Types of Pain Medications

Medications used to treat pain fall into two broad categories:  analgesics and adjuvant (supplemental) medications.  Analgesics are medications used and marketed specifically for pain relief.  Adjuvant medications have uses other than pain relief, but are often very useful either as supplements or alternatives to analgesics.  Three general categories of analgesics may be distinguished:  narcotics (now referred to as opioids), non-opioids, and combination drugs which usually contain both an opioid and a non-opioid.  Some examples of opioids are morphine, codeine, hydromorphone (Dilaudid), and methadone.   Non-narcotics include aspirin, acetaminophen (Tylenol) and the so-called non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen.  Combination drugs include Tylenol #3 and #4 (combined with 30 or 60 mg. of codeine respectively), Vicodin (acetaminophen and hydrocodone), and Percocet (acetaminophen and oxycodone).   

The following chart is a brief summary of some common types of medications used for persons with chronic pain.  Keep in mind that most medications have both a generic name and a brand name.  Examples of medications listed below are primarily referred to by their common brand name.

Analgesics	Purpose	Mechanism of Action	Examples
Narcotic Analgesics (Opioids)	Decrease pain	Acts on special opioid receptors in the nervous system	Morphine, Codeine, Oxycodone, Fentanyl, Dilaudid, Methadone
Non-opioid Analgesics, Anti-inflammatory drugs (NSAIDs)	Decrease pain	Alters chemical reactions at site of injury	Aspirin, Tylenol, Ibuprofen, Naprosyn, Indocin, Celebrex
Combination opioid and non-opioid	Decrease pain	Both of the above mechanisms	Tylenol #3 or #4, Vicodin, Percocet
Adjuvant Medications
Muscle Relaxants	Decrease painful muscle spasms	Reduces skeletal muscle activity by working on the brain stem or spinal cord	Robaxin, Soma, Norflex, Flexeril, Parafon Forte
Anticonvulsants	Decrease neurological pain	Stabilize nerve membranes	Gabapentin (Neurontin), Tegretol, Baclofen
Sedatives	Short-term treatment of insomnia	Variable depending on type	Benadryl, Dalmane, Halcion, Ambien
Anti-anxiety Drugs	Decrease anxiety, nervous tension, and excessive worry; Sometimes used to reduce muscle spasms	Alters brain chemistry	Diazepam (Valium), Xanax, BuSpar
Antidepressants	Decrease depression, Some also help with sleep problems, May reduce pain as well	Alters brain chemistry	Elavil, Sinequan Pamelor, Prozac, Zoloft, Paxil

This chart is by no means complete since there are several other types of medication used for more special pain conditions. For example, there are several other medications which are used to treat chronic headache.

In addition to pain medications, you may be taking medications for other medical conditions as well. Use the following chart to list and identify all of the medications you are currently taking.

Personal Medication Log
 

One of the biggest dilemmas for many chronic pain sufferers who are interested in the self-management approach is the issue of taking opioid pain relievers. First of all, it is important to understand the basic differences between opioid and non-opioid drugs.

Differences between Opioid and Non-opioid Analgesics.

These two categories of analgesics differ in several important ways. The primary difference has to do with how they produce their analgesic (pain relieving) effects. The opioid drugs reduce pain primarily by working on pain receptors in the brain and spinal cord. The non-opioids, on the other hand, tend to work more directly on injured body tissues. In other words, the opioids decrease the brain's awareness of the pain, whereas the non-opioids inhibit some of the chemical changes that normally take place wherever body tissues are injured. These chemical changes at the site of the injury typically result in inflammation and decreased pain threshold (i.e., increase sensitivity to pain)

It is well known that the opioids are stronger than the non-opioids in their ability to decrease pain. However, they also have some drawbacks and always require a doctor's prescription. The use of opioid pain relievers over time automatically results in tolerance and physical dependence. That is, it takes more of the drug to produce the same analgesic effects. Once tolerance has developed, withdrawal automatically occurs whenever you stop taking the drug. Unfortunately, one common symptom of withdrawal is increased pain.

Another major difference between these two categories of analgesics is the fact that the non-opioids do not interfere with mental activities, whereas the opioids can interfere with concentration, memory, and general alertness. That is why opioid prescription bottles always contain a warning about operating a car or machinery when you have taken the drug. Opioids also tend to interact with other drugs which depress the central nervous system. The most common of these central nervous system depressants is alcohol. However, tranquilizers and most sleeping pills also fall into this category. This means that you have to be very careful about using alcohol or other drugs when you are taking opioid analgesics. In fact, some people have accidentally overdosed and died by failing to heed this warning.

