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In some cases, treating the underlying disorder eliminates or minimizes the pain. For example, setting a broken bone in a cast or giving antibiotics for an infected joint helps reduce pain. However, even if the underlying disorder can be treated, pain relievers (analgesics) may still be needed to quickly manage the pain. Doctors choose an analgesic based on the type and duration of pain and on the likely benefits and risks. Most analgesics are effective for nociceptive pain (due to ordinary injury of tissues) but are less effective for neuropathic pain (due to damage or dysfunction of the nerves, spinal cord, or brain), which often requires different drugs. For some types of pain, especially chronic pain, nondrug treatments are also important.
Analgesics fall into three categories: opioid (narcotic) analgesics, nonopioid analgesics, and adjuvant analgesics (drugs that are usually given for reasons other than pain but that sometimes relieve pain).
Opioid
Analgesics
Opioid analgesics (sometimes called narcotics) are the most powerful analgesics. They are the mainstay for treatment of severe acute pain (as occurs after surgery or from burns or broken bones) and chronic pain due to cancer and other serious disorders. Opioids are preferred because they are so effective in controlling pain. Using opioids to treat chronic pain not due to cancer is becoming more acceptable but is still relatively uncommon. Opioids are not appropriate for everyone.
Opioids are chemically related to morphine , a natural substance extracted from poppies, although some opioids are extracted from other plants and other opioids are produced in a laboratory.
The dose of an opioid is increased gradually, in stages, until the pain is relieved or the opioid's side effects cannot be tolerated. Older people and newborns, who are more sensitive to the effects of opioids, are usually given lower doses. Nonopioid analgesics, such as acetaminophen , are often used with opioids, sometimes in tablets that contain both drugs.
Opioids are most effective when taken every few hours, before pain becomes severe. If more pain relief is required, the dose may be increased or another drug (such as a nonsteroidal anti-inflammatory drug) may be added, as in the following situations:
As the pain lessens, doctors reduce the dose of the opioid accordingly, and when possible, they stop the opioid and switch to a nonopioid analgesic.
Side Effects:
Opioids have many side effects. Side effects are more likely to occur in people with certain disorders: kidney failure, a liver disorder, chronic obstructive pulmonary disease (COPD), dementia, or another brain disorder.
Drowsiness, constipation, nausea, vomiting, and itching are common when opioids are started.
Some people welcome the drowsiness provided by opioids, but others do not. For most people who take opioids, drowsiness disappears or decreases within a few days. If people continue to feel drowsy, they may be given stimulant drugs, such as methylphenidate , to keep them awake and alert. These drugs may be taken regularly or only before events that require alertness, such as a family gathering. For some people, drinking beverages that contain caffeine provides enough stimulation. When feeling drowsy after taking an opioid, people should avoid driving and take extra care to prevent falls and accidents. Opioids may also cause confusion, especially in older people.
Opioids often cause constipation, especially in older people. Stimulant laxatives (see Symptoms and Diagnosis of Digestive Disorders: Laxatives), such as senna , help prevent or relieve the constipation. Increasing the intake of fluids and the amount of fiber in the diet can also help. Some people need enemas.
Opioids can cause retention of urine, especially in men with benign prostatic hyperplasia. Trying to urinate a second time after a brief pause (double voiding) or applying gentle pressure on the lowest part of the abdomen (the area over the bladder) during urination may help. Sometimes a drug that relaxes muscles of the bladder (such as tamsulosin ) is used.
Sometimes people with pain feel nauseated, and opioids can increase the nausea. Antiemetic drugs taken by mouth, suppository, or injection help prevent or relieve nausea. Some commonly used antiemetic drugs are metoclopramide , hydroxyzine , and prochlorperazine.
For most people, nausea and itching disappear or decrease within a few days. But constipation and retention of urine usually decrease much more slowly.
Taking too much of an opioid can have serious side effects, including a dangerous slowing of breathing and even coma. These effects can be reversed with naloxone, an antidote given intravenously. Nurses and family members should watch for side effects of opioids.
For most people, the same opioid dose remains effective for a long time. However, some people who take opioids repeatedly over time need higher doses because the body adapts to and thus responds less well to the drug. This phenomenon is called tolerance. Usually, the need for a higher dose means that the disorder is worsening, not that tolerance is developing.
