Pain Relief Medications

Medications for pain or pain relievers can be grouped into different categories, depending on how they work. The following is a summary of the common pain relievers.

Pain Relief Medications

Types of pain relievers

Common pain relievers	Description
Paracetamol	Paracetamol is used to treat mild-to-moderate pain. It acts mainly in your brain and has an effect on many different ways you feel pain. It is a mostly safe and useful medicine if it is taken at the correct dose and can be effective for many different types of pain. For most types of acute or short-term pain, paracetamol is best used when needed, only when you feel pain. However, for some types of chronic or long-term pain, taking paracetamol at regular times (every 6 hours) is likely to be most helpful. Read more about paracetamol.
Non-steroidal anti-inflammatories  Ibuprofen Diclofenac Naproxen Mefenamic acid	NSAIDs are used to reduce mild-to-moderate pain and inflammation (swelling). They work by blocking and reducing enzymes and hormones that cause pain and swelling in your body. NSAIDs can be used for short-term pain such as when you have an injury or a flare-up of symptoms. NSAIDs are not suitable if you have stomach problems because they may cause stomach bleeding. They may also not be suitable if you have asthma, heart, liver or kidney problems. Before taking NSAIDs, check with your pharmacist or doctor whether they are suitable for you. NSAIDs are also available as gels or creams that can be massaged onto the painful area. NSAIDs may not be useful for chronic or long-term pain as they treat inflammation and this is not often the cause of chronic pain. If they are used long-term they can have harmful side effects. If long-term NSAIDs are thought to be your best option, you will need to have blood tests and regular check-ups with your doctor. Read more about NSAIDs.
COX-2 inhibitors Celecoxib Etoricoxib	COX-2 inhibitors are a type of NSAID. They also reduce pain and inflammation but may be less harmful to your stomach. They may not be suitable if you have heart, liver or kidney problems.
Opioids Codeine Tramadol Morphine Oxycodone	Opioids can be used for moderate-to-severe short-term pain such as after an injury or surgery, or for ongoing pain due to cancer. They are not recommended for other types of ongoing pain such as nerve pain because they don’t greatly improve pain levels or help you to be able to do the things you want to do. In about 20–30% of people, they can cause unpleasant side effects, such as constipation, nausea, dizziness and sleepiness. Ongoing use can lead to dependency and addiction. Codeine, dihydrocodeine and tramadol are weaker opioids for moderate pain, while morphine and oxycodone are used for more severe pain.
Steroids Prednisone Triamcinolone Dexamethasone	Some steroids are used for pain relief by reducing swelling and inflammation when other pain relievers are not effective alone or are not suitable. They may provide short-term pain relief, but do not improve joint function or stiffness. They are most useful for treating flare-ups of pain. These types of steroids may be given as tablets or an injection directly into a painful joint.
Antidepressants Amitriptyline Nortriptyline	Tricyclic antidepressants are usually used to treat depression but low doses can relieve some types of chronic pain such as nerve pain. They have also been found to improve sleep and help with relaxation. To work effectively, tricyclic antidepressants must be taken every day, even when you do not have pain. Taking them only when you need pain relief will not work as well. Your doctor will start you on a low dose and increase the dose slowly if you need it. Antidepressants do not start working immediately — it can take a few days for you to notice the pain relief effects. If tricyclic antidepressants help your pain, you can continue to take them for as long as you need to, but do not take any more than the amount prescribed without talking to your doctor first. If you do not feel any improvement in your pain after 6–8 weeks, speak to your doctor. Many people experience side effects with tricyclic antidepressants, including drowsiness, constipation and dry mouth. If these are troublesome, talk to your doctor.
Gabapentinoids Gabapentin Pregabalin	Gabapentin and pregabalin can provide pain relief in some people with nerve pain. They do not work for everyone. To work effectively, gabapentinoids must be taken every day, even when you do not have pain. Taking them only when you need pain relief will not work. Your doctor will start you on a low dose and increase the dose slowly, to allow your body to get used to the medicine. It can take a few weeks for you to notice the full pain relief effects of gabapentinoids. If gabapentinoids help your pain, you can continue to take them for as long as you need to. If you do not feel any improvement in your pain after 6–8 weeks, speak to your doctor. Do not stop taking these suddenly without your doctor’s advice.

Which pain reliever?

The choice of pain relief medication can depend on many things, such as the type, severity and cause of your pain, other medications you may already be taking, any allergies you may have and other conditions you may have.

