23/04/2022 23:49 Chronic pain: Medication decisions - Mayo Clinic

Chronic pain: Medication decisions

Chronic pain can limit your quality of life and lead to additional, serious health problems.
Finding effective treatment is important — as is balancing pain relief with your safety.

By Mayo Clinic Staff

Chronic pain is a serious health condition. Like any long-term health problem, the condition
often leads to complications beyond your physical symptoms, such as new or worsened
depression, anxiety, and difficulty sleeping. Chronic pain can make it more difficult to keep up at
work, manage tasks at home and attend social gatherings, leading to problems in your
relationships and financial instability. Some research suggests that the more severe your pain,
the more serious these problems.

The serious consequences of chronic pain make finding effective treatment a critical goal.
Unfortunately, this process is complex and uniquely personal. What works for one person's
chronic low back pain may not offer any relief for your osteoarthritis, for a number of reasons.
Your diagnosis, biology and personal history all play a role, and finding pain therapies that bring
you adequate relief can be a lengthy effort.

Working in partnership with your doctor, however, you can identify treatments that allow you to
live an enjoyable, fulfilling life. The approach you choose should include more than just
medication, but painkillers are likely to play a role. Learn about the risks and benefits of
common pain medications so that you can make safe choices as you seek your solution.

NSAIDs are most effective for mild to moderate pain that's accompanied by swelling and
inflammation. These drugs are commonly used for arthritis and pain resulting from muscle
sprains, strains, back and neck injuries, or menstrual cramps.

Generic (brand) names. Ibuprofen (Advil, Motrin IB, others); naproxen sodium (Aleve);
others
How they work. NSAIDs work by inhibiting certain enzymes in your body, called
cyclooxygenase, that are released during tissue damage. By blocking the different types of
cyclooxygenase (COX) — including COX-1 and COX-2 — NSAIDs can help reduce pain
and inflammation that result from an injury.
Benefits and risks. When taken as directed, NSAIDs are generally safe. But if you take
more than the recommended dosage — and sometimes even just the recommended
dosage — NSAIDs may cause nausea, stomach pain, stomach bleeding or ulcers. Large
doses of NSAIDs can also lead to kidney problems, fluid retention and high blood pressure.
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Risk of these conditions increases with age and in the presence of other health problems,
including diabetes, a history of stomach ulcers or reflux, and kidney disease.
Bottom line. If you regularly take NSAIDs, talk to your doctor so that he or she can monitor
you for possible side effects. Bear in mind that NSAIDs also have a ceiling effect — a limit
as to how much pain they can control. This means that beyond a certain dosage, they don't
provide additional benefit. Exceeding the recommended dose may not relieve your pain and
may increase your risk of serious side effects.

Acetaminophen is usually recommended as a first line treatment for mild to moderate pain,
such as from a skin injury, headache or musculoskeletal condition. Acetaminophen is often
prescribed to help manage osteoarthritis and back pain. It may also be combined with opioids
to reduce the amount of opioid needed.

Generic (brand) names. Acetaminophen (Tylenol, others)

How it works. Doctors don't know exactly how acetaminophen works. Some scientists
believe there may be a third type of cyclooxygenase, COX-3, that acetaminophen blocks.
Acetaminophen doesn't affect the other two cyclooxygenase enzymes, and it doesn't target
inflammation — only pain. It may be less effective than NSAIDs.
Benefits and risks. Acetaminophen is generally considered safer than other nonopioid pain
relievers because it doesn't cause side effects such as stomach pain and bleeding.
However, taking more than the recommended dose — or taking acetaminophen with alcohol
— increases your risk of kidney damage and liver failure over time.
Bottom line. Acetaminophen is generally a safe option to try first for many types of pain,
including chronic pain. Ask your doctor for guidance about other medications to avoid while
taking acetaminophen. Acetaminophen is not as effective as NSAIDs for the treatment of
knee and hip pain related to osteoarthritis.

