When treating pain with medications there are three general categories of drug treatments:
Neuropathic Medications
Neuropathic pain is associated with injury to the nerve. Often this type of pain is associated with symptoms of burning or increased sensitivity over the painful area. Neuropathic pain is best treated by either antidepressants (e.g. Elavil, Paxil, Zoloft) or by antiepileptics (e.g. Dilantin, Tegretol). The antidepressant medications also have beneficial effects of improved mood, decreased anxiety, and improved sleep cycle. These medications are not addictive, and when appropriately managed have few side effects.
Psychiatric Medications
The most success has been achieved with antidepressant medications. As stated above, these medications can not only help with the pain symptoms, but also with many of the other depressive symptoms that are seen in patients with chronic pain.
Pain Medications
Pain medications are separated into several categories:
- Acetaminophen (Tylenol)
Tylenol is used to treat pain, but it does not have the anti-inflammatory effects of the NSAIDs listed below. Often, however, in cases of chronic pain there is no inflammation at the site of the pain, and thus Tylenol may be an appropriate treatment choice. Tylenol is a safe medication when used appropriately, but can be very dangerous when used inappropriately. The risk of liver or kidney damage is significant when more than the recommended dose of Tylenol is used. - NSAIDs
These are the nonsteroidal anti-inflammatory drugs (NSAIDs). The NSAIDs (e.g. Motrin, Aleve, etc.) are most beneficial in cases of acute pain, or flare-ups in patients with chronic pain. In general these should not be used on a daily basis for the treatment of chronic pain. When used on a daily basis for a period of several years, there is a risk of damage to the kidneys that can be significant. Furthermore, there are well known risk of ulcer formation with NSAIDs. While the newer, so-called COX-2 inhibitors (Celebrex, Vioxx), were designed to avoid this complication, caution should still be used if there is a risk of ulcers or GI bleeding. - Narcotics
When treating chronic pain, narcotic opioids should be considered if pain cannot be otherwise controlled. Although these medications can be dangerous and addicting, they can also be extremely effective when used appropriately. One common mistake when treating chronic pain with opioid medications is using the short acting types of medication (e.g. Percocet, Morphine, Vicoden, etc.). While these medications are useful for acute pain, they are also associated with sedating and euphoric side-effects. The short acting nature of these medications encourages overuse and the development of tolerance.Long-acting opioids (Methadone, Oxycodone, Fentanyl) have fewer cognitive side-effects, and better control of chronic pain. Although no adequate long-term studies have shown their effectiveness in the treatment of chronic nonmalignant pain, and they are not approved for this use, they are often used for this type of pain management. Side effects may include GI upset, nausea, constipation, and addiction. Studies show about 5-15% of chronic pain patients using narcotic pain medications develop dependence. (2) However, true addiction, where there is psychological dependence on narcotics, is thought to be quite rare.
This is simply an introduction to chronic nonmalignant pain management. One of the most useful ways to conquer pain is to understand it, and hopefully this will merely be the first of many resources you turn to. Furthermore, there are many treatment modalities for pain treatment not specifically addressed here which may be helpful.
1. Katz, WA "The Needs of a Patient in Pain" Amer. J. Med. 1998. 105(1B) Pages 2S-7S.
2. Marcus, DA "Treatment of Nonmalignant Chronic Pain" Amer. Family Physician. 2000. 61(5) Pages 1331-8.
