The Empowered Patient's Guide to Chronic Pain Medications

Pain is classified in two ways. It's either acute or chronic. Acute pain begins suddenly and feels sharp. It may be caused by broken bones or cuts. It usually resolves right away or may last up to three months.

Sometimes acute pain transitions to chronic pain. This may happen when the physical condition causing the pain is unresolved, such as cancer or arthritis. It can also happen if the nervous system gets impaired and sends pain signals when there isn't a specific cause of pain.

Chronic pain is ongoing pain that lasts for more than three months and is usually harder to daignose. It's important to distinguish between acute and chronic pain as treatment choices differ. Over-the-counter (OTC) medications, such as aspirin, acetaminophen, or ibuprofen (an NSAID), may not be strong enough.

Although there are many types and brands of medications, what medication your doctor recommends depends on you—your pain level, treatment goals, and overall health.

Our Smart Patient's Guide below can be printed or downloaded and gives a more detailed look at some of the non-opioid medications—NSAIDs, antidepressants, and more—that can be used for managing a variety of chronic pain conditions.

Before taking any medication, even if it's an over-the-counter drug, discuss it with your doctor. Some medications have serious side effects if they're not taken as directed, or if they're taken with other drugs, supplements, or foods. Your doctor should be aware of everything you're taking, including herbal remedies and supplements, because of possible drug interactions or side effects.

Now that you know the difference between acute and chronic pain, let's drill down a bit more. The cause of your pain will for the most part determine the type of pain you are experiencing. Describing your symptoms accurately is important because it helps your health care provider choose the best treatment for your pain.

Nociceptive pain and neuropathic pain are the two most common types of pain.

Nociceptive pain is caused by tissue damage or injury to the skin, bones, muscles, or joints. Think broken arm, sprained ankle, a puncture wound from a dog bite, or a banged-up knee.

Treatment for nociceptive pain may range from mild OTC meds such as Advil to powerful prescription drugs like Percocet.

Treating Nociceptive Pain with NSAIDs

Most doctors will start with an NSAID for pain. NSAIDs are divided in two categories: COX-1 inhibitors and COX-2 inhibitors. COX-1 inhibitors include medications like ibuprofen (Advil, Motrin) and naproxen (Aleve). This class can be harsh on the stomach and may cause ulcers or bleeding, so taking it with food is a good idea.

If you experience black or tarry stools, bright red blood in vomit, or severe cramps, seek medical attention immediately as these symptoms indicate a stomach bleed. These reactions can occur at any time during use and without warning symptoms.

COX-2 inhibitors are easier on the stomach and include medications like celecoxib (Celebrex) and meloxicam (Mobic). The bad news is they may increase the risk of heart attack or stroke, so be sure to discuss the risks with your doctor.

If pain exists in just one area of your body, such as an arm or leg, consider treating it with a topical NSAID such as diclofenac (Voltaren gel). Voltaren gel must be applied to clean, dry, and intact skin.

Acetaminophen (Tylenol) can also be used, but the daily dose should not exceed 4 grams to avoid liver damage. Keep in mind that acetaminophen may be contained in other prescription medications as well as OTC medications.

Let your doctor know about all the medications you are taking, including herbal remedies and supplements, to avoid any drug interactions or toxicities.

Treating Nociceptive Pain with Opioids

If the pain is still not adequately controlled, opioid therapy (for a limited period) may be recommended until the pain is controlled. Prolonged use of opioids is ill advised due to the many health risks associated with them.

To avoid unnecessary risks without a justified benefit, it is important that you and your doctor establish pain goals. For example, experiencing less pain rather than NO pain may be a reasonable goal to set.

What Are Opioids?

Opioids are sometimes referred to as narcotics. They are stong painkillers derived from the opium poppy plant and are used to block pain signals between the brain and the body. Opioids are sometimes prescribed to alleviate moderate to severe acute pain and chronic pain.

Opioids provide immediate relief to intense pain by changing your brain's perception of the pain message, but other medication options are typically used first to try to treat the pain. Opioids may be prescribed for low back pain, neuropathic (nerve) pain, or arthritis pain.

Because of the risk of addiction, abuse, or misuse, opioid use must be closely monitored by your doctor.

Examples of opioids include hydrocodone, hydromorphone, methadone, fentanyl, meperidine, morphine, tramadol, and oxycodone. The most common drugs involved in prescription opioid overdose deaths include methadone, oxycodone, and hydrocodone.

Respiratory depression is one of the most dangerous risks associated with opioids. All opioids slow down breathing, and in severe cases can cause the breathing to completely stop. The risk is higher if you have underlying breathing conditions such as asthma or sleep apnea.