These medications were developed with the aim of reducing common side effects associated
with traditional NSAIDs. COX-2 inhibitors are commonly used for arthritis and pain resulting
from muscle sprains, strains, back and neck injuries, or menstrual cramps. They are as
effective as NSAIDs and may be the right choice if you need long-term pain control without
increased risk of stomach damage.

Generic (brand) names. Celecoxib (Celebrex, Consensi)

How they work. COX-2 inhibitors, another type of NSAID, work slightly differently from
traditional NSAIDs. A COX-2 inhibitor blocks only the COX-2 enzyme — the one that's more
likely to cause pain and inflammation.
Benefits and risks. COX-1 enzymes help protect the lining of your stomach. NSAIDs,
which block COX-1, can cause side effects such as stomach pain and bleeding. COX-2
inhibitors, on the other hand, help keep the stomach protected by acting only on COX-2
enzymes, allowing COX-1 to function normally.

Although the risk of stomach bleeding is generally lower if you take a COX-2 inhibitor
instead of an NSAID, bleeding can still occur, especially at higher doses. These medications
may cause side effects, such as headaches and dizziness, and can lead to kidney
problems, fluid retention and high blood pressure.
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Bottom line. Older adults may be at higher risk of common COX-2 side effects compared
with younger adults. If these medications help you manage chronic pain, aim to take the
lowest effective dose for the shortest time possible, and follow up closely with your doctor.

Some medications commonly prescribed to manage depression and prevent epileptic seizures
have also been found to help relieve chronic pain, including back pain, fibromyalgia and
diabetes-related nerve pain (diabetic neuropathy). Because chronic pain often worsens
depression, antidepressants may doubly benefit pain and mood symptoms.

Generic (brand) names. Tricyclic antidepressants used in the treatment of chronic pain
include amitriptyline and nortriptyline (Pamelor).

Serotonin and norepinephrine reuptake inhibitors (SNRIs) that may be prescribed to relieve
chronic pain include duloxetine (Cymbalta), venlafaxine (Effexor XR, Pristiq) and
milnacipran (Fetzima, Savella).

Anti-seizure medications that are widely used for the treatment of chronic nerve pain,
including postherpetic neuralgia and diabetic neuropathy, include gabapentin (Gralise,
Neurontin, Horizant) and pregabalin (Lyrica).

How they work. These drugs may take several weeks before you notice the effects. Anti-
seizure medications quiet pain signals from your nerve cells, and may be helpful primarily
for stabbing or shooting pain resulting from nerve damage.
Benefits and risks. Side effects of these medications are generally mild, but may include
nausea, dizziness or drowsiness. As a group, antidepressants and anti-seizure medications
may, rarely, worsen depression or cause suicidal thoughts. If you notice changes in your
thinking patterns or mood while taking these medications, talk with your doctor right away.
Bottom line. To reduce the risk of side effects, your doctor may start you out on a small
amount of these medications and gradually increase the dose. Tricyclic antidepressants can
make you drowsy, so your doctor likely will recommend that you take these medications
before bedtime.

Opioid medications are synthetic cousins of opium and the drugs derived from opium, such as
heroin and morphine. These drugs are often prescribed for acute pain that stems from
traumatic injury, such as surgery or a broken bone. Opioids currently cause the most
prescription drug-related overdose deaths in the United States — and that rate is still rising.
Because the risks are so great, opioids are used at the lowest dose possible, usually for just a
few days.

Generic (brand) names. Hydrocodone (Hysingla ER, Zohydro ER); hydrocodone-

acetaminophen (Norco, Anexsia 5/325, others); fentanyl (Actiq, Duragesic-100, others),
oxycodone (OxyContin, Roxicodone, others); oxycodone-acetaminophen (Percocet,
Roxicet, others); others
How they work. Opioids, just like real opium, mimic the natural pain-relieving chemicals —
called endorphins — produced by your brain. These drugs "turn down the volume" on the
pain signals your nervous system sends through your body. They also muffle other nerve
cell functions, such as your breathing, heart rate and level of alertness.
Benefits and risks. Research shows that over time, your body adapts to these
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medications, and they bring less and less pain relief. This phenomenon, known as
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tolerance, means that you need more of the same medication to achieve the same degree
of pain relief. Long-term use of opioids may lead to dependence on these medications and,
eventually, addiction.

