184.
- Bruce BK, et al, eds. Medication. In: Mayo Clinic Guide to Pain Relief. 2nd ed. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 20 13.
- Centers for Disease Control and Prevention, et al. Increases in drug and opioid overdose deaths — United States, 2000-2014. MMWR. Morbidity and Mortality Weekly Report. 2016;64:1369. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm. Accessed Jan. 25, 2016.
- Brooks E, et al. Exploring the experience of adults using prescription opioids to manage chronic non-cancer pain. Pain Research and Management. 2015;20:15.
- Hegmann K, et al. ACOEM practice guidelines: Opioids for treatment of acute, subacute, chronic, and postoperative pain. Journal of Occupational and Environmental Medicine. 2014;56:e143.
- Rosenquiest E, et al. Overview of the treatment of chronic pain. http://www.uptodate.com/home. Accessed Feb. 15, 2016.
- Mariano E, et al. Management of acute preoperative pain. http://www.uptodate.com/home. Accessed Feb. 15, 2016.
- FDA Drug Safety Communication: FDA strengthens warning that non-steroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes. U.S. Food and Drug Administration. http://www.fda.gov/Drugs/DrugSafety/ucm451800.htm. Accessed March 10, 2016.
- Wu PI, et al. Nonpharmacologic options for treating acute and chronic pain. PM&R. 2015;7(suppl):S278.