Chronic pain is a type of pain that continues over time. It can last anywhere from 3 months or more to several years. Chronic pain may be caused by certain health conditions. It is more common in people who are older.

Treatment of chronic pain usually involves medicines and therapy. Medicines used for chronic pain include pain relievers, antidepressants, and anticonvulsants. Different types of medicines help people who have different types of pain. You usually use long-acting medicines for constant pain. Short-acting medicines treat short-term, or acute, pain.

Path to improved health

The goal of chronic pain treatment is to increase function and quality of life. Different types of medicines help people who have different types of pain. For instance, short-acting medicines treat pain that comes and goes. Long-acting medicines treat constant pain.

The most common medicines are listed below. Each one has side effects. These can range from mild to severe. It’s important to follow your doctor’s orders on how to use your pain medicine. If you have questions about side effects or about how much medicine to take, ask your doctor or pharmacist.

Acetaminophen

Acetaminophen helps many kinds of chronic pain. One brand name is Tylenol. It is also found in many and prescription and over-the-counter pain medicines. If you’re not careful, you could take more acetaminophen than is good for you. Too much acetaminophen can cause liver damage, especially if you drink alcohol. Tell your doctor if you take more than 2 acetaminophen pills a day.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Other drugs that help with pain are nonsteroidal anti-inflammatory drugs (NSAIDs). Examples include aspirin, ibuprofen (two brand names: Motrin, Advil), and naproxen (one brand name: Aleve). NSAIDs come in both prescription and over-the-counter forms. These medicines can be taken sometimes or every day. When taken regularly, they build up in the blood to fight inflammation (swelling) and give general pain relief.

Always take NSAIDs with food or milk because the most common side effects are related to the stomach. Other side effects include:

• Increased bruising
• Risk of bleeding in the stomach
• Kidney damage (when taken for long periods of time)
• High blood pressure
• Interference with blood pressure medicines

If you take other pain medicines, do not take NSAIDs without talking to your doctor first.

Antidepressants

Many drugs that treat other illnesses can also treat chronic pain. For example, antidepressants can improve function and provide pain relief. Antidepressants may be used to treat nerve damage, arthritis, and fibromyalgia. They also may help with headaches, facial pain, low back pain, and pelvic pain. It can take several weeks for the medicines to start working.

Types of antidepressants your doctor may prescribe include:

• Tricyclic antidepressants (TCAs), such as amitriptyline (Elavil), imipramine (Tofranil), nortriptyline (Pamelor), and doxepin.
• Selective serotonin/norepinephrine reuptake inhibitors (SNRIs), such as duloxetine (Cymbalta).
• Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft).

Possible side effects of antidepressants include:

• Nausea
• Drowsiness
• Insomnia (trouble sleeping)
• Dry mouth
• Dizziness
• Constipation
• Weight gain
• Heart problems

TCAs tend to have more side effects than SNRIs or SSRIs, but they usually are mild. Your doctor may start you on a low dose of medicine. This helps prevent side effects and allows your body to adjust. The doctor may increase the amount over time. If at any point while taking medicine you become depressed or have suicidal thoughts, call your doctor right away.

Anticonvulsants

Your doctor may want you to try an anticonvulsant medicine. It may help reduce some types of chronic pain, such as low back pain or nerve damage. Examples of anticonvulsants are:

• Gabapentin (Neurontin)
• Carbamazepine (Tegretol)
• Phenytoin (Dilantin)
• Pregabalin (Lyrica)
• Topiramate (Topamax)

Like antidepressants, your doctor may start you on a low dose of anticonvulsants. This helps prevent or reduce side effects. The doctor may increase the amount over time. Contact your doctor right away if you have suicidal thoughts. Minor side effects may include:

• Drowsiness
• Nausea or vomiting
• Restlessness
• Dizziness
• Loss of appetite
• Weight gain
• Itching or swelling

Narcotics

Doctors rarely prescribe narcotics or opioids to treat chronic pain. This is because they are highly addictive. Currently, there is an opioid crisis in the United States. People who become addicted can develop severe symptoms, such as increased pain, depression, or suicidal thoughts. They may begin to abuse other substances, or their behaviors could become harmful or violent. Addicts are at risk of misusing or overdosing on narcotics, which can cause death. Talk to your doctor about all risks of narcotics before starting a new medicine.