Another difference between these two categories of analgesics has to do with ceiling effects. The non-opioids have a ceiling, which means that there is an upper limit of pain relief that can be achieved.  Once you reach that ceiling, taking additional medication will not give you any additional pain relief.  Most opioids, on the other hand, have less of a ceiling. The more you take, the more pain relief you will get. 

Finally, it is important to keep in mind that opioids do more than relieve physical pain.  They can also be used to reduce emotional suffering.  To the extent that you experience emotional distress in connection with your chronic pain condition, you may find that chronic opioid use provides some relief from these distressing feelings.  Unfortunately, this fact tends to be ignored by both doctors and patients alike.  Nevertheless, this ability of opioids to reduce emotional suffering can contribute to psychological dependence on these drugs.

Summary Of Differences Between Opioid and Non-Opioid Analgesics

The following chart summarizes some of the main differences between opioid and non-opioid analgesics.

	Non-opioids	Opioids (Narcotics)
Primary Site of Action	Site of the injury	Brain and central nervous system
Require Doctor's Prescription?	Some do, some don't	All require prescription from a doctor
Potency of Pain Relief	Mild to moderate	Moderate to very strong
Interfere with mental activities?	No	Yes
Can reduce emotional distress in addition to pain	No	Yes
Can result in dependence and addiction?	No	Yes
Ceiling Effect?	Yes	No
Interact with alcohol, most sleeping medications, and tranquilizers?	No	Yes
Common Side Effects	Stomach irritation, abdominal pain, gastric ulcers	Constipation, nausea & vomiting, Urine retention, Mental clouding, Dizziness, and sleepiness, Feelings of euphoria

It should be kept in mind that most of these medications were designed primarily for temporary pain conditions. In such cases, the pain goes away after the body heals and normal function is restored. When this occurs, the opioid is no longer needed. For example, following surgery it is common for doctors to give their patients an opioid pain reliever. However, the medications are gradually withdrawn as the body heals and the person recovers.

Other opioid pain relievers have been designed to provide increased comfort to those who are suffering from severe cancer pain or other terminal illnesses. For such persons, methods have been devised to provide a continuous flow of pain medication into their systems. For those persons whose conditions are terminal, concerns about dependency and addiction are essentially irrelevant.

Long-term Use of Opioids ("Opioid Maintenance")

What about taking these drugs for chronic non-malignant pain? Unfortunately, all analgesic medications, including both opioids and non-opioids, have potential drawbacks when used over an extended period of time.  On the other hand, there is no reason why anyone should be forced to suffer from severe chronic pain when appropriate opioid pain relievers are available.

Currently, there is controversy among medical doctors regarding the use of opioid pain relievers for chronic, non-malignant pain. Some doctors believe that opioids should not be used with this group of patients because of problems with addiction.  While physical dependence is an automatic consequence of opioid use, psychological dependence and addiction can occur as well.  Not only can these drugs be abused, but their effects on mental activities can interfere with day-to-day functioning.  Most medical doctors specializing in treating chronic pain now disagree with this point of view.  Arguments regarding the potential of opioids to interfere with mental activities can be countered by the obvious fact that it is far more likely for severe, unrelieved pain to interfere with mental activities and day-to-day functioning.  These pain doctors also point out that, just because opioids do produce physical dependence and tolerance, it does not mean that they result in psychological dependence, addiction, and drug abuse. It has been noted that there are many chronic pain sufferers who have taken opioids for long periods of time and have not developed problems commonly associated with drug addiction and abuse.  Moreover, it has been pointed out that most chronic pain patients who take opioids as prescribed do not experience the euphoric effects that are usually associated with narcotic addiction. 

We know that the vast majority of medical patients on opioids do not behave like heroin addicts.  Nevertheless, problems can and do occur which can interfere with healthy functioning.  Although it is now fashionable to distinguish between physical and psychological dependence, in reality the two usually go hand in hand.  The vast majority of chronic pain patients I have met who regularly take opioids have the strong belief that they absolutely must take these drugs and fear that if they don't have these drugs they will be totally overwhelmed by pain.  Ironically, some of these patients continue to report high levels of pain and dysfunction despite regular use of opioids.  There is even some evidence to suggest that long-term opioid use can produce biochemical and molecular changes in the central nervous system which lower pain threshold and make the person even more susceptible to pain.

Studies which have been done thus far suggest out that some chronic pain patients can be safely and effectively maintained on opioids whereas many others cannot. The problem is that it is not always easy to determine in advance who can be safely maintained and who cannot. That is why most authorities recommend starting with an opioid trial period to determine how it works out.

Decisions Regarding the Use of Opioid Analgesics.

If physicians do not agree among themselves about whether or not to prescribe opioid pain relievers to chronic non-cancer pain sufferers, where does this leave you? In keeping with our self-management philosophy, we believe that the final decision and ultimate responsibility for taking these medications resides with you. You are the one who has to live with chronic pain. 

