Antidepressants and anti-seizure medications

Some medications commonly prescribed to manage depression and prevent epileptic seizures have also been found to help relieve chronic pain, including back pain, fibromyalgia and diabetes-related nerve pain (diabetic neuropathy). Because chronic pain often worsens depression, antidepressants may doubly benefit pain and mood symptoms.

  • Brand names. Tricyclic antidepressants used in the treatment of chronic pain include amitriptyline and nortriptyline (Pamelor).

    Serotonin and norepinephrine reuptake inhibitors (SNRIs) that may be prescribed to relieve chronic pain include duloxetine (Cymbalta), venlafaxine (Effexor XR) and milnacipran (Savella).

    Anti-seizure medications that are widely used for the treatment of chronic nerve pain, including postherpetic neuralgia and diabetic neuropathy, include gabapentin (Gralise, Neurontin) and pregabalin (Lyrica).

  • How they work. May take several weeks before you notice the effects. Anti-seizure medications quiet pain signals from your nerve cells, and may be helpful primarily for stabbing or shooting pain resulting from nerve damage.
  • Benefits and risks. Side effects of these medications are generally mild, but may include nausea, dizziness or drowsiness. As a group, antidepressants and anti-seizure medications may, rarely, worsen depression or cause suicidal thoughts. If you notice changes in your thinking patterns or mood while taking these medications, talk with your doctor right away.
  • Bottom line. To reduce the risk of side effects, your doctor may start you out on a small amount of these medications and gradually increase the dose. Tricyclic antidepressants can make you drowsy, so your doctor likely will recommend you take these medications before bedtime.

Opioids

Opioid medications are synthetic cousins of opium and the drugs derived from opium, such as heroin and morphine. These drugs are often prescribed for acute pain that stems from traumatic injury, such as surgery or a broken bone. Opioids currently cause the most prescription drug-related overdose deaths in the United States — and that rate is still rising. Because the risks are so great, opioids are used at the lowest dose possible, usually for just a few days.

  • Brand names. Hydrocodone (Hysingla ER, Zohydro ER); hydrocodone-acetaminophen (Norco, Zyfrel, others); fentanyl (Actiq, Duragesic, Fentora), oxycodone (OxyContin, Roxicodone, others); oxycodone-acetaminophen (Percocet, Roxicet, others); others
  • How they work. Opioids, just like real opium, mimic the natural pain-relieving chemicals — called endorphins — produced by your brain. These drugs "turn down the volume" on the pain signals your nervous system sends through your body. They also muffle other nerve cell functions, such as your breathing, heart rate and level of alertness.
  • Benefits and risks. Research shows that over time, your body adapts to these medications, and they bring less and less pain relief. This phenomenon, known as tolerance, means you need more of the same medication to achieve the same degree of pain relief. Long-term use of opioids may lead to dependence on these medications and, eventually, addiction.

    The longer you use opioids, the greater your risk of becoming addicted. However, even using opioids to manage pain for more than a few days increases your risk. Researchers at Mayo Clinic have found that the odds you'll still be on opioids a year after starting a short course increase after only five days on opioids.

  • Bottom line. Opioids are a last resort for chronic pain management. They may be the right choice for long-term pain related to cancer and its treatments or, in rare cases, noncancer pain that hasn't responded to any other medications. Because the risks are so serious, you'll need careful and frequent follow-ups with your doctor if you use opioids long term.

While there isn't a cure for chronic pain, many effective pain medications are available to help you function effectively and enjoy your days. As you try different drugs, alone or in combination, work with your doctor to target the simplest long-term solution possible. Keep your medication risks to a minimum to improve your odds of many good days, for many years to come.

Pain medications at a glance

Medication type How they work First line option for Benefits Risks
NSAIDs Block COX-1 and COX-2 enzymes involved in pain and inflammation
  • Mild to moderate pain accompanied by swelling and inflammation
  • Arthritis pain and pain resulting from muscle sprains and strains, back and neck injuries, overuse injuries, and menstrual cramps
When taken as directed, generally safe for short- and long-term use
  • May cause nausea, stomach pain, stomach bleeding or ulcers
  • When taken in high doses, can lead to kidney problems, fluid retention and high blood pressure
  • Increased risk of side effects for older adults
Acetaminophen Unknown, but possibly blocks a COX-3 enzyme Mild to moderate pain Acetaminophen Unknown, but possibly blocks a COX-3 enzyme
COX-2 inhibitors Block COX-2 enzymes Rheumatoid arthritis, osteoarthritis, menstrual cramps and injury-related pain As effective as NSAIDs without damaging stomach lining at regular doses
  • Respiratory infection, headache and dizziness
  • When taken in high doses, can lead to stomach bleeding, kidney problems, fluid retention and high blood pressure
  • Increased risk of side effects for older adults
Antidepressants Interfere with certain chemical processes that cause you to feel pain
  • Neuropathic pain, chronic daily headaches, fibromyalgia
  • May be considered for chronic low back pain
  • Can be in doses much lower than what is currently used to treat depression
  • Side effects generally mild
  • Drowsiness possible with tricyclic antidepressants
  • Can take several weeks to produce desired effects
  • May worsen depression and cause suicidal thoughts in a small number or people
Anti-seizure medications Quiet pain signals from damaged nerves Postherpetic neuralgia, diabetic neuropathy, fibromyalgia Side effects generally mild
  • May cause dizziness, drowsiness, nausea, reduced coordination and weight changes
  • May worsen depression and cause suicidal thoughts in a small number of people
Opioids Activate feel-good neurotransmitters, called endorphins, that suppress pain and boost a sense of well-being
  • Acute pain, such as pain that follows surgery or a bone fracture
  • Typically prescribed for maximum of three days
Powerful relief during short periods of severe pain
  • Tolerance, dependence, misuse, addiction and overdose, which may begin to develop within one week of use
  • Responsible for the majority of accidental overdose deaths in the U.S.
Oct. 31, 2017