Pain Medication

Information

A note from Pete Moore

I get many emails from people about pain medications and I am unable to answer. So, I thought it would be useful if to ask a Pain Healthcare Professionals to write a short and easy to understand guide.

Before we begin

It always best to discuss to talk to a GP, Pain Doctor, Prescribing Pain Nurse or Pharmacist, BEFORE taking any pain medication (prescribed or over the counter). 

Introduction

• Pain medication can help pain but rarely takes it away completely
• Medication should be part of a plan, not the only tool used to manage pain
• Side effects and loss of effectiveness over time are common

Ways to take pain medication

• As required – when the pain is bad or before doing something likely to increase pain levels
• Regularly – ‘by the clock’ to try and provide consistent pain relief throughout the day
• Some regular but with as required top ups
• A combination of drugs working in different ways may be more effective than a single drug

Types of drugs for pain

• Paracetamol
• NSAIDS (non-steroidal anti-inflammatory drugs)
• Opioids – weak or strong
• Adjuncts – drugs that are not ‘painkillers’ but can help as long term pain reducers

Paracetamol

• Generally safe and well tolerated
• Can usually be taken with other medication without interaction
• Useful for mild to moderate pain and some people find it very effective
• Reduce dose if you are under 50kg (8 stone)
• Dangerous in overdose or if taking more than recommended daily maximum – can cause liver failure

NSAIDS

• Large group of drugs but most commonly used are ibuprofen, naproxen and diclofenac
• Lots of brand names e.g. Nurofen, Naprosyn, Voltarol. Check the actual drug name
• Only take one NSAID at a time
• Good for muscular and joint pains and mild to moderate pain
• Lots of possible adverse effects. Commonly - indigestion but this can end up with bleeding from the stomach. Kidney damage, especially if you are ill, dehydrated or take blood pressure medication. Do not take with other drugs that thin the blood like warfarin or other anti-coagulants
• Adverse events more common with increasing age and the longer you take the drug

Weak opioids

• Codeine, tramadol and dihydrocodeine most commonly prescribed. Often combined with paracetamol
• Tramadol is now a controlled drug
• Used for moderate to severe pain
• Common side effects – constipation, drowsiness
• Tolerance develops as your brain gets used to the drug. The drug becomes less effective over time
• Withdrawal can occur if you suddenly stop taking any opioid drug
• Some people become addicted to weak opioids

Strong opioids

• Morphine, oxycodone, buprenorphine, fentanyl. Available as slow release and immediate release tablets or medicine. Fentanyl and buprenorphine are available as patches. All are controlled drugs
• Used for severe pain
• Not good for long term use in most people. Tolerance develops and doses can quickly escalate
• Side effects – constipation, dry mouth, drowsiness, nausea, sleep disturbance, reduced hormone levels, reduced immunity
• The long term side effects of taking strong opioids are difficult to tell apart from the unwanted effects of pain – low mood, lack of motivation, poor quality sleep
• Reducing and coming off strong opioids can improve quality of life without making the pain any worse
• If you are taking strong opioid drugs but still have severe pain, they are not working and you should slowly come off them
• Addiction is often not recognised

Adjuncts

• Gabapentin and pregabalin work in the same way to calm down overactive nerves 
• They have this effect on the whole nervous system so the main side effects are drowsiness, and poor concentration and memory
• They are most useful for nerve pain but have been used for many types of pain due to the lack of effective drugs for pain
• They are controlled drugs and are drugs of abuse
• They need to be taken regularly to maintain effectiveness but this can reduce over time
• Amitriptyline, nortriptyline and imipramine are older anti-depressant drugs
• They can be helpful for nerve pain and for improving sleep if it is very disturbed by pain
• The main side effects are drowsiness and dry mouth. They can affect the ability to pass urine, especially in older men
• These drugs should be used with caution in older patients

Summary

• There are fewer drugs for pain than people realise
• They often do not work well for persistent pain
• It may be better to take no drugs and explore other ways to manage pain
• Starting any drug should be considered a trial to see if it helps and to balance this against any side effects

If you have any issues with any medication, please contact the, Yellow Card Scheme,

Many thanks to Dr Lucy Williams for putting in information together.

Dr Lucy Williams is a Specialist in Anaesthesia and Pain Medicine at The Great Western Hospital, Swindon.

Links

• Pain Medication (extended version)