If your doctor does prescribe a narcotic, be sure to follow their directions. Do not drive or operate heavy machinery when taking narcotics. Do not use alcohol. Tell your doctor if you have side effects from narcotics. These may include nausea, constipation, and trouble focusing or thinking clearly. Your doctor can prescribe an anti-nausea drug or laxative to help with side effects.

When you’re taking narcotics, it’s important to remember the difference between physical dependence and psychological addiction. Physical dependence means that your body adjusts to a medicine and needs it to function. When you function has improved, your doctor will help you slowly and safely decrease the amount of medicine. Doing this helps prevent or reduce symptoms of withdrawal. It is critical to tell your doctor about these symptoms and work through the process together.

Psychological addiction is the desire to use a drug whether or not it’s needed to improve function and relieve pain. Using a narcotic this way is harmful to your health. Talk to your doctor if you think you are addicted to narcotics. They may give you other medicines to help your addiction. They could lower the dose, change to another drug, or stop the medicine. They may recommend counseling or rehab as well.

Things to consider

Always tell your doctor what other drugs you take. This includes medicines, vitamins, and supplements. The doctor also should know about all ongoing health conditions. Some medicines may not be safe to take. Do not start a new drug without your doctor’s approval.

It is important to follow instructions when taking chronic pain medicines. Some side effects can be harmful and cause other health concerns. They can also be harmful to your lifestyle if you develop a problem. Do not stop taking a drug without your doctor’s approval.

People who take medicine for chronic pain should have regular check-ups with their doctor. Contact your doctor right away if you have severe or abnormal side effects. This includes if you have an unplanned reaction. The doctor will tell you what you should do. Seek help if you think you are dependent on or addicted to a drug.

Questions for your doctor

• What are my options to treat chronic pain?
• What medicine(s) do I need to take?
• How long do I need to take them?
• How much and how often do I take the medicine?
• Do I need to take the medicine with anything or avoid things when I take the medicine?
• What are the possible side effects? What should I do if I have them?
• How do I safely start and stop chronic pain medicines?
• Are there alternative forms of treatment, besides medicine, that can treat chronic pain?

Resources

American Academy of Family Physicians: Chronic Pain

American Academy of Family Physicians: Opioid Addiction

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Nonsteroidal anti-inflammatory drugs (NSAIDs) are medicines you can take for pain relief. They are often sold over the counter (OTC). This means you can buy them without a prescription from your doctor. Some common brand names are Advil, Motrin, or Aleve. But these medicines are available by prescription, as well.

Path to improved health

How do prescription NSAIDs work?

NSAIDs stop a certain kind of enzyme in your body from working. These are called cyclooxygenase enzymes (also called COX enzymes). COX enzymes speed up your body’s production of hormone-like substances called prostaglandins. Prostaglandins irritate your nerve endings and cause you to feel pain. They are also part of the system that helps your body control its temperature.

By reducing the level of prostaglandins in your body, NSAIDs help relieve pain from conditions like arthritis, muscle sprains, or bone fractures. They also help reduce inflammation (swelling), lower fevers, and prevent blood from clotting.

There are 2 classes of prescription NSAIDs: traditional and COX-2 inhibitors.

Traditional NSAIDs

include:

• Aspirin
• Diclofenac
• Etodolac
• Fenoprofen
• Flurbiprofen
• Ibuprofen
• Indomethacin
• Meclofenamate
• Mefenamic Acid
• Nabumetone
• Naproxen
• Oxaprozin
• Piroxicam
• Sulindac
• Tolmetin

COX-2 inhibitors

include:

• Celecoxib
• Meloxicam

If you need to take a prescription NSAID, your doctor will help you find one that is right for you.

What’s the difference between traditional NSAIDs and COX-2 inhibitors?

You have 2 types of COX enzymes in your body: COX-1 and COX-2. Researchers believe that one of the jobs of COX-1 enzymes is to help protect your stomach lining. The COX-2 enzyme doesn’t play a role in protecting your stomach.

Traditional NSAIDs stop both COX-1 and COX- 2 enzymes from doing their jobs. When COX-1 enzymes are blocked, pain and inflammation are reduced. But the protective lining of your stomach is also reduced. This can cause problems such as upset stomach, ulcers, bloating, and bleeding in your stomach and intestines. Certain NSAIDs may be more likely to cause some of these problems.

COX-2 inhibitors only stop COX-2 enzymes from working. The COX-2 enzyme doesn’t help to protect your stomach. So COX-2 inhibitors may be less likely to irritate your stomach or intestines.

