If you’ve ever been treated for severe pain from surgery, an injury, or an illness, you know just how vital pain relief medications can be.
Pain relief treatments come in many forms and potencies, are available by prescription or over-the-counter (OTC), and treat all sorts of physical pain—including that brought on by chronic conditions, sudden trauma, and cancer.
Pain relief medicines (also known as “analgesics” and “painkillers”) are regulated by the Food and Drug Administration (FDA). Some analgesics, including opioid analgesics, act on the body’s peripheral and central nervous systems to block or decrease sensitivity to pain. Others act by inhibiting the formation of certain chemicals in the body.
Among the factors health care professionals consider in recommending or prescribing them are the cause and severity of the pain.
TYPES OF PAIN RELIEVERS
OTC Medications
These relieve the minor aches and pains associated with conditions such as headaches, fever, colds, flu, arthritis, toothaches, and menstrual cramps.
There are basically two types of OTC pain relievers: acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs).
Acetaminophen is an active ingredient found in more than 600 OTC and prescription medicines, including pain relievers, cough suppressants, and cold medications.
NSAIDs are common medications used to relieve fever and minor aches and pains. They include aspirin, naproxen, and ibuprofen, as well as many medicines taken for colds, sinus pressure, and allergies. They act by inhibiting an enzyme that helps make a specific chemical.
Prescription Medications
Typical prescription pain relief medicines include opioids and non-opioid medications.
Derived from opium, opioid drugs are very powerful products. They act by attaching to a specific “receptor” in the brain, spinal cord, and gastrointestinal tract. Opioids can change the way a person experiences pain.
Types of prescription opioid medications include
- morphine, which is often used before and after surgical procedures to alleviate severe pain
- oxycodone, which is also often prescribed for moderate to severe pain
- codeine, which comes in combination with acetaminophen or other non-opioid pain relief medications and is often prescribed for mild to moderate pain
- hydrocodone, which comes in combination with acetaminophen or other non-opioid pain relief medications and is prescribed for moderate to moderately severe pain
FDA has recently notified makers of certain opioid drugs that these products will need to have a Risk Evaluation and Mitigation Strategy (REMS) to ensure that the benefits continue to outweigh the risks.
Affected opioid drugs, which include brand name and generic products, are formulated with the active ingredients fentanyl, hydromorphone, methadone, morphine, oxycodone, and oxymorphone.
FDA has authority to require a REMS under the Food and Drug Administration Amendments Act of 2007.
Types of non-opioid prescription medications include ibuprofen and diclofenac, which treat mild to moderate pain.
USE AS DIRECTED
Pain medications are safe and effective when used as directed. However, misuse of these products can be extremely harmful and even deadly.
Consumers who take pain relief medications must follow their health care professional’s instructions carefully. If a measuring tool is provided with your medicine, use it as directed.
Do not change the dose of your pain relief medication without talking to your doctor first.
Also, pain medications should never be shared with anyone else. Only your health care professional can decide if a prescription pain medication is safe for someone.
Here are other key points to remember.
With acetaminophen:
- Taking a higher dose than recommended will not provide more relief and can be dangerous.
- Too much can lead to liver damage and death. Risk for liver damage may be increased in people who drink three or more alcoholic beverages a day while using acetaminophen-containing medicines.
- Be cautious when giving acetaminophen to children. Infant drop medications can be significantly stronger than regular children’s medications. Read and follow the directions on the label every time you use a medicine. Be sure that your infant is getting the infants’ pain formula and your older child is getting the children’s pain formula.
With NSAIDs:
- Too much can cause stomach bleeding. This risk increases in people who are over 60 years of age, are taking prescription blood thinners, are taking steroids, have a history of stomach bleeding or ulcers, and/or have other bleeding problems.
- Use of NSAIDs can also cause kidney damage. This risk may increase in people who are over 60 years of age, are taking a diuretic (a drug that increases the excretion of urine), have high blood pressure, heart disease, or pre-existing kidney disease.
With opioids:
- Use of opioids can lead to drowsiness. Do not drive or use any machinery that may injure you, especially when you first start the medication.The dose of an opioid pain medication that is safe for you could be high enough to cause an overdose and death in someone else, especially children.