If you have liver or kidney disease, opioids can build up in your body and put you at a higher risk for complications. Benzodiazepines (such as Xanax and Ativan) or Z-drugs (such as Ambien) or muscle relaxants (such as Flexeril) can also increase the risk for respiratory depression when used with opioids.

Constipation is a very common side effect of opioids. Constipation does not resolve with time and requires treatment. Stimulant laxatives such as senna are typically the most effective treatment.

Pain that results from damage to the nerves is known as neuropathic pain. It presents as tingling, numbing, or shooting pain. Some describe it as “pins and needles.”

This type of pain may occur due to poorly managed diabetes (referred to as diabetic neuropathy), trauma, the aftermath of surgery, infections, chemotherapy, fibromyalgia, or shingles (referred to as postherpetic neuralgia).

Neuropathic pain requires a different treatment from nociceptive pain, which may involve antidepressants, anti-seizure drugs, or topicals such as lidocaine and capsaicin.

Antidepressants for Pain

Not all antidepressants can work for pain. Only antidepressants that affect norepinephrine (adrenaline in the nerves) are found to be effective for chronic pain.

These antidepressants are tricyclic antidepressants (TCAs) and serotonin norepinephrine reuptake inhibitors (SNRIs). Selective serotonin reuptake inhibitors (SSRI) such as fluoxetine (Prozac) and sertraline (Zoloft) are also a class of antidepressants but have not been found to be effective in treating neuropathic pain. SSRIs do not have any effect on norepinephrine, the main component involved in pain relief.

SNRIs are the preferred treatment for neuropathic pain as they are generally better tolerated by patients. The most used SNRIs are duloxetine (Cymbalta) and milnacipran (Savella).

Duloxetine is FDA approved for the treatment of diabetic neuropathy, and milnacipran is FDA approved for fibromyalgia. Other SNRIs like venlafaxine (Effexor) and desvenlafaxine (Pristiq) are not commonly used for pain.

Unfortunately, SNRIs don't work immediately. It may take weeks to feel the effects, so be patient and take meds as prescribed for best results. Common side effects include diarrhea, nausea, dry mouth, and dizziness.

What Is Serotonin Syndrome?

Since SNRIs have a serotonin component, they are referred to serotonergic drugs. Serotonergic drugs may cause serotonin syndrome, a dangerous condition that results when too much serotonin builds up in your body.

Symptoms of serotonin syndrome may range from mild (diarrhea and chills) to severe (fever and seizure). Serotonin syndrome may be life-threatening if left untreated.

It can occur if two serotonergic agents are used together or if one serotonergic agent is taken excessively. To avoid overlap of serotonergic agents be sure your doctor is aware of all the medications you are taking.

Tricyclic Antidepressants (TCAs) for Neuropathic Pain

TCAs are the most studied antidepressants for the treatment of neuropathic pain as they have been around for a long time. Their pain-relieving properties were noted in research from the 1960s.

Similar to SNRIs, TCAs work by regulating norepinephrine, which mediates the analgesic effect. TCAs used for pain are amitriptyline, nortriptyline (Pamelor), doxepin (Silenor), imipramine (Tofranil), Desipramine (Norpramin) and clomipramine (Anafranil).

Side effects may include dry mouth, blurred vision, dizziness, nausea, weight gain, sweating, and constipation. Due to the side effects, TCAs are less commonly used in the elderly population. If your doctor recommends TCAs for your pain, he will likely start with a low dose and gradually increase it until an effective dose is achieved. TCAs are also inexpensive.

The dose used for neuropathic pain treatment is lower than the dose used for depression treatment. Higher doses are not effective for pain treatment and are associated with more side effects.

Both TCAs and SNRIs are great options for many people who are suffering from depression or anxiety along with nerve pain. However, they are still considered great options even if depression or anxiety are not present.

It is important to note that antidepressants are associated with increased risk of suicidal thoughts or behaviors. Talk to your doctor or counselor immediately if you feel depressed or suicidal.

Anti-Seizure Medications

Antiseizure medications are also known as anticonvulsants or antiepileptic drugs. This class works by calming down the overactive pain signals caused by damaged nerves.

As with antidepressants, anti-seizure medications can treat chronic neuropathic pain and may be used even if no seizure disorder is present.

Examples of anti-seizure medications are pregabalin (Lyrica) and gabapentin (Neurontin).

Gabapentin is FDA approved for postherpetic neuralgia but can be used in other types of neuropathic pain. The target dose for pain is 1800mg and the maximum dose is 3600mg. Doses must be adjusted if the patient has any renal (kidney) problems.

