Understanding pain and setting goals
Chronic Pain and Physiotherapy
The best type of medication for you will depend on your type of pain:
More than half of those living with chronic pain also experience depression and anxiety. Effectively treating these may reduce the need for pain medication. As well, reducing pain can ease depression and anxiety symptoms.
All medications have benefits and side effects. Your health care provider can help select the most appropriate type of medication. Sometimes opioid medications may be prescribed. These are discussed in the opioids article that follows.
Acetaminophen – (Tylenol™) is usually the first drug recommended to treat chronic pain because of its effectiveness and low risk of side effects. Like most pain medications, acetaminophen works best if taken regularly, not just when pain is really severe. Since the liver removes acetaminophen from the body, regularly exceeding 4000 mg a day can cause liver damage over the long term. Add up the amount of acetaminophen in all of your medications to make sure you are not going over that amount. As your liver also removes alcohol from your body, avoid heavy alcohol consumption (three or more drinks per day) when taking acetaminophen.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are used for mild to moderate pain associated with inflammation. Over-the-counter versions include ibuprofen (Advil®, Motrin®) and naproxen sodium (Aleve®). Diclofenac gel (Voltaren emugel™) is applied to the skin rather than being taken orally.
Some NSAIDs, such as naproxen, celecoxib, meloxicam, and diclofenac, require a prescription. These medications must be supervised by a health care professional, as long-term use can lead to stomach, kidney and heart problems.
Antidepressants are commonly used to treat nerve pain. Some patients describe this type of pain as burning, stabbing or tingling. These medications are also used to treat depression, which can be common in people with chronic pain.
Nerves talk to each other in the body through chemical messengers called neurotransmitters. Serotonin and norepinephrine are two types of neurotransmitters. Anti-depressants increase the number of these transmitters between the nerves, smoothing and improving communication between them. As this medication affects the nerves and neurotransmitters, you may need to take it for several weeks or longer before seeing results.
Tricyclic Antidepressants (TCAs) are named after the three cyclical rings in the drug's chemical structure. TCAs treat clinical depression, anxiety disorders, insomnia, migraine headaches and chronic pain syndromes.
You must start off slowly when using TCAs. With proper monitoring and dosing adjustments, they can be very effective. Generic versions include amitriptyline, nortriptyline, imipramine, desipramine and doxepin. If you experience side effects, your health care provider may be able to suggest solutions. For instance, artificial saliva such as Oralbalance® gel can improve a dry mouth.
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) This type of antidepressant increases both serotonin and norepinephrine, and is effective in pain management. These medications include duloxetine (Cymbalta®), venlafaxine (Effexor®) and mirtazepine (Remeron®). Most people tolerate SNRIs well. Side effects can include dry mouth, nausea, loss of appetite, dizziness and nervousness.
Selective Serotonin Reuptake Inhibitors (SSRIs) This type of antidepressant, which includes Celexa®, Cipralex®, Luvox®, Paxil® and Zoloft®, can help treat depression which will improve pain control and are usually well tolerated.
Anticonvulsant or Antiepileptic Drugs (ACDs or AEDs) are used to treat neuropathic pain. They appear to work by stabilizing overactive and sensitive nerves. The most commonly used medication in this group is gabapentin. Pregabalin (Lyrica©), carbamazepine (Tegretol®), phenytoin, valproic acid, lamotrigine, topiramate, or zonisamide are also used on occasion.
Topical lidocaine may help with postherpetic neuralgia. It works by numbing the nerves so they can't transmit pain messages.
Over-the-counter ointments, many containing menthol, can ease muscle pain. NSAIDS, tricyclic antidepressants or anticonvulsants may be compounded in an ointment or gel form for people who have difficulty with an oral medication.
Corticosteroids may be used for pain associated with heavy inflammation. However, if possible they are usually only prescribed for a short period of time.
Muscle relaxants can also provide short-term pain relief, but longer use is not recommended. These medications work by making the brain drowsy and the resulting side effects are not well tolerated.
Finding the right medication can be tricky. Everyone's pain is different, and so is the body's response to pain medications. You may need to try a few different medications before finding one that works. While the process may be frustrating, keep in mind that it may take a while for a medication to take effect. Don't get discouraged or give up! Remember, too, that other pain management strategies are just as important as those involving medication. The best way to relieve chronic pain is to follow the management plan your health care advisors have designed for you.