KNOW THE ACTIVE INGREDIENTS
A specific area of concern with OTC pain medicines is when products sold for different uses have the same active ingredient. A cold and cough remedy may have the same active ingredient as a headache remedy or a prescription pain reliever.
To minimize the risks of an accidental overdose, consumers should avoid taking multiple medications with the same active ingredient at the same time.
All OTC medicines must have all of their active ingredients listed on the package. For prescription drugs, the active ingredients are listed on the container label.
Talk with your pharmacist or another health care professional if you have questions about using OTC medicines, and especially before using them in combination with dietary supplements or other OTC or prescription medicines.
MISUSE AND ABUSE
Misuse and abuse of pain medications can be extremely dangerous. This is especially so in regard to opioids. These medications should be stored in a place where they cannot be stolen.
According to the National Institutes of Health, studies have shown that properly managed medical use of opioid analgesic compounds (taken exactly as prescribed) is safe, can manage pain effectively, and rarely causes addiction.
But the abuse of opioids is a significant public safety concern. Abusers ingest these drugs orally, and also crush the pills in order to snort or inject them.
Commonly abused opioid pain medicines include prescription drugs such as codeine, and the brand-name products Oxycontin (oxycodone), Vicodin (hydrocodone with acetaminophen), and Demerol (meperidine).
Addiction is just one serious danger of opioid abuse. A number of overdose deaths have resulted from snorting and injecting opioids, particularly the drug OxyContin, which was designed to be a slow-release formulation.
USE OPIOIDS SAFELY: 3 KEY STEPS
- Keep your doctor informed. Inform your health care professional about any past history of substance abuse. All patients treated with opioids for pain require careful monitoring by their health care professional for signs of abuse and addiction, and to determine when these analgesics are no longer needed.
- Follow directions carefully. Opioids are associated with significant side effects, including drowsiness, constipation, and depressed breathing depending on the amount taken. Taking too much could cause severe respiratory depression or death. Do not crush or break pills. This can alter the rate at which the medication is absorbed and lead to overdose and death.
- Reduce the risk of drug interactions. Don’t mix opioids with alcohol, antihistamines, barbiturates, or benzodiazepines. All of these substances slow breathing and their combined effects could lead to life-threatening respiratory depression.
February 23, 2009
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SOURCES:
The American Academy of Pain Medicine: “AAPM Facts and Figures on Pain.”
Acta Paulista de Enfermagem: “Chronic low back pain: pain intensity, disability, and quality of life.”
Mayo Clinic: “Back pain: Diagnosis & treatment.”
Johns Hopkins Medicine: “7 Ways to Treat Chronic Back Pain Without Surgery.”
Choosing Wisely: “Medicines to Relieve Chronic Pain.”
BMJ: “Opioids for low back pain.”
The New England Journal of Medicine: “Opioid abuse in chronic pain–misconceptions and mitigation strategies.”
National Institute on Drug Abuse: “Opioid Overdose Crisis.”
U.S. Department of Health & Human Services: “About the Epidemic.”
Truven Health Analytics: “Health Poll: Back Pain.”
Pharmacoepidemiology and Drug Safety: “Coronary heart disease outcomes among chronic opioid and cyclooxegenase-2 users compared with a general population cohort.”
Spine: “Prescription opioids for back pain and use of medications for erectile dysfunction.”
JAMA Internal Medicine: “Opioid dose and risk of road trauma in Canada: a population-based study.”
University of Utah: “Side Effects and Risks of Opioid Use for Chronic Pain: Patient Education.”
Addiction: “Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system.”
The JAMA Network: “CDC Guideline for Prescribing Opioids for Chronic Pain–United States, 2016.”
Medscape: “Acetaminophen Toxicity.”
CDC: “CDC Guideline for Prescribing Opioids for Chronic Pain.”
Ineffective Treatment Often Prescribed For Lower Back Pain, Report Says
Enlarge this image Peter Dazeley/Getty Images 
Peter Dazeley/Getty Images
Chances are, you — or someone you know — has suffered from lower back pain.
