In the past 20 years, a host of new pain medications
have become available. These new formulations give people
with chronic pain more options than ever. But all drugs
can have side effects that limit how they're used.
Two strategies can guide your use of pain medications:
- First, if you're taking pain medications, you'll
want to find the lowest dose that controls your pain.
The lower the dose, the fewer and less severe the side
effects.
- And second, it's often better to "stay ahead" of
chronic pain by taking your medication at regular
intervals, rather than waiting until the pain becomes
intolerable. If the pain is predictable, as migraine
pain can be, taking your medication before the pain
begins may be the best approach.
The following are among the most common drugs used
for chronic pain:
Example: Tylenol
Description: Acetaminophen is a safe and mild pain
reliever when used in moderation.
Side effects: If you drink alcohol regularly, high doses
of acetaminophen can cause liver damage, so be sure to
tell your physician if you drink.
Examples: Aspirin, ibuprofen and naproxen
Description: NSAIDs reduce inflammation. They also relieve
pain, even if there's no inflammation.
Side effects: Minor side effects associated with NSAIDs
are common and include rash, nausea and heartburn;
however, ulcer disease is the most common of the serious
side effects. The risk of ulcers appears to be lower with
newer NSAIDs, including celecoxib and rofecoxib.
Trade name: Zostrix
Description: Capsaicin is a cream that is applied to the
skin. Usually applied sparingly three or four times each
day, capsaicin is used to reduce pain in the treated area.
It is mostly used for nerve pain (neuropathy) or arthritis
(in the fingers).
Side effects: Capsaicin can cause burning sensation on the
skin. Contact with the eyes should be avoided, as it is
quite irritating.
Examples: Prednisone, methylprednisolone and
dexamethasone
Description: Corticosteroids are anti-inflammatory drugs.
They may be taken orally or injected directly into the
site of nerve irritation or inflammation. In some cases of
chronic back or leg pain caused by spinal stenosis,
degenerative joint disease or disk disease, injecting
corticosteroids into the spine (often along with an
anesthetic) can reduce or eliminate the pain for weeks or
months. Usually, no more than three injections per year
are recommended because of the risk of side effects.
Side effects: Regardless of how you take corticosteroids,
the higher the dose and the longer the therapy, the
greater your risk of side effects, including weight gain,
diabetes, hypertension, facial puffiness, osteoporosis and
infection. If corticosteroids are injected, side effects
include discomfort, infection and thinning or
discoloration of the skin at the injection site, but these
problems are quite rare when injections are not frequent.
Examples: Cyclobenzaprine, methocarbamol and
carisoprodol
Description: Muscle relaxants are particularly good for
treating muscle spasm, which contributes to many cases of
back pain. These drugs may reduce pain by acting directly
on certain chemical messengers in the brain rather than by
directly relaxing muscles.
Side effects: Because muscle relaxants may act on chemical
messengers in the brain, this may explain why they also
cause drowsiness.
Examples: Amitriptyline, nortriptyline, desipramine
and doxepin (tricyclic antidepressants); fluoxetine
(Prozac)
Description: Antidepressants likely act on chemical
messengers in the brain. By doing so, they can dull pain
perception. In some cases, antidepressants work by
treating accompanying depression that is making chronic
pain more difficult to tolerate. These drugs sometimes
work well even in doses too low to treat depression.
Side effects: Side effects include dry mouth, sedation
(drowsiness) and heart rhythm disturbances.
Examples: Carbamazepine, phenytoin and gabapentin
Description: Anticonvulsants (antiseizure medications) may
be particularly helpful for pain caused by neuropathy
(nerve damage). Unlike antidepressant drugs, which affect
certain chemical messengers in the brain, anticonvulsants
also act directly on nerve tissue.
Side effects: Sedation, liver damage and blood cell
changes are the most common side effects that limit the
use of anticonvulsants.
Examples: Codeine, hydrocodone, morphine and
meperidine
Description: Narcotics are often used to treat severe,
unrelenting pain, such as cancer pain. They are the most
powerful pain relievers available and are generally used
when other treatments have failed. Narcotics can be given
by mouth, can be injected or can be administered by a
patch, which delivers the drugs through the skin. In some
cases, patients can wear a small device that feeds a
trickle of narcotics into the spinal fluid through an
implanted tube, or the painkiller can be delivered by a
pump implanted directly into the abdomen. In general,
narcotics are not used alone for chronic pain. They are
often part of an approach that includes nondrug options
(such as counseling and physical therapy), as well as
other nonnarcotic drugs.
Research shows that many people who do not have adequate
pain relief with narcotic analgesics are either receiving
prescriptions that undertreat their pain or are not
following the recommendations for those prescriptions
because they fear side effects. For example, a recent
study from the University of California at San Francisco
interviewed cancer patients in their homes and found that
fear of side effects was a major cause of inadequate drug
use. In addition, fewer than a third of patients had been
prescribed both as-needed and around-the-clock pain drugs
as recommended by current guidelines.
Side effects: Unfortunately, narcotics can cause
constipation, sedation and nausea. In susceptible persons
(especially people with lung disease), these drugs may
dangerously slow breathing. They can also be addictive and
may require steadily increasing doses to remain effective;
in the past, however, the risk of addiction for people
with chronic pain may have been overestimated. Although
side effects and the risk of addiction have caused some
patients and their health-care providers to shy away from
using narcotics, even when they may be the best way to
treat severe pain, this anxiety about narcotics is
gradually changing. More health-care providers are willing
to prescribe these drugs when needed.
Trade name: Ultram
Description: Tramadol is a fairly new nonnarcotic pain
reliever that acts in a similar way on the brain as
narcotics do; it also affects levels of the chemical
messenger serotonin in the brain.
Side effects: Stomach upset, an increased risk of seizures
(in susceptible persons) and harmful interactions with
other drugs are the most common side effects.
Examples: Lidocaine and bupivacaine
Description: Similar to novocaine, anesthetic nerve blocks
may be injected into specific nerve bundles to interrupt
pain signals before they are sent to the brain. The relief
is usually temporary but may provide information that can
lead to better treatment; if the nerve block works, for
example, a second injection in the same area with a
chemical that damages the involved nerve can block the
signals and provide longer relief.
Side effects: Side effects may include nerve damage and
infection.
