‘Skills before pills’
The use of medication in chronic pain
Introduction
At the Pain Self-Management Service no new medication will be prescribed for you;
instead, the aim is to help you to use your medication effectively and safely. We can
also support you in reducing your medication intake if this is a goal you want to work
on.
Medication can be very helpful in acute or short term pain, but although it can be a
useful tool in the management of chronic pain it can also have some disadvantages
such as unpleasant side effects. Also medication is unlikely to get rid of all the pain
and therefore it is important to develop other self-management skills such as
exercise, relaxation and participating in enjoyable and meaningful activities.
If you use medication to manage your chronic pain it is important to know what you
are taking and to use it safely and skilfully. Remember ‘skills before pills’.
Medications used in chronic pain
Various different types of medication are used in chronic pain, not only pain killers
but also anti-inflammatories (NSAIDs), anti-epilepsy medications and antidepressants can also be helpful in the management of chronic pain.
We will briefly describe the way these medications work with some examples of
each.
Painkillers
Pain killers are sometimes referred to as analgesics and will often be prescribed for
chronic pain.
Mild painkillers can be purchased over the counter and will often have brand names.
For example paracetamol may be called Panadol and ibuprofen may be sold as
Nurofen. If you are not sure whether an over the counter medication is safe to take
with your other medication, always ask the pharmacist before you buy it.
Mild painkillers
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Paracetamol: this is a widely used painkiller that can be purchased over the
counter. The dose of paracetamol is no more than 2 tablets at a time and no
more than 8 tablets in 24 hours. It is very important to stay within dose limit
as you can damage your liver if you exceed the recommended dose. Some
other medications contain paracetamol including cold remedies and some
medications prescribed by doctors. It is therefore very important to know if a
prescribed medication that you are taking contains paracetamol and to avoid
adding any more if you are already taking a full day’s dose.
Non-steroidal anti-inflammatory drugs (NSAIDs)
These are useful in joint and inflammatory conditions. They prevent the release
of chemicals that sensitise nerve endings and produce pain.
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Examples are Ibuprofen (Brufen, Nurofen), Naproxen (Naprosyn), Diclofenac
(Voltarol), Celecoxib (Celebrex)
NSAIDs can work well in a flare up of pain but are not suitable for everyone.
NSAIDs can cause stomach problems such as indigestion and bleeding if
taken regularly. In the long term doctors may consider giving another
medication such as Omeprazole or Lansoprazole to protect the stomach.
NSAIDs can also worsen asthma.
Although less common, long term, NSAIDs can affect the kidneys and slightly
increase the risk of stroke or heart attack.
Moderate Painkillers
Examples of these are Codeine, Codydramol, Tramacet, Tramadol.
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These medications are weaker morphine based drugs that work by mimicking
our own in-built pain killers (endorphins) and dampen down pain messages.
Side effects include constipation, nausea, feeling drowsy and ‘not really with
it’ and difficulty concentrating.
After a while our body gets used to morphine based medications: we call this
tolerance and it means that you may need more to have the same effect.
Constipation tends to persist and often people have to alter their diet and take
medication to help deal with this problem.
Strong Painkillers
Examples are morphine( eg MST, MXL, Oramorph, Sevredol) Oxycodone
(Oxycontin, Oxynorm). Drugs such as buprenorphine (BuTrans) or fentanyl
(Durogesic) may also be used as patches.
These are all strong opiate drugs. Strong opiate medication can present some
disadvantages:
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It can affect the immune system, leaving people more prone to infections and
also affects hormone levels.
Taking strong morphine drugs can also stir up pain messages themselves
which can actually aggravate the pain.
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People often worry about becoming addicted to morphine drugs, but although
there is a risk, it is quite low. However this is increased if you have had
previous problems with addiction.
If these drugs are stopped suddenly you may experience unpleasant
withdrawal symptoms including an increase in pain.
For more patient information about the use of opioids in chronic pain you may find
the British Pain Society website patient information helpful.
Anti-convulsant (anti-epilepsy) medication.
These medications are normally used for the treatment of epilepsy but can also be
helpful for nerve pain, that often feels like shooting, stabbing or ‘pins and needles’.
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Examples of these medications are Gabapentin (Neurontin) and Pregabalin
(Lyrica)
Side effects may be dizziness, sickness, drowsiness, memory problems and
weight gain.
Normally people start on a small dose to let their body get used to it and it is
then gradually increased over time. It is important not to stop these drugs
suddenly.
Antidepressants for pain
Antidepressants are sometimes used because they act on the effect of the chemicals
in the nervous system that reduce when you have persistent long term pain.
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Amitriptyline is an older style antidepressant which can be useful for chronic
pain when use in a lower dose than would be used for treating depression. It
is usually taken at night and has the added advantage of helping with sleep.
It takes several weeks to impact on the pain.
Possible problems with amitriptyline are: dry mouth, constipation, blurred
vision, dizziness, drowsiness.
Some people say that amitriptyline makes them feel ‘woozy’ or ‘hung over’ in
the morning. Sometimes you can reduce these problems by taking the
amitriptyline slightly earlier in the evening.
Other, newer antidepressant medications such as duloxetine (Cymbalta) have
been found to be helpful for pain but tend to be given at the standard
antidepressant dose.
General information
If you take medication every day or most days it is usually helpful to take it at regular
times or ‘by the clock use’ and maintain a consistent level of the medication in your
system rather than wait until the pain is very severe and prompts you to take it.
Some medications are slow release (SR, MR) which means that you take a larger
dose of the drug usually twice a day and it releases slowly into your system.
Strong morphine based painkillers are sometimes prescribed as patches that you
stick on to the skin and the drug is absorbed over a few days.
Some medications, such as NSAIDs, come in the form of lotions or gels.
It is important that you always take medication safely by following the advice given
by your doctor or pharmacist. Never make changes to your medication without first
discussing it with your doctor or pain nurse.
What would you like to do about medication?
People with chronic pain often report that they would like to take less medication. It
can be helpful to review your medication use and consider whether you are getting
more advantages or disadvantages. You are welcome to discuss your medication
use with the nurse on the Pain Self-Management Programme and if you would like to
work on reducing the amount that you take we can help you to do that.
Remember that although medication can be very useful it is important that you don’t
rely on it as your only strategy for managing pain but develop other self management
skills as well.
Remember: skill before pills
Pain Medication Manual Update Feb 2014
Aims
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To promote safe and effective use of medication for chronic pain
To provide education and information about the medications commonly used
in chronic pain
To encourage reflection on the use of medication and weighing up of the
benefits against the problems associated with long term use
To facilitate understanding of the use of medication as one part of a wide
range of strategies to manage pain, particularly including self- management
To support patients who want to set a goal to be less reliant on medication, to
work towards safe reduction