It can be debilitating. It’s a leading cause of disability globally.
And the number of people with the often-chronic condition is likely to increase.
This warning comes via a series of articles published in the medical journal Lancet in March. They state that about 540 million people have lower back pain — and they predict that the number will jump as the world’s population ages and as populations in lower- and middle-income countries move to urban centers and adopt more sedentary lives.
“We don’t think about [back pain] the same way as cancer or heart attacks. But if you look at disability it causes, especially in middle- and low-income where there isn’t a safety net, it impacts half a billion people,” says Roger Chou, a physician who is a pain specialist at the Oregon Health and Science University and a co-author of the articles.
Disability from chronic back pain can hurt a person’s ability to earn a living. One of the Lancet studies found that among rural Nigerian farmers, half reduced their workload because of back pain — an example of how the disability could contribute to the cycle of poverty in countries that lack benefits such as sick days or a social safety net.
Another study from Australia found that people who retired early because of back pain potentially lost out on hundreds of thousands of dollars of accumulated wealth when compared with healthy people who worked all the way to 65.
An overarching issue with back pain management is that the treatments doctors prescribe are often the wrong ones, the report concludes. Also, in many low-income countries, accessing health care is challenging — and getting appropriate care of back pain, specifically, is even harder. In some poor parts of Asia, pain medications are hard to come by and doctors may not have been trained on the most effective treatments.
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“For chronic back pain, ineffective therapies are used way too often, and things that are shown to work are significantly underused,” says study co-author Judith Turner, a clinical psychologist specializing in pain management at the University of Washington School of Medicine.
For most people with back pain, guidelines developed by pain management specialists at the American Pain Society and the American College of Physicians recommend staying active, using cognitive behavioral therapy and techniques like focused breathing, and getting regular exercise. But doctors are more likely to recommend rest, decreased physical activity and treatments such as surgery or injections.
Why the disparity?
Lack of awareness among both the general public and doctors who are not pain management specialists is a big reason. Another reason many doctors aren’t following the guidelines is because, in countries like the U.S., surgeries, injections and medications, like opioids, tend to be better covered by insurance than psychological interventions like cognitive behavioral therapy or patient training.
“Our understanding of what causes low back pain is very limited. We have very little knowledge about what exactly is causing the pain,” says Andrea Furlan, a pain researcher at the Institute of Work and Health in Toronto and a pain management physician at the University of Toronto School of Medicine.
A complex matrix of factors is implicated in back pain including genetics, social and psychological causes, and chronic conditions like obesity, smoking and insomnia. Treatments such as surgery, injections and opioids only address a narrow subset of those factors. It has been difficult for researchers to tease out how those causal factors interact, so the ability to treat back pain is still rudimentary.
Pain management doctors and researchers say they would like to see a shift toward evidence-based treatments that recent guidelines recommend — emphasizing nonpharmacological treatments for most patients.
In 2010, the back and neck pain group at Cochrane, a nonprofit organization that reviews and analyzes medical literature, assessed 30 studies of behavioral therapies for back pain, which included almost 3,500 patients. Andrea Furlan is also an editor for the group. The researchers found that cognitive behavioral therapy and other behavioral therapies were more effective at relieving pain than what is usually prescribed — physical therapy and medication. The team also reviewed the literature and found that individual patient education classes about coping with back pain helped.
Furlan says she worries about deaths from opioid overdoses that started with a prescription for back pain — and complications of surgeries and injection treatments.
“This is a big part of the origin story of the opioid epidemic,” says Steven George, a physical therapy researcher at Duke University. Like Furlan, he was not involved in writing the Lancet overview. He noted that the series of articles explain “why chronic pain is such an important issue and why we haven’t been able to make inroads.”
But moving closer to the guidelines would require more access to treatments other than medication, greater insurance coverage of these treatments and greater training for doctors in alternate treatments.
Turner says such training is already happening for health care providers from Southeast Asia.
What’s clear is that the solution “has to be tailored,” she says, to the culture and health care system that already exists in a country.
Rina Shaikh-Lesko is a science journalist who writes about medicine, global health and the life sciences. She can be reached @rinawrites
