Chronic Pain: OTC or Prescription Medicine?

From the WebMD Archives

If you are one of the millions of Americans who suffers from chronic pain, you have more options than ever to treat the pain. Your choices range from simple remedies such as an ice pack or heating pad to more complex treatments like surgery.

Somewhere in between these pain management options are medications: over-the-counter (OTC) medication and prescription drugs. And while an aspirin or two might be the best way to knock out a headache or ease low back pain, a stronger prescription drug may be needed to relieve long-term, severe pain.

More choices mean more decisions. Should you always use an OTC drug first? Should you get a prescription for something stronger? Or should you call your doctor and get his or her input first?

When Should You Use an OTC?

The answer to the first question depends on a few factors, according to Beth Minzter, MD, a pain management specialist at Cleveland Clinic.

"An over-the-counter drug might make sense if a person has osteoarthritis of the knee and it occasionally hurts more than usual. But it might also be appropriate for that same person to take a stronger prescription drug," she says. The decision depends on if the drug is helping, how regularly you are using it, and the severity of side effects, Minzter tells WebMD.

OTC pain relievers are commonly used for arthritis pain, headaches, back pain, sore muscles, and joint pain. Aspirin, ibuprofen (Advil, Motrin IB), and naproxen sodium (Aleve) are nonsteroidal anti-inflammatory drugs (NSAIDs).

"Nonsteroidal drugs are extremely effective because they reduce swelling and relieve pain," Minzter says. "If you have a bad shoulder that occasionally gets to the point where you cannot sleep, a NSAID might be great on a short-term basis. But if that shoulder hurts all the time, it is reasonable to ask your doctor -- in a non-urgent manner -- about switching to a long-acting drug that would give you around-the-clock pain relief."

"Just because one NSAID doesn’t work, it doesn’t mean a different NSAID won’t work, either," says Minzter. "Nonsteroidals are very patient-specific. Different people have different reactions."

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Although doctors don’t fully understand how acetaminophen works, it belongs to a class of painkillers called non-opioid analgesics. Also used as a fever reducer, acetaminophen is thought to relieve pain by affecting the part of the brain that receives pain messages and controls body temperature. It often helps relieve pain due to headaches, back pain, sore muscles, and joint pain.

Acetaminophen may also be used in combination with opioid medications. For example, a doctor may prescribe a combination of acetaminophen and a narcotic medication such as codeine or hydrocodone for moderately severe pain.

Don’t Underestimate Side Effects

NSAIDs can cause stomach irritation and bleeding. The chances are higher if you are age 60 or older, have had stomach ulcers, take a blood thinner, have three or more alcoholic drinks a day, or take them for longer than recommended.

If you need an NSAID for longer than 10 days, check with your doctor to see if you need a prescription NSAID or some other alternative. Also ask if you need to take extra steps to help protect your stomach.

Acetaminophen carries a risk of liver damage, which can lead to liver failure, if not taken as directed. Make sure you take no more than recommended on the label. And watch out that you do not mix it with other medications, including prescription painkillers that may also contain acetaminophen. The risk of liver damage increases if you drink alcohol. In fact, the FDA recommends that you do not mix acetaminophen with any alcohol.

The strength of a pain reliever also matters when it comes to side effects. That’s why it’s important to avoid taking more than the recommended amount of an OTC pain reliever.

"If you are feeling better, consider decreasing the frequency or dosage of any pain medicine," says Minzter. "Give your body an occasional vacation from pain drugs.” But remember, when it comes to OTC pain relievers, you shouldn't take them for more than 10 days without talking to your doctor.



 

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Prescription Drugs: Not Always the Next Step

If OTC drugs are not effective in relieving your pain, moving to a prescription drug is not always necessarily the next step. In many cases, drugs may not always be the best course of treatment.

"Pain management doesn’t have to involve a drug," Minzter tells WebMD. Non-medication approaches include avoiding certain activities, exercising, heat or cold applications, weight management, bioelectric currents, complementary and alternative medicine, and surgical procedures.

But if you and your doctor decide that prescription medications are the way to go, there are plenty of options.

Many prescription drugs are designed to treat chronic pain, including back and neck pain, headaches, nerve pain, fibromyalgia, rheumatoid arthritis, and osteoarthritis. The following are a few examples:

Antidepressant Medications

Over the years, doctors have discovered that antidepressants actually help with certain types of pain, such as:

Doctors have found that tricyclic antidepressants are helpful in easing pain and may also improve sleep. While researchers aren’t exactly sure how they reduce pain, studies suggest that tricyclic antidepressants boost chemicals in the brain that help diminish pain signals.

