Prescription Pain Relievers
If you often suffer from pain that's too tough for a simple aspirin, you may need stronger relief. Prescription pain medicines may be the only real option for easing severe pain, including the pain caused by cancer, arthritis, or serious injuries. Unfortunately, both doctors and patients often have misconceptions about prescription pain relievers. Learning about prescription medications for pain can be an important first step toward getting your pain under control. Keep in mind, every medication has risks and benefits, and what works for one person may not be a good choice for another.
You may know this drug as Tylenol, but acetaminophen is also available by prescription, usually in combination with opioid drugs like hydrocodone (Vicodin) and oxycodone (Percocet). Doctors consider acetaminophen to be safe in doses up to 2,000 to 3,000 milligrams (mg) per day for most people, and it is often the first-line pain medication that they recommend, especially to people who may have problems with anti-inflammatory medicines like ibuprofen. Acetaminophen is effective against many types of pain and gentler on the stomach than anti-inflammatory drugs.
The main concern with acetaminophen is that in large doses the drug may stress or damage the liver, measured by elevated liver enzymes. Damage can begin even in healthy adults taking as little as 4,000 mg a day after as few as four days, according to a recent study. Acetaminophen overdose is now the leading cause of acute liver failure in the US, and cases are on the rise. About half of acetaminophen overdoses are accidental overdoses (most of the rest are suicide attempts).
A study in the journal Hepatology found that 63 percent of patients who overdosed accidentally had been using prescription drugs that combined acetaminophen and an opioid drug, and 38 percent had been using two drugs that contained acetaminophen. (A large number of nonprescription formulas contain acetaminophen, including pain relievers like Excedrin, multi-symptom remedies like TheraFlu, sinus medicines like Sinutab and Sudafed Cold and Sinus, and combination pain and sleep aids like Anacin PM and Midol PM.)
People who take acetaminophen regularly should not drink alcohol and should check all their prescription and over-the-counter drugs to see if they contain any additional acetaminophen in them. (It may also be listed as APAP.) Although current labeling still allows 4,000 mg/day, some experts feel a lower maximum of 2,000 or 3,000 mg/day may be safer for some patients, such as the elderly, who may have decreased kidney or liver function. Those with liver or kidney disease need to be extra careful, and should check with their doctors before taking any acetaminophen, even in over-the-counter medications.
Painkillers known as nonsteroidal anti-inflammatory drugs (NSAIDs) include the old standby, aspirin. For common pain like muscle cramps, menstrual cramps, headache, back pain, arthritis, and related conditions, NSAIDs are usually very effective in reducing both pain and inflammation. When over-the-counter options don't provide enough relief, prescription NSAIDs are usually the next option that doctors try.
These medications work by blocking certain enzymes called COX-1 and COX-2 involved in inflammation (the immune response to injury or irritation). Examples of NSAIDs include ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), diclofenac (Cataflam, Voltaren), indomethacin (Indocin), and ketoprofen (Orudis). Ibuprofen and naproxen are available over-the-counter at lower doses than prescription versions.
Although still controversial, certain prescription NSAIDs may increase the risk of heart attack. A 2013 review of varies medical studies in the Lancet found that most NSAIDs do contribute to an increased risk of heart problems, including heart attacks, heart failure and stroke. However, naproxen in high doses was considered less of a risk than the other medications.
NSAIDs can also cause gastritis or bleeding ulcers in the stomach. Other common side effects of prescription NSAIDs include stomach pain, heartburn, dizziness, headaches, gas, diarrhea, constipation, fatigue, and dry mouth. NSAIDs can make chronic kidney problems worse, so if you have kidney problems your doctor will be monitoring you closely with regular tests. People who have to take the drugs for more than a week or two at a time should thoroughly discuss the risks with their doctors.
Celebrex (COX-2 inhibitor)
Celecoxib (Celebrex) is an NSAID that belongs to a class of drugs called COX-2 inhibitors. These drugs were heralded as a major breakthrough when they first appeared on the market because they work in a more targeted way than traditional NSAIDs, selectively blocking the COX-2 enzyme. As COX-1 is involved in many "housekeeping" functions in the body, including producing protective stomach mucus, this makes the targeted drugs less likely to cause gastrointestinal bleeding or ulcers, in theory.