The longer you use opioids, the greater your risk of becoming addicted. However, even
using opioids to manage pain for more than a few days increases your risk. Researchers at
Mayo Clinic have found that the odds you'll still be on opioids a year after starting a short
course increase after only five days on opioids.

Bottom line. Opioids are a last resort for chronic pain management. They may be the right
choice for long-term pain related to cancer and its treatments or, in rare cases, noncancer
pain that hasn't responded to any other medications. Because the risks are so serious, you'll
need careful and frequent follow-ups with your doctor if you use opioids long term.

While there isn't a cure for chronic pain, many effective pain medications are available to help
you function effectively and enjoy your days. As you try different drugs, alone or in combination,
work with your doctor to target the simplest long-term solution possible. Keep your medication
risks to a minimum to improve your odds of many good days, for many years to come.

First line
Medication type How they work Benefits Risks
option for

NSAIDs Block COX-1 and Mild to When taken as May cause

COX-2 enzymes moderate directed, nausea,
involved in pain pain generally safe stomach pain,
and inflammation accompanied for short- and stomach
by swelling long-term use bleeding or
and ulcers
inflammation When taken in
Arthritis pain high doses, can
and pain lead to kidney
resulting from problems, fluid
muscle retention and
sprains and high blood
strains, back pressure
and neck Increased risk
injuries, of side effects
overuse for older adults
injuries, and
menstrual
cramps

Acetaminophen Unknown, but Mild to Acetaminophen Unknown, but

possibly blocks a moderate possibly blocks
COX-3 enzyme pain a COX-3
enzyme
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23/04/2022 23:49 Chronic pain: Medication decisions - Mayo Clinic

First line
Medication type How they work Benefits Risks
option for

COX-2 Block COX-2 Rheumatoid As effective as Respiratory

inhibitors enzymes arthritis, NSAIDs infection,
osteoarthritis, without headache and
menstrual damaging dizziness
cramps and stomach lining When taken in
injury-related at regular high doses, can
pain doses lead to stomach
bleeding,
kidney
problems, fluid
retention and
high blood
pressure
Increased risk
of side effects
for older adults

Antidepressants Interfere with Neuropathic Can be in Drowsiness

certain chemical pain, chronic doses much possible with
processes that daily lower than tricyclic
cause you to feel headaches, what is antidepressants
pain fibromyalgia currently used Can take
May be to treat several weeks
considered depression to produce
for chronic Side effects desired effects
low back pain generally mild May worsen
depression and
cause suicidal
thoughts in a
small number
of people
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23/04/2022 23:49 Chronic pain: Medication decisions - Mayo Clinic

First line
Medication type How they work Benefits Risks
option for

Anti-seizure Quiet pain signals Postherpetic Side effects May cause

medications from damaged neuralgia, generally mild dizziness,
nerves diabetic drowsiness,
neuropathy, nausea,
fibromyalgia reduced
coordination
and weight
changes
May worsen
depression and
cause suicidal
thoughts in a
small number
of people

Opioids Activate feel-good Acute pain, Powerful relief Tolerance,

neurotransmitters, such as pain during short dependence,
called that follows periods of misuse,
endorphins, that surgery or a severe pain addiction and
suppress pain bone fracture overdose,
and boost a Typically which may
sense of well- prescribed begin to
being for maximum develop within
of three days one week of
use
Responsible for
the majority of
accidental
overdose
deaths in the
U.S.

Show References
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3. Bruce BK, et al., eds. About pain medications. In: Solutions for Living With Chronic Pain. New York, N.Y.: Oxmoor
House; 2016.
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Jan. 09, 2021

Original article: https://www.mayoclinic.org/chronic-pain-medication-decisions/art-20360371

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