General Treatments

	Over-the-Counter (OTC) Pain Relievers (Non-Prescription Drugs)
	Nonsteroidal Anti-Inflammatory Drugs (NSAIDS)
	Adjuvant Medications
	Opioid Analgesics
	Interventional Approaches
	Rehabilitation Approaches
	Stimulatory Approaches
	Psychological Approaches
	Complementary Approaches

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How to Prescribe

When using a drug to treat pain, it is very important to use it as prescribed by the physician. Many drugs used for pain must be started at a low dose, then slowly increased -- a method called titration. Because not every patient is the same with regard to his or her pain and body chemistry, every patient responds differently to each drug. Patients with the same pain syndrome may or may not experience pain relief or side effects from any particular drug and, additionally, the best dose often varies from patient to patient.

Over-the-Counter (OTC) Pain Relievers (Non-Prescription Drugs)

Over-the-counter (OTC) pain relievers are among the most widely used drugs. Most people self-medicate their usual aches and pains with medications such as acetaminophen and nonsteroidal anti-inflammatory agents (aspirin, ibuprofen, naproxen, and ketoprofen). Acetaminophen, the active ingredient in Tylenol®, has few side effects. However, long-term regular use of high dose acetaminophen can cause serious liver damage.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used as OTC pain relievers and are also prescribed by doctors in larger doses ("prescription strength"). NSAIDs reduce the production or release of prostaglandins, chemicals in the body responsible for inflammatory pain. Most NSAIDs are taken orally. There are many drugs, and the best drug varies from person to person. NSAIDs are nonspecific analgesics but are most commonly used to treat musculoskeletal pains and headache. The most important side effect is peptic ulcer disease.

Adjuvant Medications

By definition, adjuvant analgesics are drugs whose initial use was not for pain but rather for other conditions. They are a diverse group of drugs that includes antidepressants, anticonvulsants (antiseizure drugs), and others.

Antidepressants
The best studied adjuvant analgesics are the tricyclic antidepressants (TCAs), such as amitriptyline (Elavil®), and desipramine. There is overwhelming evidence that this class of drugs can be effective for migraine headache, tension-type headache, postherpetic neuralgia, painful diabetic neuropathy, arthritis, low back pain, and other painful conditions. These drugs have been shown to relieve pain independent of their effects on depression; that is, patients who are not depressed may experience pain relief. Once the correct dose is found for the individual patient, favorable results are usually seen within a week; however, side effects, including weight gain, dry mouth, blurred vision and constipation, are possible.

There are many newer antidepressants, such as the selective serotonin reuptake inhibitors (like fluoxetine [Prozac®], paroxetine [Paxil®], sertraline [Zoloft®]), and others (like venlafaxine [Effexor®] and nefazadone [Serzone®]. Most of these antidepressant drugs have not been shown to be effective pain relievers in clinical studies, but some have, and many pain specialists believe that most, if not all, can potentially relieve pain. They are usually better tolerated than the TCA's.

Anticonvulsants
Drugs that are primarily used to treat epilepsy (seizures) have been used to treat nerve pain conditions and migraine headache for several decades. Many anticonvulsant drugs have been shown in clinical studies to be effective.

Gabapentin (Neurontin®) has become a first-line drug for neuropathic conditions due to its proven effectiveness and its low incidence of side effects. Other anticonvulsant drugs may be useful, including carbamazepine [Tegretol®], phenytoin [Dilantin®], valproate [Depakote®], clonazepam [Klonopin®], topiramate [Topamax®], and lamotrigine [Lamictal®]. The most common use of these drugs is for nerve pains, such as trigeminal neuralgia, postherpetic neuralgia, painful diabetic neuropathy, and migraine headache.

Alpha-2-Adrenergic Agonists
Currently, there are two alpha-2-adrenergic agonists that have some evidence as pain relievers: tizanidine (Zanaflex®) and clonidine (Catapres®). There are some studies showing that tizanidine can be effective for tension-type headache, back pain, neuropathic pain, and myofascial pains. Clonidine has been used to treat refractory neuropathic pain. Tizanidine tends to be better tolerated than clonidine and, unlike clonidine, rarely decreases blood pressure.

Local Anesthetics
Mexiletine is a drug that was first approved to treat irregular heart rhythms. However, several scientific studies have shown this drug to be effective in chronic nerve pain syndromes. Other oral local anesthetics are also used. Intravenous infusion of a local anesthetic is a special technique that may be used by pain specialists.

Steroids
Corticosteroids can be used as an effective analgesic for treating some cancer pain syndromes. Also, corticosteroids given as short-term tapers can be effective in treating migraine headache and complex regional pain syndrome (reflex sympathetic dystrophy).

Other Adjuvant Analgesics
Baclofen is on the market as a muscle relaxant and is used to treat nerve pain syndromes. There is very good evidence that it works in trigeminal neuralgia.

There are many drugs that are called "muscle relaxants" and are used to treat minor musculoskeletal pains. These include carisoprodol (Soma®), cyclobenzaprine (Flexeril®), metaxolone (Skelaxin®), and others. These drugs do not actually relax skeletal muscle, but they can relieve pain, and they are commonly used.

