Pain Management Medication|Chronic Pain Management Medications

Chronic Pain Medications

Studies differ on the prevalence of chronic pain, but a safe estimate would be between 15-25% of the general population has chronic pain. Gureje, O, Simon, G. E., & Von Korff, M. (2001). A cross-national study of the course of persistent pain in primary care. Pain, 92, 195-200. Toblin, R. L., Mack, K. A., Perveen, G., & Paulozzi, L. J. (2011). A population-based survey of chronic pain and its treatment with prescription drugs. Pain, 152, 1249-1255.


Most people with chronic pain do not seek healthcare for it on a regular basis. Cote, P., Cassidy, J. D., & Carroll, L. (2001). The treatment of neck and low back pain: Who seeks care?  Who goes where? Medical Care, 39, 956-967. Presumably, they are neither distressed nor impaired enough to seek care. However, some people do suffer from chronic pain and consequently seek recommendations from healthcare providers. 


Patients often tend to look to their healthcare providers to prescribe a medication to help reduce pain. There are many common medications for chronic pain:

  • Anti-inflammatory medications & acetaminophen

  • Muscle relaxant medications

  • Antidepressant medications (used for pain)

  • Anticonvulsant medications (used for pain)

  • Opioid, or narcotic, medications

It is important to know something of their use and relative effectiveness.


Anti-inflammatory medications & acetaminophen

Anti-inflammatory medications and acetaminophen are commonly used for pain. On average, these medications have been shown to be mildly to moderately effective in reducing chronic pain. Koes, B. W., Scholten, R. J., Mens, J. M., & Bouter, L. M. (1997). Efficacy of non-steroidal anti-inflammatory drugs for low back pain: A systematic review of randomized clinical trials. Annals of the Rheumatic Diseases, 56, 214-223 The quality of this research is good. Chou, R., & Huffman, L. H. (2007). Medications for acute and chronic low back pain: A review of the evidence for an  American Pain Society/American College of Physicians clinical practice guideline. Annals of Internal Medicine, 147, 505-514.


Muscle relaxant medications

In their review of the research, Chou and Huffman 5 found that muscle relaxants, on average, were moderately helpful in reducing acute back pain. Studies testing the effectiveness of muscle relaxants for chronic pain are lacking.


Antidepressant medications

As the name suggests, antidepressant medications were originally developed for use with depression. However, they have long been known to reduce chronic pain and are commonly used for such purposes.


In meta-analyses, antidepressant medications are moderately helpful in reducing chronic pain, but do not tend to improve daily functioning. Onghana, P. & Van Houdenhove, B. (1992). Anti-depressant-induced analgesia in chronic non-malignant pain: A meta-analysis of 39 placebo-controlled studies. Pain, 49, 205-219. Salerno, S. M., Browning R., & Jackson, J. L. (2002). The effect of antidepressant treatment on chronic back pain: A meta-analysis. Archives of Internal Medicine, 162, 19-24. Tricyclic antidepressants, in particular, have the best quality of research evidence supporting their effectiveness. 


Anticonvulsant medications

Anticonvulsant medications are medications that were originally developed for the management of seizures. However, they have also been shown to be helpful in managing nerve pain. 


Tricyclic antidepressants and anticonvulsants are largely equally effective in reducing nerve pain. Chou, R., Carson, S., & Chan, B. K. (2009). Gabapentin versus tricyclic antidepressants for diabetic neuropathy and post-herpetic neuralgia: Discrepancies between direct and indirect meta-analyses of randomized controlled trials. Journal of General Internal Medicine, 24, 178-188. Collins, S. L., Moore, R. A., McQuay, H. J., & Wiffen, P. (2000). Antidepressants and anticonvulsants for diabetic neuropathy and post-herpetic neuralgia: A quantitative systematic review. Journal of Pain and Symptom Management, 20, 449-458.


While noting the effectiveness of anticonvulsant medications for nerve pain, Chou and Huffman 5 report that they found only one study of the effectiveness of anticonvulsant medications for chronic back pain. The study showed that topiramate is modestly better than placebo. 


Opioid, or narcotic, medications

Opioid, or narcotic, pain medications are commonly used for chronic pain. Despite their common use, there is little research on the long-term effectiveness of opioids for chronic pain. Chou, R., Ballantyne, J. C., Fanciullo, G. J., Fine, P. G., & Miaskowski, C. (2009). Research gaps on use of opioids for chronic noncancer pain: Findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. Journal of Pain, 10, 147-159. In their review of this research, Kroenke, Krebs, and Bair Kroenke, K., Krebs, E. E., & Bair, M. J. (2009). Pharmacotherapy of chronic pain: A synthesis of recommendations from systematic reviews. General Hospital Psychiatry, 31, 206-219. found that, when used on a short-term basis, opioid medications are modestly better at reducing pain than a placebo. However, they also found that opioids were no better than non-narcotic pain medications at reducing pain. Moreover, they found that opioid medications were slightly less effective than non-narcotic pain medications on functional outcomes. 


In their meta-analysis of the research, Martell, et al., Martell, B. A., O’Connor, P. G., Kerns, R. D., Becker, W. C., Morales, K. H., Kosten, T. R., Fiellin.  D. A. (2007). Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Annals of Internal Medicine, 146, 116-127. found that opioid medications are no better than placebo when it comes to reducing pain. 


Ballantyne and Shin Ballantyne, J. C. & Shin, N. S. (2008). Efficacy of opioids for chronic pain: A review of the evidence. Clinical Journal of Pain, 24, 469-478. reviewed evidence showing that opioids lose their effectiveness over time because of tolerance. Tolerance is the phenomenon that occurs when the body gets adjusted to the use of a medication over time and, as such, the medication loses its effectiveness. Tolerance occurs with opioid medications. As a result, patients commonly need periodic increases in their dose of opioids in order to get the same level of pain relief.

Tolerance is a significant problem. Assuming a normal lifespan, most patients eventually get tolerant to even the highest doses of opioids long before they get elderly. As such, they essentially buy pain relief today at the cost of having the medications become no longer effective for them in the future, should they have an altogether different injury or require a surgery.


Addiction, of course, is also a significant problem. The pain management field defines addiction as a loss of control over the use of opioid medications or continued use of the medications despite harm. American Academy of Pain Medicine and the American Pain Society. (1997). The use of opioids for the treatment of chronic pain: A consensus statement. The Clinical Journal of Pain, 13, 6-8. In their meta-analysis cited above, Martell, et al., 12 found that upwards of 20% of patients on opioid pain medications demonstrate problematic behaviors that are suggestive of addiction.


Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain. The Institute for Chronic Pain is an educational and public policy think tank. Its purpose is to bring together thought leaders from around the world in the field of chronic pain rehabilitation and provide academic-quality information that is also approachable to all the stakeholders in the field: patients, their families, generalist healthcare providers, third party payers, and public policy analysts. Its aim is to change the culture of how chronic pain is managed through education and consultation efforts that advocate for the use of empirically supported conceptualizations and treatments of chronic pain. He also blogs at the Institute for Chronic Pain Blog.


Last Updated on Sunday, 25 October 2015 23:57

Published on Sunday, 20 May 2012 23:45

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