Although Celebrex may raise your blood pressure and increase the risk of heart disease or stroke, a 2016 study in the New England Journal of Medicine concluded that it puts patients at no more risk than other NSAIDs you can buy over the counter.
However, another COX-2 inhibitor Vioxx (rofecoxib) -- was pulled off the market in 2004 after studies found that an unexpectedly large number of patients developed heart trouble. Again, patients taking Celebrex for prolonged periods should talk to their doctor about the potential risks.
Opioids: Serious relief for serious pain
Two hundred years after the discovery of morphine, opioids and others like it continue to play a major role in pain relief. About 3 to 4 percent of adults in the U.S. take opioids on a long-term basis, and some experts believe that opioid abuse is at crisis levels.
Morphine and codeine are opiates, found naturally in opium poppies. Newer synthetic drugs such as oxycodone (Oxycontin), hydrocodone (Vicodin), and fentanyl (Duragesic) all belong to a class of medications called opioids because they are related to the opiate drugs. These drugs all work by blocking pain messages in the brain, and are commonly prescribed to treat chronic pain caused by cancer, damaged nerves, and inflammatory diseases such as rheumatoid arthritis.
Short-acting formulas are often combined with acetaminophen, so make sure you check the label if you are already taking it in another medication; according to the American Liver Foundation, the total dosage of acetaminophen should not exceed 3,000 mg/day for any prolonged period of time. People with liver or kidney problems, or who drink regularly, should also check with their doctor before using acetaminophen.
Although they are highly effective for many types of patients, opioids are also controversial. When taken inappropriately or for long periods of time, the drugs can be highly addictive: Heroin is derived from morphine, and oxycodone addiction is a growing problem. In addition, oxycodone users are 40 times more likely than non-users to abuse heroin.
In 2016, the federal government issued national guidelines aimed at reducing opioid overuse. The guidelines suggest that your doctor prescribe the lowest effective dose for you and monitor your regularly to see if it is still working. But some expert suggest still more caution. Over time, the body can become used to opioids, and a patient may need gradually increasing doses to get the same level of relief. In an interview with Health News Review, Dr. David Juulink, a Canadian expert on opioid research, said that the "elephant in the room" is that virtually all patients who take opioids regularly for chronic pain are physically dependent on them and develop early symptoms of opioid withdrawal when they stop taking them.
Addiction isn't the only possible risk when taking opioids. Constipation is almost inevitable with long-term treatment. A doctor may prescribe stool softeners or laxatives along with opioids to avoid this unpleasant complication, especially if you are taking opioids daily. Other common side effects include dry mouth, nausea, vomiting, and itching. If you haven't taken these drugs before, you and your family will be asked to watch carefully for extreme drowsiness or dizziness, confusion, bluish or clammy skin, dramatic slowdowns in breathing or heart rate, and other signs of extreme sensitivity and overdose.
Opioids come in several different forms. A controlled release drug that spreads the medication throughout the day will bring more consistent relief than a quick-acting drug that works all at once. Controlled release drugs are available in pills (such as CR oxycodone) or patches (such as transdermal fentanyl). Fentanyl patches have been linked to accidental fatal overdoses and should be used with extreme caution. Cancer patients or patients in hospice who have trouble swallowing, among others, may also be given liquid morphine.
Lidocaine, prilocaine, and similar medications have prevented many tears from being shed in doctors' and dentists' offices. Anesthetic drugs numb nerve endings and are often applied to skin to take the sting out of shots. They are also used to relieve itchy skin and numb toothaches and mouth sores. More recently, doctors have found new uses for these medications. A patch that slowly releases lidocaine is now a common treatment for pain that comes from nerve damage, including pain associated with shingles. Lidocaine can also be injected to relieve chronic pain stemming from injured nerves, such as in carpal tunnel syndrome.