Things to consider

Like all medicines, prescription NSAIDs can cause side effects. However, the side effects usually are not severe and are not experienced very often.

Common side effects of prescription NSAIDs may include:

• Dizziness
• Headache
• Nausea
• Diarrhea
• Excess gas
• Constipation
• Extreme weakness or fatigue
• Dry mouth

Serious, but rare, side effects of prescription NSAIDs may include:

• Allergic reaction (difficulty breathing, hives, and swelling of the lips, tongue, or face)
• Muscle cramps, numbness, or tingling
• Rapid weight gain
• Black, bloody, or tarry stools
• Bloody urine or bloody vomit
• Decreased hearing or ringing in the ears (also called tinnitus)
• Jaundice (the yellowing of the skin and the whites of the eyes)
• Abdominal cramping
• Heartburn
• Indigestion

In addition to the side effects listed above, people taking a COX-2 inhibitor may be at risk for:

• Swelling or water retention
• Skin rash or itching
• Unusual bruising or bleeding
• Difficulty sleeping (insomnia)

Call your doctor as soon as possible if your side effects become severe.

Is it safe to take NSAIDs for a long period of time?

If you take NSAIDs. you increase your risk of developing severe bleeding in your stomach. You may also be at risk for heart attacks and strokes. These risks get worse if you take higher doses. It also gets worse if you take these medicines for a long period of time. If you need to take pain medicine for longer than a week, you should discuss this risk with your family doctor. You may want to explore other pain treatment options.

What is a drug interaction?

If you use 2 or more medicines at the same time, the way your body processes each one can change. When this happens, the risk of side effects from each one increases. Each medicine may not work the way it should. This is called a drug-drug interaction. For example, NSAIDs thin the blood. If you take a blood thinning medicine such as warfarin and you take an NSAID, there could be a drug-drug interaction. Vitamins and herbal supplements can affect the way your body processes medicines, too.

Certain foods or drinks can also prevent your medicine from working the way it should. Or they can make side effects worse. This is called a drug-food interaction. For example, if you’re taking a traditional NSAID, drinking alcohol can increase your risk of liver disease or stomach bleeding.

Drug-drug interactions and drug-food interactions can be dangerous. Be sure that your doctor knows all the medicines you are taking. This includes OTC and prescription medicines, vitamins, and herbal supplements. Also, talk to your doctor before you take any new OTC or prescription medicine, vitamin, or supplement.

It’s important to take medicines exactly as your doctor prescribes. Ask your doctor whether you need to avoid any foods or drinks while using a prescription NSAID.

Two NSAIDs or an NSAID and COX-2 should not be combined. A prescription NSAID or COX-2 should also not be taken with an OTC NSAID. You should be especially careful not to add an NSAID or COX-2 if you already take aspirin.

Questions to ask your doctor

• What is the difference between an OTC NSAID and a prescription NSAID?
• What is the best NSAID for me?
• What are the side effects?
• How long is it safe for me to take a prescription NSAID?
• Are there any drug-drug or food-drug interactions I need to watch out for?

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People used to think they had to suffer through pain after surgery. But it’s normal to need medicine to control your pain. Different types of pain medicine are available, and your doctor can help you pick the right one. Some medicines, such as local anesthetics, are given before surgery to prevent pain. Other types, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids, are given after surgery to relieve pain. Opioids can be highly addictive and should be used following your doctor’s instructions.

Why is it important?

Treatment of pain can help you in the following ways:

• It can make you feel more comfortable. This reduces stress and tension, which helps your body heal.
• It can help you move better. If you feel less pain, you can start moving around or walking. This helps avoid problems such as bedsores, blood clots, and urinary infections.
• It can lead to fewer complications. People whose pain is well controlled do better after surgery. You can take deep breaths and be active sooner. You are less likely to get sick with conditions such as pneumonia.

Path to improved health

Before surgery: Local anesthetics

What are local anesthetics, and when are they used?
Local anesthetics block the nerves that send pain signals to your brain. You may get them in a shot near your incision, through a small tube, or as a cream applied to your skin. A doctor (anesthesiologist) or nurse (nurse anesthetist) will give you this medicine before surgery.

What are the benefits of local anesthetics?
Local anesthetics only block pain in a specific part of your body. This means there are fewer side effects and risks. You may remain awake or be sedated. You are able to go home and return to your normal routine. Local anesthetics reduce your need for opioids.

