Medication therapy for managing chronic pain: The good, the bad, and the ugly
By Dr. Michael H. Lowenstein, MD
One in four Americans, an estimated 76.2 million people, suffer from chronic pain. Not only is chronic pain a leading cause of disability and loss of productivity, but it presents enormous challenges for people to cope with on a daily basis.
Consider here the pros and cons of the following medications for managing pain, and talk to your doctor about the medication that is best for you. If you would like to leave us a question or comment, we invite your feedback at the end!
Acetaminophen is the active ingredient in many over-the-counter painkillers, including Tylenol. Acetaminophen is particularly helpful for backaches, headaches, muscular aches, and arthritis. Unlike some other pain relievers, acetaminophen can be used by people with a history of stomach problems, kidney disease, high blood pressure, and heart problems.
Acetaminophen is usually well tolerated when you take the recommended dosage. Some people experience nausea, vomiting, or constipation when taking the drug. One of the biggest dangers of acetaminophen is the potential to overdose. Taking too much acetaminophen may cause vomiting, diarrhea, increased sweating, and stomach cramps. Acetaminophen overdose can seriously harm your liver functioning, making it important to follow the recommended dosage when taking this medication.
Nonsteroidal Anti-inflammatory Medications (NSAIDs)
Non-steroidal anti-inflammatory medications, or NSAIDs, include:
- ibuprofen (e.g., Advil)
- naproxen (e.g., Aleve)
This class of medications is commonly used for pain relief for arthritis and other conditions that cause chronic pain. In addition to blocking pain pathways, NSAIDs can lower fevers, prevent blood clotting, and reduce inflammation. This is particularly beneficial for people for whom chronic inflammation contributes to pain.
NSAIDs block the activity of an enzyme that protects the lining of the stomach. As a result, they can increase your risk of nausea, upset stomach, and stomach ulcers.
Although antidepressants were discovered for their ability to improve mood, they also can be used to treat chronic pain. Tricyclic antidepressants are most commonly prescribed, such as:
These antidepressants can be helpful for people suffering from arthritis, fibromyalgia, nerve damage or nerve pain, low back pain, migraines, and pelvic pain. Although the exact chemical mechanisms are unknown, antidepressants appear to increase the level of certain neurotransmitters in the nervous system.
Tricyclic antidepressants are not without side effects. Common side effects include dry mouth, drowsiness, blurred vision, nausea, lightheadedness, weight gain, and confusion.
Anticonvulsants are sometimes prescribed “off label” for chronic pain. These medications can be effective for neuropathic pain, such as pain due to diabetes, nerve fiber damage, or central nervous system problems.
Side effects of anticonvulsants include drowsiness, swelling of the lower extremities, and weight gain. Patients should avoid abruptly stopping use of anticonvulsants and only discontinue the medications under the advisement of a physician.
Back pain is one of the most common forms of chronic pain. Spasms in the muscles of the back are strong contributors to back pain. Medications such as muscle relaxants can prevent these spasms and force muscles to relax, improving pain symptoms. This also translates to better mobility in the affected area.
Muscle relaxants can be habit-forming, meaning that they are most appropriate for short-term or occasional use. People taking antihistamines or drinking alcohol should avoid use of muscle relaxants. It is also important to avoid driving or operating heavy machinery after taking a muscle relaxant.
Over the past few decades, physicians have become more likely to prescribe opioid medications for chronic pain relief. Opioids cross into the brain, stimulating receptors that decrease pain and cause feelings of euphoria.
In the short term, such as after surgery, opioids can be an effective pain management strategy.
Opioids also carry a significant side effect profile. The most common side effects include nausea, slowed breathing, drowsiness, lethargy, and paranoia. At higher doses, opioids can slow the central nervous system (i.e., heart and respiratory activity) to levels that can be deadly.
As a result, it is essential to be cautious when taking opioid medications and to take them only as prescribed.
The Ugly Side of Opioids
In addition to their side effects, opioids have an ugly side when used for long-term management of chronic pain. Chronic opioid use leads to physical dependence, in which the body becomes dependent on the presence of opioids for normal functioning.
There are two major signs of opioid dependence. First, the body develops a tolerance for the drug, meaning that it takes a higher dose to achieve the same effect as before. Second, people may develop withdrawal symptoms when the drug is no longer taken (such as a missed dose or trying to go “cold turkey”).
These withdrawal symptoms are the body’s response to the absence of the drug, indicating that it has become accustomed to the presence of opioids to maintain normal functioning.
Talk with your Physician about the pros and cons
With more than 70 million sufferers nationwide, chronic pain is not going to go away on its own. There are various medications that may help and at the same time, may have drawbacks. Also, the approach of prescribing opioid painkillers for chronic pain is not without the risk of dependence, given the exploding opioid epidemic in this country.
With that said, this does not mean that people with chronic pain need to continue to suffer. Talk to your physician about the pros and the cons of the medication options for pain management. Find out what might be the best medications for you.
Further, non-pharmaceutical approaches such as physical therapy, massage, biofeedback, acupuncture, and cognitive therapy can also be beneficial to manage pain, in lieu of or in conjunction with medication therapy. Such therapies may help minimize the cons of medication therapy and also the risk of opiate dependence.