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Medicines for pain management

The role of medicines in persistent/chronic pain

Medication alone for the treatment of persistent pain can, at best, reduce your pain by around 30%.

Therefore, evidence has shown that a wider management plan must be implemented to include strategies that are non-medicine based. Many patients find that the side effects and longer-term risks of taking medication, especially if multiple medicines are prescribed together, outweigh the benefits and can actually make symptoms worse or add to the problem.

Medication is a small piece of the pain self-management jigsaw.

Do not stop any medicines abruptly without first discussing this with your Doctor, Pharmacist or Pain Specialist.

Opioids

Including, but not limited to:

  • codeine
  • dihydrocodeine
  • tramadol
  • morphine
  • oxycodone
  • fentanyl
  • buprenorphine

Opioids work well for pain:

  • after injury or surgery
  • at the end of life

Some patients may benefit from their use in pain that persists for longer than three months, if used at low doses for shorter periods of time such as when their pain flares up.

As doses increase, you will be at higher risk of side effects with very little extra benefit. If you have pain that remains severe despite taking opioids, it means they are not working and should be stopped, even if no other treatment is available. Doses should be reduced slowly before stopping.

It’s important that you never stop using opioids suddenly without first discussing this with a healthcare professional.

For further guidance, see:

Gabapentinoids

Gabapentin and Pregabalin

Gabapentinoids are used to treat neuropathic (nerve) pain.

This is a type of pain related to an increase in the number of signals sent by the nerves. It may be caused by injury to the nerve but can also occur in the absence of injury. It is thought to result from a “rewiring” of the nerves of the spinal cord, causing you to feel pain.

Symptoms may be described as a burning, shooting or stabbing pain. This can sometimes feel like numbness, electric shocks or “pins and needles”.

Only around one in seven patients benefit from treatment in nerve pain.

Benefit from taking medication should always be more than any side effects you may have. It is important this medication is reviewed regularly to assess if it helps to improve your pain, allows you to do more or to check if you are experiencing any side-effects.

The aim of treatment is to reduce your pain enough that you can:

  • participate in supported self-management
  • regain useful function

See NHS Ayrshire & Arran’s information leaflets on gabapentinoids:

Live Well with Pain’s gabapentinoids leaflet covers:

  • effectiveness of gabapentinoids
  • side effects
  • whether gabapentinoids are the right treatment for you
  • how to reduce gabapentinoids

NSAIDs (anti-inflammatory medicines)

  • Non-selective: Ibuprofen, Diclofenac, Naproxen
  • COX-2 selective: Celecoxib, Etoricoxib

These types of medicines can be useful when there is inflammation involved in your pain condition.

]It is recommended that the lowest effective dose is used for the shortest period possible. This is in order to minimise side effects and long-term risks.

You may be prescribed a medicine like omeprazole or lansoprazole to protect your stomach whilst taking an NSAID.

Paracetamol

Paracetamol is a safe and effective form of pain relief for those who find a benefit from them. It can be taken regularly at maximum doses, but this may be reduced if you are under 50kg and/or you have liver disease.

A trial at the full therapeutic, maximum dose should be tried before being started on an alternative analgesic.

Paracetamol can be used safely in combination with other pain medication. However, it is no longer recommended to be taken in fixed dose combination medicines, such as co-codamol or co-dydramol. Taking these as separate components gives you more flexibility and control over what you need to take, day to day.

Antidepressants

  • Tricyclic Antidepressants: Amitriptyline, Nortriptyline
  • Selective serotonin reuptake inhibitors (SSRIs): Sertraline, Fluoxetine, Citalopram
  • Serotonin–norepinephrine reuptake inhibitors (SNRIs): Duloxetine, Venlafaxine

We now know that physical and mental health can have an impact on not only how you develop pain that becomes persistent, but also affects the ability to cope with pain, day to day.

Some antidepressants (such as amitriptyline and duloxetine) are licensed for the treatment of nerve pain. However, other antidepressants can also be helpful due to the impact they can have on your:

  • general wellbeing
  • sleep
  • motivation
  • psychological distress
  • quality of life

Lidocaine plasters

Brand names: Ralvo ®, Versatis ®, Lidocaine Grunenthal Plasters

These plasters are indicated for the treatment of pain that persists following a bout of shingles – also known as post-herpetic neuralgia. Very occasionally, specialists in pain management and palliative care may prescribe these for other indications.

They work by numbing the surface of the skin and also have a cooling effect on the skin.

We know that many people who receive these plasters are using them for other indications. These are started with the best of intentions but we now know that other options are more appropriate. It is important that these plasters are reviewed on an ongoing basis and only continued if they provide benefit.