Opioids like oxycodone, hydrocodone, and morphine are often believed to be the holy grail of pain relief. But, rates of opioid abuse and overdose deaths have skyrocketed in recent years, as has our knowledge of the risks of these painkillers. Opioid medications are not the only effective painkillers out there. In fact, often, they are not nearly as effective as people think. This can lead to folks taking more and more to try to relieve their pain, and getting lots of unpleasant side effects instead (including addiction).
What you need to know about pain
Pain is reported by over 20% of people seen by primary care doctors worldwide.
When it comes to controlling persistent pain, it’s important to be realistic. You should not expect your pain to vanish completely with painkillers. On average, pain medications help reduce pain by a third—this is usually enough to have a positive change on your day-to-day life.
It is also important to know the difference between pain from tissue damage (nociceptive pain) and pain caused by nerve damage (neuropathic pain) and to know that opioids are not always the best treatment for the pain you feel. For example, opioid painkillers are not good at treating nerve pain.
Let’s walk through the options for non-opioid pain relief here.
Best treatments for pain caused by tissue damage
Acetaminophen, the active ingredient in Tylenol, is an over-the-counter drug that is good at relieving headaches, back pain and osteoarthritis. It is also found in many combination cold and flu medicines. It is not an anti-inflammatory, but it does lower fevers.
Acetaminophen doesn’t need a prescription and has very few side effects.
It is a great “first-line” pain reliever and can be used as a safe base on which to layer other non-opioid and opioid painkillers. Layering your pain relief this way means that you will need less of the stronger painkillers, and so get less of their unpleasant side effects.
Caution! Acetaminophen can lead to liver damage if you take too much or if you have liver disease or drink alcohol heavily.
2) Traditional nonsteroidal anti-inflammatory drugs (NSAIDs)
NSAIDs, or nonsteroidal anti-inflammatory drugs, are great for mild to moderate pain, such as that caused by soft tissue injury, strains, sprains, headaches, and arthritis. They are a good first choice for pain or can be taken with acetaminophen for additional pain relief—and they help avoid (or lower) the need for opioid painkillers. Good to know: If opioids are needed, NSAIDs can help the opioids work better.
NSAIDs also reduce inflammation and lower fevers.
NSAIDs are available over the counter (OTC) or by prescription. They can be generics like ibuprofen, naproxen, and aspirin or brands like Advil, Motrin, and Aleve. Prescription-only NSAIDs include Naprelan, Anaprox, and Voltaren. There are lots to choose from! If you don’t get a good result with one, it is sensible to try another before giving up.
Caution! NSAIDs have many side effects: They can cause heartburn, stomach ulcers, gut bleeding, and kidney damage, and can also increase the risk of heart disease and stroke. Do not take NSAIDs long term, especially if you are a senior.
A newer NSAID, celecoxib (Celebrex], is available by prescription only. Celebrex is a type of drug called “COX-2 inhibitor”. It works well as a painkiller and anti-inflammatory and is a good choice if stomach ulcers or bleeding of the gut is a worry. It has a smaller risk of stomach and gut problems than all other NSAIDs, but the risks of kidney damage, heart disease, and stroke are just the same as other NSAIDs.
4) NSAID sprays, gels, and creams
NSAIDs also come in sprays, gels, and creams. These can help with some types of pain, particularly when the pain is centered around a joint or in a specific area of the body.
These are worth a try and may lower your need for painkiller pills.
5) Non-drug options
Depending on the cause of your pain, there is a whole range of treatment options available which do not involve taking pills.
Some examples include:
- Physical therapy
- Chiropractic therapy
- Cognitive behavioral therapy
- Relaxation therapy
Organizations as diverse as the American College of Physicians, the U.S. Department of Veterans Affairs, and the Centers for Disease Control and Prevention recommend non-drug treatments as the first course of action for persistent pain.
6) Opioid painkillers
If all else fails, and your doctor recommends it, there may be a need for short-term, lowest-dose-possible opioid painkillers—in addition to acetaminophen, NSAIDs, and non-drug treatments.
Best treatments for pain caused by nerve damage
1) Anti-epileptic drugs
Anti-epileptic drugs, especially newer ones like gabapentin (Neurontin) and (Lyrica), are used to treat persistent nerve pain from conditions like diabetes, shingles, herniated disks, and fibromyalgia. But, how well they work is still unclear—some people find them really helpful, while others experience no benefit at all.
Caution! Gabapentin and pregabalin can have dangerous effects when taken with opioid painkillers, causing higher rates of opioid-related deaths.
Did you know that some antidepressants, when taken at a low dose, can sometimes also treat pain? Older tricyclic antidepressants like [coupon drug=imipramine]imipramine (Tofranil), nortriptyline (Pamelor), and amitriptyline (Elavil), and SNRIs (serotonin-norepinephrine reuptake inhibitors) like venlafaxine and duloxetine, have been shown to lessen pain caused by damaged nerves.
These antidepressants can also relieve any symptoms of depression that can exist with persistent pain, and help with difficulty sleeping too.
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So, to sum it up, here are some golden rules for using painkillers safely:
- If you have persistent pain, try to have realistic expectations for your pain relief: Think about what you want to be able to do rather than how you want to feel.
- Always try non-drug treatments first, and continue using them even if you start taking painkillers.
- Take more of the safest medication you are on so that you can take as little as possible of the drugs with more side effects.
- Take the lowest dose of pain medication possible to give you the effect you are happy with (see #1).
- There are very few situations when it is necessary to take NSAIDs or opioids long term. Ask for help from your doctor or a pain specialist if you have been