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Chronic pain: Medication decisions

Nonsteroidal anti-inflammatory drugs (NSAIDs)
Content
Nonsteroidal anti-inflammatory drugs, known as NSAIDs
Acetaminophen
COX-2 inhibitors
Antidepressants and anti-seizure medications
Opioids
Pain medications at a glance

Pain medications at a glance

Medication type How they work First line option for Benefits Risks
NSAIDs Block COX-1 and COX-2 enzymes involved in pain and inflammation
  • Mild to moderate pain accompanied by swelling and inflammation
  • Arthritis pain and pain resulting from muscle sprains and strains, back and neck injuries, overuse injuries, and menstrual cramps
  • When taken as directed, generally safe for short-term use
  • Available without a prescription
  • May cause nausea, stomach pain, stomach bleeding or ulcers
  • When taken in high doses, can lead to kidney problems, fluid retention and high blood pressure
  • Increased risk of side effects for older adults
Acetaminophen Thought to block prostaglandin production in the central nervous system Mild to moderate pain Available without a prescription When more than the recommended dose is taken or when taken with alcohol, increased risk of kidney damage and liver failure over time
COX-2 inhibitors Block COX-2 enzymes Rheumatoid arthritis, osteoarthritis, menstrual cramps and injury-related pain As effective as NSAIDs without damaging stomach lining at regular doses
  • Headache and dizziness
  • When taken in high doses, can lead to stomach bleeding, kidney problems, fluid retention, high blood pressure, heart attack and stroke
  • Increased risk of side effects for older adults
Antidepressants Interfere with certain chemical processes that cause you to feel pain
  • Neuropathic pain, chronic headaches, fibromyalgia
  • May be considered for chronic low back pain
  • Can be in doses much lower than what is currently used to treat depression
  • Side effects generally mild, depending on the type of antidepressant
  • Drowsiness possible with tricyclic antidepressants
  • Can take several weeks to produce desired effects
  • May worsen depression and cause suicidal thoughts in a small number of people
Anti-seizure medications Quiet pain signals from damaged nerves The burning pain of shingles, known as postherpetic neuralgia; diabetic neuropathy; fibromyalgia Side effects generally mild
  • May cause dizziness, drowsiness, nausea, reduced coordination and weight changes
  • May worsen depression and cause suicidal thoughts in a small number of people
Opioids
  • Blocks opioid receptors, which stop the release of chemicals that cause pain
  • Can stop the transmission of pain signals
  • Acute pain, such as pain that follows surgery or a bone fracture
  • Typically prescribed for a few days or less
 Powerful relief during short periods of severe pain
  • Feeling drowsy, nausea, itchiness, constipation
  • Tolerance, dependence, misuse, addiction and overdose
  • Taking opioids for longer than the prescribed length of time increases the risk of staying on them long term
  • Responsible for the majority of overdose deaths in the U.S.