Pregabalin is also FDA approved for postherpetic neuralgia, as well as diabetic neuropathy and fibromyalgia. The typical starting dose is usually 75mg twice daily. The maximum dose is 600mg. Dose must also be adjusted if patient has kidney problems.

Side effects of gabapentin and pregabalin include weight gain, fluid buildup, sleepiness, and drowsiness. Gabapentin and pregabalin cannot be stopped abruptly; they must be withdrawn gradually to minimize withdrawal symptoms such as confusion, delusions, agitation, and sweating.

Topical Anesthetics

Topical drugs are valuable options in pain management as they achieve relief with a low risk of side effects and drug interactions.

There are many formulations available such as creams, ointments, gels, lotions, and patches. Counterirritants are an over-the-counter class of medications such as salicylates, camphor, and menthol.

Counterirritants work by irritating the nerves as a distraction from the original pain. Capsaicin can be an effective option and is available as an 8% patch (Qutenza) and as cream, gel, and liquid.

Qutenza is available by prescription only and is FDA approved for neuropathic pain associated with postherpetic neuralgia. The initial response may be seen at one week as opposed to over the counter formulations, which may take up to six weeks for effect.

Lidocaine 5% patch (Lidoderm) is also FDA approved for the treatment of postherpetic neuralgia. A maximum of three patches may be applied to the painful area per day. Apply the patch for 12 hours then take it off for 12 hours.

Wash hands after application and avoid contact with eyes. Avoid exposing the application site to any heat sources such as heat lamps or electric blankets. The patch may cause some redness in the application site.

Corticosteroids

Steroids are powerful anti-inflammatory medications that can be taken orally or injected. If prescription-strength NSAIDs haven't reduced your pain, your doctor may recommend that you try corticosteroids. They're responsible for stopping your body from producing the chemical that causes inflammation.

However, as mentioned above, steroids have certain side effects (eg, weight gain), and you can't just stop taking them—your dose must be slowly decreased. Corticosteroids are used to treat migraines, osteoarthritis, rheumatoid arthritis, and low back pain. Prednisone (Deltasone) and Decadron (dexamethasone) are examples of corticosteroids.

Muscle Relaxants

These medications are used to reduce aches and pains associated with muscle strains, sprains, or spasms. Muscle relaxants can provide the pain relief you need to manage your daily activities by helping relax tight muscles and improve the quality of sleep you get. Muscle relaxants aren't typically recommended for treating chronic pain, but they may help with fibromyalgia and low back pain symptoms. Examples of muscle relaxants are carisoprodol (Soma) and baclofen (Lioresal).

NSAIDs

• May increase risk of bleeding

• Multiple NSAIDs should not be used together, except if patient is using baby aspirin for heart benefit. If using aspirin for heart and ibuprofen for pain, take aspirin one hour before or eight hours after ibuprofen.

• Avoid if you have kidney problems

• Avoid with alcohol

Acetaminophen

• Can be used with warfarin (blood thinners), but if used chronically, need to monitor closely as it may increase bleeding risk

• Avoid or limit alcohol use due to risk of liver damage

Opioids

• Avoid alcohol completely with all opioids, especially if extended-release formulations

• Use caution if already taking a benzodiazepine or muscle relaxant as they can increase the risk for respiratory depression where the breathing slows and can completely stop

SNRIs

• Serotonin syndrome possible if combined with serotonergic agents such as SSRIs

• Increases bleeding risk if using along with an NSAID or a blood thinner such as warfarin or supplements like gingko

• If taking a blood pressure medication, use caution and monitor blood pressure as SNRIs may increase blood pressure readings

• Separate from monoamine oxidase inhibitors (MAOIs) such as isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate) and linezolid, by two weeks

TCAs

• Caution if you have existing heart problems as TCAs may cause Qt prolongation, which happens when the heart’s electrical system takes longer than normal to recharge between beats

• Separate from monoamine oxidase inhibitors (MAOIs), such as isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate) and linezolid, by two weeks

Anticonvulsants

• Monitor closely if patient is on opioid therapy

The most important thing to remember when taking medications to treat your chronic pain is that you need to be an active participant in your own treatment plan. Don't be afraid to ask questions—you have to be your own advocate.

Over time, you may need to increase or decrease your dose of medication or perhaps change medications, so it's essential that you carefully follow your doctor's directions.

Also, be on the lookout for side effects. If you notice any new symptoms, tell your doctor immediately. But don't stop taking your medication unless your doctor tells you to do so.