Antidepressants and antiseizure drugs
If your pain has not responded to other treatments, your doctor may consider prescribing something different. Drugs developed to treat depression and epilepsy are now widely used off-label (often in combination with other medications) to treat certain types of chronic pain because they alter spinal cord and brain chemistry. (Off-label use refers to the legal practice of prescribing drugs for a purpose outside the scope of the drug's Food and Drug Administration-approved label.) They are most helpful in treating neuropathic conditions, in which someone feels chronic pain from nerves that have been damaged during tissue injury. In these conditions, the nervous system often keeps sensing pain even when there is no current injury; they include phantom limb pain (in which an amputee feels pain in a missing limb), diabetic neuropathy, multiple sclerosis, and Parkinson's disease. Physicians may prescribe antidepressants and antiepileptics for certain non-neuropathic pain syndromes such as fibromyalgia and low back pain.
Commonly used drugs include tricyclic antidepressants such as desipramine (Norpramin) and amitriptyline (Elavil), and antiepileptic drugs such as carbamazepine (Tegretol) and pregabalin (Lyrica). Keep in mind that antidepressants such as desipramine and amitriptyline carry black box warnings from the FDA for increased risk of suicidal behavior. If you and your doctor decide to use a drug for an off label use, your doctor will want to monitor you closely and may try several different drugs or combinations before finding something that works for you. As always, please be sure to tell your doctor about all medications and supplements you are taking, whether OTC or prescription, because of many possible drug interactions, especially with antidepressants.
Dowell, Deborah MD, MPH et al. CDC Guidelines for Prescribing Opioids for Chronic Pain, United States, 2016. JAMA. April 19, 2016. http://jamanetwork.com/journals/jama/fullarticle/2503508
Chen, Jonathan H. MD, PhD et al. Distribution of Opioids by Different Types of Medicare Prescribers. JAMA February 2016. http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2474400
Nissen, Steven E. MD et al. Cardiovascular Safety of Celecoxib, Naproxen, or Ibuprofen for Arthritis. NEJM. November 2016 http://www.nejm.org/doi/full/10.1056/NEJMoa1611593
Bhala N, Emberson J, et al. The CNT Collaborative Group. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. The Lancet. May 30, 2013. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60900-9/fulltext
Mayo Clinic. Antidepressants: Another weapon against chronic pain. November 18, 2008.
Solomon, DH, et al. Subgroup analyses to determine cardiovascular risk associated with nonsteroidal anti-inflammatory drugs and coxibs in specific patient groups. Arthritis and Rheumatism. August 15, 2008; 59(8): 1097-104.
Fentanyl Transdermal System (marketed as Duragesic) Information. December 2007. http://www.fda.gov/cder/drug/infopage/fentanyl/default.htm
US Food and Drug Administration. Managing chronic pain. June 2004. http://www.fda.gov/fdac/features/2004/204_pain.html
Johns Hopkins University. Pain management: The benefits and risks of opioids. http://www.hopkins-arthritis.som.jhmi.edu/mngmnt/opioids.htm
American Academy of Family Physicians. Prescription pain medicines. http://familydoctor.org/802.xml
Acetaminophen-Induced Acute Liver Failure: Results of a United States Multicenter, Prospective Study, Larson, Lee, and the Acute Liver Failure Study Group. Hepatology.
Kidney and Urology Foundation of America What You Should Know About Painkillers And Your Kidneys. http://www.kidneyurology.org/Patient_Resources/PaR_Lib_Painkillers.htm
National Kidney Foundation. Analgesics. http://www.kidney.org/atoz/atozItem.cfm?id=23
American Academy of Hospice and Palliative Medicine. Fast fact and concept #018; short acting oral opioid dosing intervals.
National Institutes of Health. Drugs as opiates, drugs as research tools: synthetic opiates and opioids. http://history.nih.gov/exhibits/opiates/index.html
U.S. Food and Drug Administration. FDA strengthens warnings for oxycontin. http://www.fda.gov/bbs/topics/ANSWERS/2001/ANS01091.html
Pharo GH, et al. Pharmacologic management of cancer pain. The Journal of the American Osteopathic Association. 105;suppl 5: 21-28.
American College of Physicians. Common side effects of opioids. http://www.acponline.org/journals/news/dec04/pain/side_effects.htm
WorstPills.org. Drug Profile: pregabalin. http://www.worstpills.org/member/drugprofile.cfm?m_id=312