Chronic pain: Medication decisions

Chronic pain can limit your quality of life and lead to additional, serious health problems. Finding effective treatment is important — as is balancing pain relief with your safety.

By Mayo Clinic Staff

Chronic pain is a serious health condition. Like any long-term health problem, the condition often leads to complications beyond your physical symptoms, such as new or worsened depression, anxiety and difficulty sleeping. Chronic pain can make it more difficult to keep up at work, manage tasks at home and attend social gatherings, leading to problems in your relationships and financial instability. Some research suggests that the more severe your pain, the more serious these problems.

The serious consequences of chronic pain make finding effective treatment a critical goal. Unfortunately, this process is complex and uniquely personal. What works for one person's chronic low back pain may not offer any relief for your osteoarthritis, for a number of reasons. Your diagnosis, biology and personal history all play a role, and finding pain therapies that bring you adequate relief can be a lengthy effort.

Working in partnership with your doctor, however, you can identify treatments that allow you to live an enjoyable, fulfilling life. The approach you choose should include more than just medication, but painkillers are likely to play a role. Learn about the risks and benefits of common pain medications so that you can make safe choices as you seek your solution.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are most effective for mild to moderate pain that's accompanied by swelling and inflammation. These drugs are commonly used for arthritis and pain resulting from muscle sprains, strains, back and neck injuries, or menstrual cramps.

  • Generic (brand) names. Ibuprofen (Advil, Motrin IB, others); naproxen sodium (Aleve); others
  • How they work. NSAIDs work by inhibiting certain enzymes in your body, called cyclooxygenase, that are released during tissue damage. By blocking the different types of cyclooxygenase (COX) — including COX-1 and COX-2 — NSAIDs can help reduce pain and inflammation that result from an injury.
  • Benefits and risks. When taken as directed, NSAIDs are generally safe. But if you take more than the recommended dosage — and sometimes even just the recommended dosage — NSAIDs may cause nausea, stomach pain, stomach bleeding or ulcers. Large doses of NSAIDs can also lead to kidney problems, fluid retention and high blood pressure. Risk of these conditions increases with age and in the presence of other health problems, including diabetes, a history of stomach ulcers or reflux, and kidney disease.
  • Bottom line. If you regularly take NSAIDs, talk to your doctor so that he or she can monitor you for possible side effects. Bear in mind that NSAIDs also have a ceiling effect — a limit as to how much pain they can control. This means that beyond a certain dosage, they don't provide additional benefit. Exceeding the recommended dose may not relieve your pain and may increase your risk of serious side effects.

Acetaminophen

Acetaminophen is usually recommended as a first line treatment for mild to moderate pain, such as from a skin injury, headache or musculoskeletal condition. Acetaminophen is often prescribed to help manage osteoarthritis and back pain. It may also be combined with opioids to reduce the amount of opioid needed.

  • Brand names. Acetaminophen (Tylenol, others)
  • How it works. Doctors don't know exactly how acetaminophen works. Some scientists believe there may be a third type of cyclooxygenase, COX-3, that acetaminophen blocks. Acetaminophen doesn't affect the other two cyclooxygenase enzymes, and it doesn't target inflammation — only pain. It may be less effective than NSAIDs.
  • Benefits and risks. Acetaminophen is generally considered safer than other nonopioid pain relievers because it doesn't cause side effects such as stomach pain and bleeding. However, taking more than the recommended dose — or taking acetaminophen with alcohol — increases your risk of kidney damage and liver failure over time.
  • Bottom line. Acetaminophen is generally a safe option to try first for many types of pain, including chronic pain. Ask your doctor for guidance about other medications to avoid while taking acetaminophen. Acetaminophen is not as effective as NSAIDs for the treatment of knee and hip pain related to osteoarthritis.

COX-2 inhibitors

These medications were developed with the aim of reducing common side effects associated with traditional NSAIDs. COX-2 inhibitors are commonly used for arthritis and pain resulting from muscle sprains, strains, back and neck injuries, or menstrual cramps. They are as effective as NSAIDs and may be the right choice if you need long-term pain control without increased risk of stomach damage.

  • Brand names. Celecoxib (Celebrex)
  • How they work. COX-2 inhibitors, another type of NSAID, work slightly differently from traditional NSAIDs. A COX-2 inhibitor blocks only the COX-2 enzyme — the one that's more likely to cause pain and inflammation.
  • Benefits and risks. COX-1 enzymes help protect the lining of your stomach. NSAIDs, which block COX-1, can cause side effects such as stomach pain and bleeding. COX-2 inhibitors, on the other hand, help keep the stomach protected by acting only on COX-2 enzymes, allowing COX-1 to function normally.

    Although the risk of stomach bleeding is generally lower if you take a COX-2 inhibitor instead of an NSAID, bleeding can still occur, especially at higher doses. These medications may cause side effects, such as headache and dizziness, and can lead to kidney problems, fluid retention and high blood pressure.

  • Bottom line. Older adults may be at higher risk of common COX-2 side effects compared with younger adults. If these medications help you manage chronic pain, aim to take the lowest effective dose for the shortest time possible, and follow up closely with your doctor.
Oct. 31, 2017