Some examples of tricyclic antidepressants that may relieve pain include:

Other types of antidepressants called SNRIs (serotonin and norepinephrine reuptake inhibitors) that may help relieve pain include:

Other antidepressants known as SSRIs (selective serotonin reuptake inhibitors) may be used to treat the depression that often accompanies chronic pain. This, in turn, also may help relieve pain.

Possible side effects of certain antidepressants include dry mouth, blurred vision, constipation, weight gain, and/or sexual problems, such as the inability to achieve orgasm.

Antispasmodics

Another class of drugs used for pain relief is antispasmodics. Antispasmodics work by relaxing the smooth muscle of the gut. These drugs are used to treat irritable bowel syndrome, diverticular disease, and other digestive conditions, as well as menstrual pain and interstitial cystitis.

Antispasmodic drugs include:

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Side effects of antispasmodic medication may include constipation, headache, blurred vision, drowsiness, difficulty sleeping, and decreased sweating or thirst.

Anticonvulsant Medications

Some anticonvulsants are used for pain caused by nerve damage associated with diabetes and shingles, as well as for fibromyalgia pain. These medications may include:

Experts aren't exactly sure how these medications ease pain. Anticonvulsants are thought to block pain signals from the central nervous system.

Side effects of anticonvulsants may include headache, confusion, skin rash, nausea or vomiting, loss of appetite, or weight gain. If you are pregnant or thinking about getting pregnant, be sure to let your doctor know, because taking certain anticonvulsant drugs during pregnancy may increase the risk of birth defects.

Opioid Medications

Narcotic pain drugs, also called opioids, have a proven record of effectiveness, but many people have concerns about their side effects -- constipation, sweating, and increased sensitivity to pain, among them -- and becoming physically dependent on them.

"The dose necessary for continued pain relief often increases with opioids and can lead to side effects," says Minzter. "Nevertheless, they play an important role for some people. For them, pain relief outweighs the negative consequences."

Due to the risk of becoming physically dependent on them, opioid drugs are often a last resort for people who have tried several other treatments and who still have severe pain.

The opioid drugs listed below relieve moderate to severe pain caused by a variety of illnesses, including cancer, and some are used for pain following surgery.

Tramadol

Tramadol (Ultram) may be appropriate for people with moderate to moderately severe pain. Tramadol is in a class of drugs called opiate agonists. The extended-release version of this medicine can be prescribed for people who need medication around the clock to relieve their pain.

The most common side effects of tramadol include nausea, vomiting, constipation, lightheadedness, dizziness, drowsiness, headache, or weakness.

Intrathecal Therapy

Intrathecal therapy is a method of delivering pain medication directly to the spinal cord via a "pain pump." This medication delivery system is used for long-term pain that has not responded to non-invasive pain relief methods.

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When to Call the Doctor

If your pain medications are not working or your pain temporarily increases, it's important to talk to your doctor about finding the pain medication that is effective in managing your pain. So when should you call your doctor about your pain?

"Typically, temporary increases in pain are not a reason to call the doctor," says Minzter. "These episodes can be expected with a chronic pain problem. But always call your doctor if the change in the way you feel is alarming or when there are signs of infection." Fever, inflammation, or swelling is a red flag.

Experts maintain that people react to pain differently. That is, the way you experience pain is likely to differ from how another person experiences it. You and your doctor should work together for develop a plan for how you should respond to an increase in pain and when you need to call your doctor.



 

Managing Your Pain: Be Proactive

When it comes to managing chronic pain, studies suggest that people tend to fall into one of three groups:

  • The first group of people is made up of people who never report their pain or seek medical help for it.
  • The second group seeks a “magic pill” that will eliminate pain and not cause any side effects. This goal is not realistic.
  • The third type of group is more proactive. This type of patient actively participates in managing his or her pain, is well-informed about pain medications and their side effects, and works closely with a doctor to find the most effective drugs that have the fewest side effects.

Be a proactive patient and aim to be part of the third group of people. Tracking the severity of your pain and sharing this information with your doctor can help you manage your pain more effectively. Your doctor can evaluate whether or not your pain management plan is working based on the information you provide.



 

WebMD Feature Reviewed by Melinda Ratini, DO, MS on March 11, 2014

Sources

SOURCES:

American Pain Foundation web site: "Pain Facts & Figures."

Beth Minzter, MD, department of pain management, Cleveland Clinic.

Pain Management: Advances in Diagnosis & Treatment, Cleveland Clinic and Belvoir Media Group, 2010.

WebMD Medical Reference from Healthwise: "Pain Management - Side Effects of Pain Medicines."

Gonzalez, E.  Arthritis &Rheumatism, June 2010.

Consumer Guide to Pain Medication &Treatment, American Chronic Pain Association, 2010.

Drugs.com: "Drugs & Medications, A-Z Drug List."

Watkins, E. Mayo Clinic Proceedings, February 2006.

News release, FDA.

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