Although the final decision regarding the use of opioid pain relievers rests with you, I believe that ideally, the decision should be made following an open discussion between you and your doctor about the pros and cons of long-term opioid use. I would like to see a situation in which your physician lays out and discusses a variety of alternative pain control methods available to you. Hopefully, your physician is also enlightened enough to include the wide range of self-management approaches which are discussed in this book. Unfortunately, some unenlightened physicians are only willing to consider strictly medical approaches such as prescribed medications, injections, and surgical procedures.  On the other other hand, you may be one of those who can and should be maintained on opioid analgesics but have a physician who won't prescribe them to you due to misplaced fears of addiction or worries about getting into trouble with regulatory agencies.  I would suggest that you refer your doctor to the Consensus Statement  developed by the American Academy of Pain Medicine and the American Pain Society regarding the use of opioids for treatment of chronic pain.   

A Personal Point of View.

I do not take a strong stand one way or the other regarding the long-term use of opioid analgesics. I see no purpose in condemning those who rely on opioids to control their chronic pain. Moreover, I see no value in needless suffering. Hopefully, if you do decide to continue using opioids, it is because you and your doctor have both determined that the advantages (pros) significantly outweigh the disadvantages (cons). Obviously, my own bias is toward non-medical, non-pharmacological self-management pain control methods. But it doesn't have to be an either-or decision. Those of you who do decide to take opioid analgesics can still make considerable use of pain self-management techniques.

In my opinion, decisions regarding the value of long-term opioid use should ultimately boil down to two key issues or goals. These goals are increased comfort (less pain) and improved functioning (being more active and able to carry out the normal activities of daily living). Ideally, use of pain medications should help you fulfill both goals. However, if one has to be sacrificed, you might ask yourself which of these two you value more. Some achieve pain relief through use of opioids, but then find that they have to retreat to their bedroom or end up lying around the house all day. In other words, their ability to function in their natural environment becomes even more impaired. Some place such a high premium on seeking pain relief that they keep taking more and more pain medication to offset the tolerance effects and prevent withdrawal. As a result, their level of functioning may actually be less than it could be without all the drugs.

For those of you who are currently taking opioid pain relievers but are concerned about whether they are truly healthy and beneficial, you might consider the following issues.  After carefully considering each of these issues, you will be asked to list the pros and cons of taking opioids. Based upon this self-analysis exercise, it is my hope that you will be able to arrive at an intelligent and wise decision.

1.    Relationship with your doctor

• Do you have a single doctor who is primarily responsible for the medical management of your chronic pain condition, or are you receiving medications from more than one physician?  If more than one physician are involved, are they working together as a team on your behalf, or do they work independently?
• Have you and your primary care doctor reviewed the various options for management of chronic pain, including the pros and cons of opioid analgesics?
• Are you and your doctor in agreement as to whether you should be taking opioids?  Are you satisfied with the type and amount of opioids that are being prescribed?
• Has your doctor expressed any concerns about the amount of opioids you are taking?  If so, what alternatives were suggested?
• Do you keep changing doctors in search of one who will give you more pain medications?

2.    Frequency of use

• How often do you take opioid pain relievers? Do you take them every day throughout the entire day, or perhaps only at one time each day, like before going bed at night?  Do you take them only a few times a week or even just a few times a month?
• How do you go about deciding whether or not to take opioid pain relievers? Do you take them on a regular basis by the clock, or do you wait until your pain becomes especially intense? If the latter, how intense does the pain have to be before you decide to take pain pills?  What other non-drug techniques do you try first before turning to opioids?
• How does your frequency of medication use compare with the way the doctor  ordered your prescription?   Do you take the exact amount that your doctor prescribes or do you use less than was prescribed to you?   Do you tend to use up all of the pain pills before your normal prescription renewal period?  What do you do if you run out of pills early?
• Do you sometimes go to an emergency room or urgent care center to get an emergency prescription or injection of opioids? If so, how often does this occur and how do you feel about it?

3.    Degree of pain relief

• When you take opioid pain relievers, how much actual pain relief do you get? Do you expect total pain relief, or are you satisfied to only take the edge off the pain?
• Do you find that you now have to take more pills or stronger ones than you used to take in order to get the same level of pain relief? In other words, have you developed a tolerance to the pain drugs so you have to keep taking more and more?

4.    Effects on daily functioning

• What effects do the medications have on your activity level and ability to function? Do the opioids enable you to be more physically active and productive, or do you become less active?  Do you find that when you take pain pills, you usually retreat to your bedroom and withdraw from any physical or social activity? 
• If you are more active on the medication, is there a possibility that by masking the pain with opioids you may be overdoing it and actually causing more physical harm. 