People who take opioids for a long time usually become physically dependent on them. That is, they experience withdrawal symptoms if the drug is stopped. When opioids are stopped after long-term use, doctors reduce the dose gradually over a period of time to minimize the development of such symptoms. Physical dependence is not the same as addiction, which is characterized by a craving for the drug and compulsive, uncontrolled use of the drug despite the harm done to the user or other people. Although addiction is possible, it appears to be rare among people who take opioids to control pain and have not previously had problems with drug abuse. Too often, exaggerated concern about the addiction potential of opioids (see Drug Use and Abuse: Opioids) leads to undertreatment of pain and needless suffering. People with severe pain should not avoid opioids, and adequate doses should be taken as needed. Doctors carefully weigh the benefits and side effects when they consider opioids for the treatment of chronic pain.
Administration:
When possible, opioids are taken by mouth. When they need to be taken for a long time, they may be given through a patch placed on the skin. Opioids are given by injection when pain occurs suddenly or when people cannot take them by mouth or through a skin patch. If people are helped by an opioid but cannot tolerate its side effects, an opioid can be injected directly into the space around the spinal cord through a pump. This method gets high concentrations of the drug to the brain. For long-term pain relief, a device that slowly releases an opioid can be implanted in the space around the spinal cord.
Morphine , the prototype of these drugs, can be taken by mouth (orally) or by injection. There are three oral forms: immediate-release, controlled-release, and sustained-release. Different controlled- and sustained-release forms provide relief for 8 to 24 hours. These drugs are widely used to treat chronic pain. The immediate-release form provides short-lived relief, usually for less than 3 hours. In injected forms, 2 to 6 times less morphine is required than in oral forms because when morphine is taken by mouth, much of the drug is chemically altered (metabolized) by the liver before it reaches the bloodstream. Usually, the route used does not change the drug's effects, even though different routes use different amounts of morphine . Pain relief with injected forms is quicker than that with oral forms, but relief does not last as long.
Morphine may be injected into a vein (intravenously), into a muscle (intramuscularly), or under the skin (subcutaneously).
Injections can be given every few hours, but repeated injections can become annoying. Alternatively, a catheter can be inserted in a vein or under the skin and connected to a continuous-infusion pump, which supplies morphine continuously. The continuous infusion can be supplemented with extra doses when needed. Sometimes a device that enables a person to release the drug by pressing a button is used. This technique is called patient-controlled analgesia. Usually, continuous infusion is used for people who have severe pain due to a serious disorder.
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Drug
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Length of Effectiveness
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Comments
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Morphine
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By intravenous or intramuscular injection: 2 to 3 hours
Immediate-release by mouth: 3 to 4 hours
Controlled- and sustained-release by mouth: 8 to 24 hours
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Morphine starts to work quickly. The oral form can be very effective for chronic pain. It is more likely to cause itching than other opioids.
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Codeine
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By mouth: 3 to 4 hours
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Codeine is less potent than morphine . It is usually taken with aspirin or acetaminophen .
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Fentanyl
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By mouth: 3 to 4 hours
By patch: up to 72 hours
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Fentanyl lozenges and dissolvable tablets can be used to treat breakthrough pain. Fentanyl lozenges can also be used to relieve pain and provide sedation (before painful procedures) in children. A fentanyl patch is often used to treat chronic pain.
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Hydrocodone
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By mouth: 3 to 5 hours
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Hydrocodone is similar to codeine in effectiveness.
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Hydromorphone
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By intravenous or intramuscular injection: 2 to 4 hours
By mouth: 2 to 4 hours
By rectal suppository: 4 hours
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Hydromorphone begins to work quickly. It can be used instead of morphine and is useful for chronic pain.
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Levorphanol
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By intravenous or intramuscular injection: 4 hours
By mouth: about 4 hours
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The oral form is strong. It can be used instead of morphine .
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Meperidine
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By intravenous or intramuscular injection: about 3 hours
By mouth: not very effective
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Although meperidine can be effective for short-term use, it is not preferred for long-term use because it has side effects, such as muscle spasms, tremors, seizures, and confusion or psychosis (especially in older people).
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Methadone
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By mouth: 4 to 6 hours, sometimes much longer
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Methadone is used for treating addiction to heroin and other opioids. It can also be used to treat chronic pain.