Type of pain

Acute pain

Acute pain usually occurs because of surgery, injury or infection, such as a dental infection or bone fracture (break). It often comes on quickly, lasts for a short time and goes away as the underlying cause resolves. Treatments usually only need to be given for a short time while the injury is healing.

• Paracetamol and NSAIDs are commonly used.
• Opioids are useful and usually only need to be given for a few days. The dose of opioid should be reduced as healing occurs.
• Read more about acute pain.

Chronic pain

Chronic pain, also called persistent pain or long-term pain, is pain that lasts longer than 3 months. It is often described as pain that does not go away as expected after an injury or illness.

• Chronic pain is thought to occur when nerves become over-sensitive and send warning messages to your brain even when there is no injury, or the original injury causing pain has healed. In other words, the fire has been put out, but the fire alarm is still going off.
• Chronic pain is complex and can be difficult to treat. The aim of treatment is to find ways to support you and reduce the impact of the pain on your life.
• Medicines generally, and opioids in particular, are often not very effective for chronic pain because they do not greatly improve chronic pain levels or help you to be able to do the things you want to do. However, medication can be used in some situations alongside other strategies, such as physiotherapy, exercise, diet, relaxation, different ways of thinking and responding to pain (mindfulness and cognitive behaviour therapy), or other non-medicine treatments such as electrical stimulating techniques (TENS machine) and acupuncture.
• Read more about chronic pain and medicines for chronic pain.

Nerve pain

Nerve pain is a type of chronic pain from an injury to your nerves or nervous system. Types of nerve pain include sciatica from disc prolapse, nerve injury after spinal surgery, pain after infection such as shingles, pain with diabetes, pain after amputation (phantom limb pain or stump pain) and pain with multiple sclerosis or stroke.

• Medicines used to treat nerve pain include tricyclic antidepressants (amitriptyline, nortriptyline) and gabapentinoids (gabapentin, pregabalin).
• If these medicines help your pain, you can continue to take them for as long as you need to. If you do not feel any improvement in your pain after 6–8 weeks, speak to your doctor.
• Read more about nerve pain.

Severity of the pain

Pain is usually grouped into mild pain, moderate pain or severe pain. The step-wise or ladder approach to managing pain is based on the severity of your pain. It is a 3-step approach.

• Step 1: Mild-to-moderate pain
  This type of pain is best treated with paracetamol, ibuprofen and other NSAIDs. Read more about paracetamol and NSAIDs.
• Step 2: Moderate-to-severe pain
  More intense pain is treated with mild opioid pain relievers such as codeine and tramadol. These may be used together with paracetamol or NSAIDs.
• Step 3: Severe pain
  Severe pain is treated with strong opioids such as morphine and oxycodone. These may be used together with paracetamol or NSAIDs. Read more about opioids.

 

Cause of the pain

Depending on the cause and site of your pain, you may need to use other things to ease the pain.

• Muscle sprain may be relieved by R.I.C.E. (rest, ice, compression and elevation).
• Pain caused by indigestion may be relieved by antacids.
• If you have migraine headaches, you may need to take triptan medicines, a special type of painkiller for migraine headaches. They’re thought to work by reversing the changes in the brain that may cause migraine headaches.

 

Medical conditions

Some types of pain medication can worsen some medical conditions and should be avoided. For example, NSAIDS can make stomach ulcers worse, so if you have a history of stomach ulcers, you should avoid them. NSAIDs must also be used with caution by older adults and people with heart disease, type 2 diabetes or kidney problems.

Medications you are taking

Before taking medication for pain relief, it is important to ask if these may interact with medications that you are already taking for another condition. If you are unsure, check with your doctor or pharmacist.

Allergies

Some allergies may prevent you from taking certain types of pain relief medicines. For example, NSAIDs can cause allergic reactions in some people. Soon after taking the medicine, you may develop flushing, itchy rashes (hives), blocked and runny nose, and asthma (sometimes severe). If you have had hives (urticaria), nasal polyps or asthma, your risk of NSAID allergy is much higher compared to people without these conditions.

What can I do to make sure I’m taking my pain relief medication safely and effectively?

Ask your doctor or pharmacist for advice or read the packaging of over-the-counter medicines. This will help to reduce the risks of taking these medications. You can also compare the benefits and risks of commonly used painkillers.

Pain Relief Medications

References

1. The principles of managing acute pain in primary care BPAC, NZ, 2018
2. Prescribing gabapentin and pregabalin: upcoming subsidy changes BPAC, NZ, 2018
3. Managing patient with neuropathic pain BPAC, NZ, 2018
4. Helping patients cope with chronic non-malignant pain: it’s not about opioids BPAC, NZ, 2014