What are the risks of local anesthetics?
You may be dizzy, weak, or confused after surgery. Local anesthetics often require several shots to make pain relief last. Too much of a local anesthetic can cause problems.

After surgery: Pain medicines

Many types of medicines can help with pain after surgery. Pills and liquids (oral medicines) are taken by mouth. Other types of medicines are given in your rectum (anal or suppository). Injections into your skin, muscle, or vein are another form.

What are the benefits of oral medicines?
There are many benefits to oral medicines. Pills and liquids work as well as shots and cause less discomfort. Plus, they’re often less expensive. Also, they’re easy to take when you go home after surgery.

What are the risks of oral medicines?
There’s a delay in pain relief with oral medicines. That’s because you have to wait for your body to absorb the medicine. It can be hard to take them if you’re nauseous or vomiting. (Some medicines come in rectal form so you can still take them.)

What are the benefits of injected medicines?
Pain medicine in injection form works even if you’re nauseous or vomiting. The medicine gets into your bloodstream quickly.

What are the risks of injected medicines?
The injection site often hurts for a short time. Side effects may include dizziness, headache, breathing problems, or seizures.

There are different types of injections.

• Intravenous (IV) catheter.Medicine is injected into your vein through a small tube. The tip of the tube stays in your vein during recovery at the hospital. This method of pain relief works well for short-term pain.
• Patient-controlled analgesia (PCA) pump.This is used in combination with an IV. A PCA pump lets you control when you receive pain medicine. If you feel pain, you push a button to inject medicine into your vein. Your doctor or nurse will show you how and when to use the pump. They program the pump so can’t overdose.
• Epidural catheter.Pain medicine is injected into your back through a small tube. The doctor may inject medicine all at once or in small doses. This method works well for surgery on your chest or stomach. It is more complex and requires close monitoring to prevent problems.

NSAIDs

What are NSAIDs, and when are they used?
NSAIDs are used to treat mild pain after surgery. They reduce swelling and soreness. Examples of NSAIDs are aspirin, ibuprofen, and naproxen.

What are the benefits of NSAIDs?
Depending on your pain level, NSAIDs can stop or lessen pain. They prevent you from using stronger medicine, such as morphine. You can’t get addicted to NSAIDs.

What are the risks of NSAIDs?
NSAIDs may cause nausea, stomach bleeding, or kidney problems. Most NSAIDs thin your blood and can prevent blood clotting. They can increase your blood pressure and make your blood pressure medicine not work properly.

If your pain is too strong, your doctor may prescribe an opioid.

Opioids

What are opioids, and when are they used?
Opioids are stronger pain medicines. They most often are used for severe pain after surgery. Examples of opioids are morphine and codeine.

What are the benefits of opioids?
Opioids work well for severe pain. They do not cause bleeding in your stomach or other parts of your body. Your doctor will prescribe opioids only for extreme pain and only short-term.

What are the risks of opioids?
Opioids can cause drowsiness, nausea, constipation, or itching. They can affect urination and breathing. Many people become addicted to opioids with repeated usage. They can cause serious harm, including overdose and even death. It’s important to use them as prescribed by your doctor and to avoid depending on them indefinitely.

Things to consider

Your doctor will help you decide how to control pain after surgery. The type and amount of pain medicine you need varies. It will depend on your overall health and what kind of surgery you have. Some pain medicines may interact with other medicines. Talk to your doctor about what medicines you take regularly before starting a new pain medicine.

Talk to your doctor about ways to manage chronic pain. They can help you create a plan to manage your pain, limiting the use of pain medications. The plan may include applying ice and/or heat to the area, acupuncture, and relaxation techniques.

Questions to ask your doctor

• Do I need pain medicine before my surgery? If so, what kind?
• What kind of pain medicine will I need after my surgery?
• How long will I need to take pain medicine?
• What should I do if I still have pain after finishing my medicine?

Resources

National Institutes of Health, MedlinePlus: Post Surgical Pain Treatment – Adults

U.S. Food and Drug Administration: Opioid Medications

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Shoulder pain can be caused by many factors. One common cause of shoulder pain is soreness of the tendon (a cord that attaches a muscle to a bone) in the rotator cuff. This is the part of the shoulder that helps circular motion. Another common cause is soreness of the subacromial bursa (a sac of fluid under the highest part of the shoulder).