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Oxycodone
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By mouth: 3 to 4 hours
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Oxycodone can be used instead of morphine to treat chronic pain. A long-acting, controlled-release formulation is available, lasting about 8 to 12 hours. The short-acting formulation is usually combined with aspirin or acetaminophen .
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Oxymorphone
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By intravenous or intramuscular injection: 3 to 4 hours
By rectal suppository: 4 hours
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Oxymorphone can be used instead of morphine to treat chronic pain. Like oxycodone , it is available in a long-acting, controlled-release formulation, lasting about 12 hours.
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Pentazocine
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By mouth: up to 4 hours
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Pentazocine can block the pain-relieving action of other opioids. It is about as strong as codeine. The usefulness of pentazocine is limited because higher doses do not provide more pain relief and because the drug can cause confusion and anxiety, especially in older people. It is not a good choice for older people.
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Propoxyphene
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By mouth: 3 to 4 hours
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At safe doses, propoxyphene provides little or no more pain relief than aspirin . At high doses, it is likely to have side effects. Thus, it is not often used.
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Nonopioid
Analgesics
A variety of nonopioid analgesics are available. They are often effective for mild to moderate pain. People do not become physically dependent on these drugs or tolerant of their pain-relieving effects. Aspirin and acetaminophen are available without a prescription (over-the-counter, or OTC). Several other nonopioid analgesics (such as ibuprofen , ketoprofen, and naproxen ) are available OTC and by prescription, usually in higher-dose formulations, with more active ingredient per dose than OTC formulations (see Over-the-Counter Drugs). OTC analgesics are reasonably safe to take for short periods of time, but their labels caution against taking them for more than 7 to 10 days to treat pain. A doctor should be consulted if symptoms worsen or do not go away.
Nonsteroidal
Anti-Inflammatory Drugs
Most nonopioid analgesics are classified as nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are used to treat mild to moderate pain and may be combined with opioids to treat moderate to severe pain. NSAIDs not only relieve pain, but they also reduce the inflammation that often accompanies and worsens pain. All NSAIDs are taken by mouth. One NSAID, ketorolac , can also be given by injection into a vein (intravenously) or muscle (intramuscularly). Indomethacin can be given by suppository.
Although widely used, NSAIDs can have side effects, sometimes serious ones.
Taking NSAIDs for a short time is unlikely to cause serious problems. If NSAIDs are taken a long time, certain tests are done regularly. They include blood pressure measurement, blood tests (such as a complete blood count and tests to check kidney and liver function), and tests for blood in stools.
For older people, the risk of side effects due to NSAIDs, particularly indomethacin and ketorolac , is increased. For people who drink alcoholic beverages regularly and take NSAIDs, the risk of digestive upset, ulcers, and liver damage may be increased. The risk of heart attacks and stroke may be higher for people with coronary artery disease, other heart and blood vessel (cardiovascular) disorders, or risk factors for these disorders. Older people and people who have heart failure, high blood pressure, or a kidney or liver disorder require a doctor's supervision when they take NSAIDs. Some prescription heart and blood pressure drugs may not work as well when taken with these analgesics.
NSAIDs vary in how quickly they work and how long they relieve pain. Although NSAIDs are about equally effective, people respond to them differently. One person may find a particular drug to be more effective or to have fewer side effects than another.
Aspirin:
Aspirin ( acetylsalicylic acid ) has been used for about 100 years. Aspirin is taken by mouth and provides 4 to 6 hours of moderate pain relief.
Because aspirin can irritate the stomach, it may be combined with an antacid (in a buffered product) to reduce this effect. The antacid creates an alkaline environment that helps aspirin dissolve and may reduce the time aspirin is in contact with the stomach lining. However, buffered aspirin can still irritate the stomach because aspirin also reduces the production of substances that help protect the stomach's lining. These substances are a type of prostaglandin, which are similar to hormones.
Enteric-coated aspirin is designed to pass through the stomach intact and dissolve in the small intestine, thus minimizing direct irritation of the stomach. (Enteric refers to the small intestine.) However, enteric-coated aspirin may be absorbed erratically. If food and enteric-coated aspirin are ingested at about the same time, the aspirin is not absorbed as quickly because food delays the emptying of the stomach. Consequently, pain relief is delayed.