Topical Drugs
Topical drugs are applied directly to the skin, as a patch, gel, or cream and have their pharmacologic activity directly under the skin site without any significant amount of drug entering the blood stream. Thus, true topical drugs should not produce any systemic side effects, that is, side effects caused by the drug's effects throughout the body. Currently, only one topical drug has an FDA approved indication for pain treatment -- a topical lidocaine patch (Lidoderm®) -- for the treatment of postherpetic neuralgia. This patch can be tried for many types of nerve pain.

A widely used topical pain reliever is capsaicin, which is available as an over-the-counter cream. There have been some studies that show pain relief with capsaicin and others that do not. This drug is being used to treat nerve pain and arthritis pain.

Opioid Analgesics
(Follow this link to read about opioid analgesics.)

Interventional Approaches

For patients with chronic pain who fail conservative therapies, an interventional therapy might be helpful. The simpler of these approaches include trigger point injections (injecting local anesthetic and/or steroid into myofascial trigger points), epidural steroid injections and joint injections. The more complex include nerve blocks, spinal cord stimulation, and intraspinal drug administration. These more sophisticated procedures are typically provided by anesthesiologists with advanced training in pain management.

Spinal cord stimulation (also called dorsal column stimulation) provides low-voltage stimulation inside the spinal cord and may block or decrease the pain signals going to the brain. This technique has been used to treat chronic low back pain, chronic sciatica, and complex regional pain syndrome (reflex sympathetic dystrophy), among other conditions.

Intraspinal drug administration involves the delivery of low doses of analgesic drugs, such as morphine or clonidine, through a catheter inserted directly into the spine. This approach is used often to manage cancer pain and refractory nonmalignant pain.

Rehabilitation Approaches

Physical therapy and occupational therapy may reduce pain and help restore function. Chronic pain sufferers may benefit from a supervised exercise regimen, designed by a physical therapist trained in treating chronic pain, that includes range of motion maneuvers, strengthening techniques, and aerobic conditioning. Heat and cold and other so-called modalities (e.g., vibration or ultrasound) also may help alleviate pain, although they should not be applied to areas without sensation or in patients who are unable to communicate. Sources of heat or cold include heating pads, hot-water baths, ice packs or vapocoolant sprays like ethyl chloride or fluorimethane.

There are also a variety of alternative physical medicine techniques that appear to benefit some patients. The Alexander technique, which focuses on proper body alignment and positioning, is often used to treat chronic pain. Other techniques used include craniosacral manipulation, osteopathic manipulation, and myofascial release, to name just a few.

Stimulatory Approaches

Pain relief also can be achieved through approaches which stimulate nerve pathways to produce analgesia. The invasive approach, spinal cord stimulation, was mentioned before. The best known and most widely prescribed are acupuncture and transcutaneous electrical nerve stimulation (TENS). Patients receiving TENS carry a small, box-shaped device that transmits electrical impulses into the body through the electrodes to interfere with pain signals. A buzzing, tingling or tapping sensation is felt. TENS should not be used on inflamed or infected skin, in the presence of a pacemaker, or if the patient is pregnant.

Psychological Approaches

Distraction is sometimes called cognitive refocusing. Essentially, it is a strategy that directs a person's attention and concentration at other stimuli, thereby shielding them from their pain. Stimuli may be internal (daydreaming) or external (television). They may be self-initiated, such as making phone calls, or passive, as with listening to music or humor. The most effective distraction techniques are those that are unique and changing, those that require input from most or all of the senses -- seeing, hearing, tasting, touching and smelling -- and those that are interesting to and appropriate for the person practicing them. In some cases, awareness of the pain, as well as fatigue and irritability, increases when the distraction ends.

Relaxation may be used for almost any type of pain, but it is particularly effective for chronic pain by helping to produce a state of relative freedom from anxiety and skeletal muscle tension. Relaxation strategies tend to concentrate on one thing, such as a word, sound, phrase or physical activity, and commonly use music, massage or slow, deep breathing. They also may involve imagery, in which a person focuses mentally on a pleasant or peaceful experience, or superficial body massage, felt to be especially helpful for people with little physical contact or for whom verbal communication is limited or impossible. For maximum relaxation, researchers suggest three 20-minute periods daily, in a quiet environment, assuming a comfortable well-supported position. Practice of a particular technique is suggested to establish a conditioned relaxation response.

Complementary Approaches

Complementary or alternative approaches are often used in combination with traditional analgesic treatments, rather than as substitutes for them. Some therapies that are typically considered alternative are actually considered mainstream by most pain specialists. These include approaches that have been called mind-body (psychologists usually refer to them as cognitive therapies), such as relaxation therapy, distraction techniques, biofeedback, and hypnosis, as well as acupuncture and therapeutic massage. Other complementary therapies include a wide range of practices such as meditation, chiropractic, and nutritional or other remedies that are thought to prompt the body's release of pain-relieving substances. Many of these therapies are readily available, easy to do, inexpensive and low risk. In addition to helping relieve pain, they also may improve sleep, reduce anxiety and increase one's sense of control.