5.    Presence of negative side effects

• How do the medications affect your ability to think clearly, concentrate, or remember? Do you think more clearly and remember better when you get pain relief from the opioids, or when you do not take any of these drugs?
• Have the pain pills had any notable effects on your mood or personality? If so, what effects have they had on you? Do you feel more upbeat and cheerful, or have you become more irritable, depressed, and withdrawn?
• Have the pain pills had any negative effects on other body systems such as the functioning of your bowels or your appetite? If so, how have they affected these other body functions? Are the negative physical side effects worth putting up with?

6.    Signs of psychological dependence and addictive behavior

• Do you secretly worry that you may be taking too many pain pills for your own good? If so, why do you feel that way?
• Do you sometimes use your pain as an excuse to take opioids when actually you take the pills to feel good or forget your troubles?
• Are you taking more of the medication than your doctor has prescribed?
• Do you sometimes make up excuses to get a prescription renewal when you run out of medications early, such as claiming you lost them or that they were stolen?
• Do you get your opioid pain relievers from more than one source (e.g., different doctors)?  Is each source aware of the fact that you have another source for obtaining these drugs?
• Have your family and other loved ones expressed concerns about the amount of opioid pain relievers you are taking?   If so, why do you think they feel that way?   Do you ever try to hide from them how much or how often you use the drugs? How has your opioid use affected your family life?
• Do you resort to illegal or semi-legal methods to procure opioids?  Do you sometimes take pain pills that were prescribed to someone else? 

The Pros and Cons of Taking Opioid Pain Relievers
 

Deciding How to Take Opioid Analgesics

This section is written for those of you who have decided to take opioid pain relievers. The question under consideration is, what is the best method for taking these drugs? I am assuming that you and your doctor have already decided upon a particular kind of opioid. The two primary choices are between the "as needed" (prn) basis, and the "time contingent" (by the clock) basis.

Taking pain pills "as needed."

This is by far the most commonly used method for taking pain pills. Of course there is considerable variability among pain sufferers as to when the pills are thought to be needed. Following are some common examples:

• "I need to take pain pills every day." Some feel that they need to take several pills every day because they are in pain every day.  In this case the issue of tolerance needs to be addressed.  The danger is getting into a cycle where you must keep taking more and more to attain satisfactory pain relief.
• "I only take the pills after the pain has become unbearable." This method is used primarily by those who try to keep their use of opioid pain relievers to a minimum. Of course, there is considerable variability as to when the pain is considered to be unbearable.
• "I take pills only when I feel an acute pain episode coming on."  Some take the pain pills when they feel their pain is increasing, but before it reaches a peak. The goal here is to prevent the pain from getting out of control.
• "I take pain pills before doing certain physically demanding activities." This method is used by those who know that particular physical activities will increase their pain. Therefore, in an effort to prevent an increase in pain, they take the pills prior to doing the activity. A drawback to this approach is that you may end up overdoing it and hurting yourself because the pain has been masked by the opioids.
• "I take pain pills only at night before going to sleep." Many persons with chronic pain experience the most pain at night, and consequently have their sleep disrupted as a result of the pain. Those who take pain pills only at night do so because they want to remain fully alert during the day and yet get a good night's rest. Of course, there are medications other than pain pills which can be taken to help you sleep.

The alternative to taking pains on an "as needed" basis is to take them at regular time intervals throughout the day irrespective of your pain level. The goal here is to maintain a relatively constant amount of the opioid pain relievers in your system and thus minimize extreme fluctuations in pain intensity. This method has been used in hospital settings where the nurse brings the medications at specific times, and has been used successfully with those suffering from cancer-related pain. It is also the method of choice used to gradually reduce one's intake of opioid analgesics. In the tapering program, such as the one we use here, the opioid ingredient is gradually reduced and is replaced with plain Tylenol.

This time contingent method has been found to avoid some of the pitfalls associated with the "as needed" approach. Most important, it may be possible under this method to maintain a relatively stable dosage level of the medication and thereby avoid many of the problems associated with tolerance and addiction. It is especially preferable to the "as needed" method in which you wait until the pain is at a peak before taking the medication since, when the pain reaches a very high level of intensity, the pain pills are the least effective. As a result, you may have to take a much higher dosage to get effective pain relief. Decisions about the frequency and timing of opioid pain relievers are best made between you and your doctor.

The Opioid Pump

The most radical means of taking opioid analgesics on an ambulatory basis is to have a special pump implanted into your body which delivers a continuous supply of morphine or other opioid into your system. This method has typically been used only in the most extreme cases, such as persons suffering from severe cancer pain. My advice is that you carefully consider all of your options before resorting to this drastic procedure.

Return to Pain Handbook Index