You might experience soreness after cleaning, painting, lifting items, or playing a sport—anything that requires you to lift your arms, especially overhead. Or you may not remember any specific injury, but you still feel pain in your shoulder.

The main joint in the shoulder is formed by the arm bone and the shoulder blade. The joint socket is shallow, allowing a wide range of motion in the arm. The rotator cuff is made up of 4 muscles that surround the arm bone. This cuff keeps the shoulder steady as the arm moves, especially to the side or over your head.

The supraspinatus muscle rests on top of the shoulder. Its tendon travels under the bone on the outside of the shoulder (the acromion). This tendon is the one most often injured because of its position between the bones. As the tendon becomes inflamed (sore and swollen), it can become pinched between the 2 bones. The sac of fluid that cushions the tendon can also be irritated and swollen.

If the rotator cuff is involved, the pain is usually in the front or outside of the shoulder. This pain is usually worse when you raise your arm or lift something above your head. The pain can be bad enough to keep you from doing even the simplest tasks. Pain at night is common, and it may be bad enough to wake you. It also may worsen when lying down or onto that side.

Path to improved health

Your doctor can help you with a treatment plan to relieve the pain and help you restore your shoulder to normal function. Pain relief strategies include active rest. During active rest, you can and should move your shoulder. Avoid difficult activities like lifting heavy objects or repetitive overhead movements.

You may also get relief by:

• Applying ice
• Taking nonsteroidal anti-inflammatory medicine such as ibuprofen (brand names: Advil, Motrin) or naproxen (brand name: Aleve)
• Getting an injection of anti-inflammatory steroids
• Doing special exercises

The first step of rehabilitation therapy is simple range-of-motion exercises. Bend over and move (rotate) your shoulder in large circles. This will help to avoid the serious complication of rotator cuff injury, called a frozen shoulder. You should follow these range-of-motion exercises with resistance exercises. Resistance exercises use rubber tubing or light dumbbells. The final step is resistance training with weight machines or free weights.

The following exercises may help you deal with shoulder pain:

• Range of motion exercises: Stand up and lean over so you’re facing the floor. Let your sore arm dangle straight down. Draw circles in the air with your sore arm. Start with small circles, and then draw bigger ones. Repeat these exercises 5 to 10 times during the day. If you have pain, stop. You can try again later. Once you can tolerate these exercises, you can try using your good arm to lift the painful shoulder in all directions multiple times throughout the day.
• Good posture exercises: Having good shoulder posture can help treat and prevent shoulder pain. Many people with shoulder pain often lift or hunch their shoulder forward. Work on improving your posture if you find yourself slumping or hunching. Throughout the day, focus on bringing your shoulder or shoulder blade down and holding there. Another exercise is to stand against the wall with the back of your head, shoulders, legs, and heels touching the wall. Notice if your painful shoulder blade doesn’t touch the wall completely. Keep trying that position throughout the day.
• Upper extremity strengthening: As your pain goes away, try adding a general upper body weight-lifting program using weight machines or free weights. Lie on your right side with your left arm at your side. With a weight in your left hand and your forearm across your tummy, raise your forearm. Keep your elbow near your side.
• Aerobic exercises: This will help improve the blood flow to the tendon or bursa. The blood flow will help reduce soreness. Smokers should quit smoking so more oxygen reaches the injured tendon. This will help the injury heal faster.

You can also try these rotator cuff exercises.

Things to consider

It often takes a shoulder a long time to heal. The earlier you address the pain, the better. Depending on your injury, you should be able to make a full recovery. However, many people complain that even with a full recovery, their shoulder is not as strong as before.

If you fell or felt a sudden pull, you shouldn’t wait more than a few days before you see your doctor because it could be a torn tendon. Tell your doctor if your pain goes on despite a good treatment program. Or when there is weakness in certain motions of the arm. You may have torn your rotator cuff. This type of injury may need surgery.

Questions to ask your doctor

• What is causing my shoulder pain?
• Could my shoulder pain be caused by my sleep position?
• How much should I limit my activities?
• Why is it taking so long for my shoulder to heal?
• How can I prevent a repeat of my shoulder pain if I don’t know what caused it?
• Will my shoulder heal completely?
• What exercises should I avoid?

Resources

National Institute of Arthritis and Musculoskeletal and Skin Diseases: Shoulder Problems

National Institutes of Health, MedlinePlus: Shoulder Injuries

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