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Treating Pain With Medications

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:

Acetaminophen Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Capsaicin Corticosteroids Muscle Relaxants Antidepressants
Anticonvulsants Narcotics (Opioids) Tramadol Anesthetic Nerve
Blocks

Acetaminophen

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.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

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.

Capsaicin

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.

Corticosteroids

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.

Muscle Relaxants

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.

Antidepressants

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.

Anticonvulsants

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.

Narcotics (Opioids)

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 ****gesics 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.

Tramadol

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.

Anesthetic Nerve Blocks

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.

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