Aspirin increases the risk of bleeding throughout the body because it makes the particles that help blood clot (platelets) less likely to do so. People who bruise easily may be especially vulnerable to this effect. Anyone who has ever had a bleeding disorder or uncontrolled high blood pressure should not take aspirin except under a doctor's supervision. People who take aspirin and anticoagulants (such as warfarin ) are closely monitored to avoid life-threatening bleeding. Usually, aspirin should not be taken in the week before scheduled surgery.
Aspirin can aggravate asthma. People with nasal polyps are likely to develop wheezing if they take aspirin . A few people, who are sensitive (allergic) to aspirin , may have a severe allergic reaction (anaphylaxis), leading to a rash, itching, severe breathing problems, or shock (see Shock). Such a reaction requires immediate medical attention.
In very high doses, aspirin can have serious side effects such as abnormal breathing, fever, or confusion. One of the first signs of an overdose may be noise in the ears (tinnitus).
Most children and teenagers should not take aspirin because they could develop Reye's syndrome if they have or have just gotten over influenza or chickenpox. Although rare, Reye's syndrome can have serious consequences, including death.
Ibuprofen, Ketoprofen,
and Naproxen
NSAIDs such as ibuprofen , ketoprofen, and naproxen are generally believed to be gentler on the stomach than aspirin , although few studies have compared the drugs. Like aspirin , these drugs can cause digestive upset, ulcers, and gastrointestinal bleeding. They can make asthma worse and increase blood pressure. Taking one of these drugs probably slightly increases the risk of stroke, heart attack, and blood clots in the arteries of the legs.
Although ibuprofen , ketoprofen, and naproxen generally interfere with blood clotting less than aspirin does, people should not take these drugs with anticoagulants (such as warfarin ) except under a doctor's close supervision.
People who are allergic to aspirin may also be allergic to ibuprofen , ketoprofen, and naproxen . If a rash, itching, breathing problems, or shock develops, medical attention is required immediately.
Coxibs (COX-2 Inhibitors):
Coxibs, such as celecoxib , differ from other NSAIDs. Other NSAIDs block two enzymes:
Coxibs tend to block mainly COX-2 enzymes. Thus, coxibs are as effective as other NSAIDs in the treatment of pain and inflammation. But coxibs are less likely to damage the stomach and to cause nausea, bloating, heartburn, bleeding, and peptic ulcers. They are also less likely to interfere with clotting than are other NSAIDs.
Because of these differences, coxibs may be useful for people who cannot tolerate other NSAIDs and for people who are at high risk of certain complications (such as gastrointestinal bleeding) from use of other NSAIDs. Such people include older people, people who are taking anticoagulants, those who have a history of ulcers, and those who must take an analgesic for a long time. However, blockage of COX-2 enzymes appears to make blood clots more likely to form. Thus, taking coxibs, like taking other NSAIDs, is likely to increase the risk of heart attack, stroke, and blood clots in the legs. How much the risk is increased depends on the drug used. The risk is higher when higher doses are taken and when the drug is taken for a longer time. Thus, before people who have a cardiovascular disorder (such as coronary artery disease), who have had stroke, or who have risk factors for these disorders are given a coxib, they are told about the risk and the need to be closely monitored. Coxibs are not appropriate for people who have heart failure or who are at increased risk of heart failure (such as those who have had a heart attack).
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Acetaminophen
Acetaminophen is roughly comparable to aspirin in its potential to relieve pain and lower a fever. But unlike NSAIDs, acetaminophen has virtually no useful anti-inflammatory activity, does not affect the blood's ability to clot, and has almost no adverse effects on the stomach. How acetaminophen works is not clearly understood.
Acetaminophen is taken by mouth or suppository, and its effects generally last 4 to 6 hours. Acetaminophen appears to be a very safe drug. However, high doses can lead to liver damage, which may be irreversible. People with a liver disorder should use lower doses than those usually prescribed. Whether lower doses taken for a long time can harm the liver is less certain. People who regularly consume large amounts of alcohol are probably at highest risk of liver damage from overuse of acetaminophen . People who are taking acetaminophen and stop eating because of a bad cold, influenza, or another reason may be more vulnerable to liver damage. Taking high doses for a long time may lead to kidney damage.
Adjuvant
Analgesics
Adjuvant analgesics
are drugs that are not usually used for pain relief but may relieve pain
in certain circumstances. When used to relieve pain, they are usually
used with other analgesics or nondrug pain treatments.
