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.1, 2 

Most people with chronic pain do not seek healthcare for it on a regular basis.3 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.4 The quality of this research is good.5 

Muscle relaxant medications

In their review of the research, Chou and Huffman5 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.6, 7 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.8, 9

While noting the effectiveness of anticonvulsant medications for nerve pain, Chou and Huffman5 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.10 In their review of this research, Kroenke, Krebs, and Bair11 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.,12 found that opioid medications are no better than placebo when it comes to reducing pain.

Ballantyne and Shin13 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.14 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.

References

1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

 

Date of publication: May 20, 2012

Date of last modification: October 25, 2015

Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Its mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides Academic quality information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

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