• By Dana Sparks

Chronic pain and medication decisions

May 23, 2018

a middle-aged woman sitting on a bed with her hand on her back revealing painChronic pain can limit your quality of life and lead to additional health problems. Finding treatment is important, as is balancing pain relief with your safety.

Like any long-term health problem, chronic pain often leads to complications beyond your physical symptoms, such as new or worsened depression, anxiety and difficulty sleeping. The condition can make it more difficult to keep up at work, manage tasks at home and attend social gatherings. This could lead to problems in your relationships and financial instability.

The consequences of chronic pain make finding effective treatment critical. But this process is complex and personal. What works for one person's chronic low back pain may not relieve your osteoarthritis. Your diagnosis, biology and personal history all play a role, and finding pain therapies that bring you adequate relief can be a lengthy effort.

Working in partnership with your health care provider, however, you can identify treatments that enable you to live an enjoyable, fulfilling life. The approach you choose should include more than just medication, but painkillers are likely to play a role. Learn about the risks and benefits of common pain medications, so that you can make safe choices as you seek your solution.

Nonsteroidal anti-inflammatory drugs (NSAID)

NSAIDs are most effective for mild to moderate pain that's accompanied by swelling and inflammation. These drugs commonly are used for arthritis and pain resulting from muscle sprains, strains, back and neck injuries, or menstrual cramps.

  • Generic (brand) names
    NSAIDs include ibuprofen sold as Advil and Motrin IB as well as other names, and naproxen sodium, sold as Aleve.
  • How they work
    NSAIDs work by inhibiting certain enzymes in your body, called cyclooxygenase, that are released during tissue damage. By blocking the different types of cyclooxygenase (COX), including COX-1 and COX-2, NSAIDs can reduce pain and inflammation resulting from an injury.
  • Benefits and risks
    When taken as directed, NSAIDs are generally safe. But if you take more than the recommended dosage — and sometimes even just the recommended dosage — NSAIDs may cause nausea, stomach pain, stomach bleeding or ulcers. Large doses of NSAIDs also can lead to kidney problems, fluid retention and high blood pressure. Risk of these conditions increases with age and in the presence of other health problems, including diabetes, a history of stomach ulcers or reflux, and kidney disease.
  • Bottom line
    If you regularly take NSAIDs, talk to your health care provider, so that he or she can monitor you for possible side effects. Bear in mind that NSAIDs also have a "ceiling effect." That is, there is a limit as to how much pain they can control. Beyond a certain dosage, they don't provide additional benefit. Exceeding the recommended dose may not relieve your pain and may increase your risk of side effects.

Watch: Mayo Clinic Minute - Avoids opiopids for chronic pain.

Journalists: Broadcast-quality video pkg (1:00) is in the downloads. Read the script.

Acetaminophen

Acetaminophen usually is recommended as a first-line treatment for mild to moderate pain, such as from a skin injury, headache or musculoskeletal condition. Acetaminophen often is prescribed to manage osteoarthritis and back pain. It also may be combined with opioids to reduce the amount of opioid needed.

  • Brand names
    Acetaminophen sold as Tylenol and under other names.)
  • How it works
    Scientists don't know exactly how acetaminophen works. Some believe there may be a third type of cyclooxygenase, COX-3, that acetaminophen blocks. Acetaminophen doesn't affect the other two cyclooxygenase enzymes, and it doesn't target inflammation — only pain. It may be less effective than NSAIDs.
  • Benefits and risks
    Acetaminophen generally is considered safer than other nonopioid pain relievers because it doesn't cause side effects such as stomach pain and bleeding. However, taking more than the recommended dose — or taking acetaminophen with alcohol — increases your risk of kidney damage and liver failure over time.
  • Bottom line
     Acetaminophen is generally a safe option to try first for many types of pain, including chronic pain. Ask your health care provider for guidance about other medications to avoid while taking acetaminophen. Acetaminophen is not as effective as NSAIDs for the treatment of knee and hip pain related to osteoarthritis.

COX-2 inhibitors

These medications were developed to reduce common side effects associated with traditional NSAIDs. COX-2 inhibitors commonly are used for arthritis and pain resulting from muscle sprains, strains, back and neck injuries, or menstrual cramps. They are as effective as NSAIDs and may be the right choice if you need long-term pain control without increased risk of stomach damage.

  • Brand names
    An example of a COX-2 inhibitor is Celecoxib (Celebrex).
  • How they work
    COX-2 inhibitors, another type of NSAID, work slightly differently from traditional NSAIDs. A COX-2 inhibitor blocks only the COX-2 enzyme — the one that's more likely to cause pain and inflammation.
  • Benefits and risks
    COX-1 enzymes help protect the lining of your stomach. NSAIDs, which block COX-1, can cause side effects such as stomach pain and bleeding. COX-2 inhibitors, on the other hand, help keep the stomach protected by acting only on COX-2 enzymes, allowing COX-1 to function normally. Although the risk of stomach bleeding is generally lower if you take a COX-2 inhibitor instead of an NSAID, bleeding can still occur, especially at higher doses. These medications may cause side effects, such as headache and dizziness, and can lead to kidney problems, fluid retention and high blood pressure.
  • Bottom line
    Older adults may be at higher risk of common COX-2 side effects compared with younger adults. If these medications help you manage chronic pain, take the lowest effective dose for the shortest time possible, and follow up closely with your health care provider.

This article is written by Mayo Clinic staff. Find more health and medical information on mayoclinic.org.

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