The adjuvant analgesics most commonly used for pain are antidepressants (such as amitriptyline, bupropion , desipramine , fluoxetine , and venlafaxine —see Mood Disorders: Drugs Used to Treat Depression ), anticonvulsants (such as gabapentin and pregabalin —see Seizure Disorders: Drugs Used to Treat Seizures), and oral and topical local anesthetics.
Antidepressants:
These drugs can potentially relieve pain in people who do not have depression. Tricyclic antidepressants may be more effective for this purpose than other antidepressants, but newer antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and selective serotonin and norepinephrine reuptake inhibitors (SSNRIs, such as duloxetine ) are tolerated better. People may respond to one antidepressant and not others.
Anticonvulsants:
These drugs may be used to relieve neuropathic pain. Gabapentin is used most often, but many others, including carbamazepine , clonazepam , divalproex , lamotrigine , oxcarbazepine , phenytoin , pregabalin , and topiramate , may be tried. Pregabalin can be used to relieve pain caused by nerve damage due to diabetes (diabetic neuropathy) or a complication of shingles (postherpetic neuralgia). Anticonvulsants, such as divalproex , can prevent migraine headaches.
Anesthetics:
Mexiletine, used to treat abnormal heart rhythms, is sometimes used to treat neuropathic pain. It is similar to local anesthetics that are placed directly on or near a sore area to help reduce pain. Doctors may inject a local anesthetic, such as lidocaine , into the skin to control pain due to an injury or even due to neuropathic pain. Local anesthetics can also be injected in nerves to block pain—a procedure called a nerve block. For example, a sympathetic nerve block involves injecting a local anesthetic into a group of nerves near the spine—in the neck for pain in the upper body or in the lower back for pain in the lower body.
Topical anesthetics, such as lidocaine applied as a lotion, ointment, or skin patch, can be used to control pain due to some conditions. These anesthetics are usually used for a short period of time. For example, gargling small amounts of an anesthetic mouthwash, limited to a few times a day, can relieve a sore throat. However, some people with chronic pain benefit from using topical anesthetics for a long time. For example, a lidocaine patch can relieve postherpetic neuralgia.
A cream containing capsaicin , a substance found in hot peppers, sometimes helps reduce the pain caused by such disorders as herpes zoster and osteoarthritis. It is most often used by people with localized pain due to arthritis. This cream must be applied several times a day.
Nondrug
Pain Treatments
In addition to drugs, many other treatments can help relieve pain. Applying cold or warm compresses directly to a painful area often helps (see Rehabilitation: Treatment of Pain and Inflammation). Ultrasonography that provides deep heat (diathermy) may relieve the pain of osteoarthritis and muscle strain.
Some people benefit from transcutaneous electrical nerve stimulation (TENS). A gentle electric current is applied through electrodes placed on the skin's surface. TENS produces a tingling sensation without increasing muscle tension. It can be applied continuously or several times a day for 20 minutes to several hours. The timing and length of stimulation vary because each person responds differently. Often, people are taught to use the TENS device, so that they can use it as needed. TENS may be useful for chronic pain. If pain is particularly severe and other treatments are ineffective, electrodes may be implanted along the affected nerves or in the space around the spinal cord.
Occasionally, pain due to nerve damage can be treated by disrupting a nerve pathway that transmits pain signals. The pathway is disrupted by injecting a caustic substance (such as phenol) into a nerve to destroy it, by freezing the nerve (in cryotherapy), or by burning the nerve with a radiofrequency probe. These procedures may be used to treat facial pain due to trigeminal neuralgia.
Acupuncture involves inserting tiny needles into specific areas of the body (see Complementary and Alternative Medicine (CAM): Acupuncture). How acupuncture works is poorly understood, and some experts still doubt the technique's effectiveness. Some people find substantial relief with acupuncture, at least for a time.
Biofeedback and other cognitive techniques (such as relaxation training, hypnosis, and distraction techniques) can help people control, reduce, or cope with pain by changing the way they focus their attention. In one distraction technique, people may learn to visualize themselves in a calm, comforting place (such as in a hammock or on a beach) when they feel pain.
The importance of psychologic support for people in pain should not be underestimated. Friends and family members should be aware that people in pain suffer, need support, and may develop depression and anxiety, which may require psychologic counseling.
Last full review/revision August 2007 by Russell K. Portenoy, MD
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