Getting the best out of medication for persistent (chronic and long term) pain
This page is designed to help you to understand pain medications and how to get the most out of them.
Here are some key facts that you should know about pain medications:
- Medication works best when taken in the minimum effective dose so that the benefits outweigh the side effects.
- Medications are only one of a number of ways for managing pain.
- Pain medications are not always helpful and the body can become used to them, even if they help to start with.
We recommend using a range of strategies for managing pain, as this is more effective than using medication alone.
Other areas to consider are shown in the puzzle diagram above.
There are more details about each of the pieces of the puzzle on our website - www.gloshospitals.nhs.uk/our-services/services-we-offer/pain-management-service/management-options-pain/
You can discuss them with your GP or pain specialist.
How do pain medications work?
Short term pain
Most common pain medications, such as paracetamol, anti-inflammatories, codeine and morphine work to reduce pain caused by inflammation, injury or damage. This is why these medications are useful and effective when treating short term pain such as after surgery or a broken bone.
Persistent (long-term) pain
All pain is not the same. Some pain results from injury to the nervous system such as shingles or diabetic neuropathy. Persistent pain often results in abnormal functioning of the nervous system, with increased activity in the parts of the brain associated with sensing pain. The nervous system becomes over-active like in epilepsy or anxiety. In these circumstances there is often no ongoing injury to the body and the symptoms become out of proportion to what can be seen on scans.
There are some less common pain medications (anti-neuropathics) which work on the nervous system, for example amitriptyline, gabapentin and duloxetine. Most of these medications benefit around 1 out of every 4 or 5 people, and on average, reduce the pain by around a third.
Tips for starting new medications or changing doses
During any medication change, it is important to understand the likely benefits and side effects and to have a plan to review. Your prescriber will be able to help with this.
- New medications: We hope that a new medication will allow you to do things you couldn’t do without it. Pain medication is normally started at a low dose, as it is common to have side effects to begin with but many people overcome them quite quickly (usually within 2 weeks). However, new medication should be stopped if there is no clear benefit or if there are significant side effects.
- Increasing the dose: An increased dose can be helpful if it allows you to do more activities. If not, it is best to reduce the dose.
- Reducing the dose: Doses should be gradually reduced with advice from a professional. During a reduction, it is normal to notice a short term increase in pain as the body adjusts; this can sometimes last for a couple of weeks. Try not to rush into increasing the dose again, allow your body to recover before making further decisions.
- Stable dose/long term medication use: We would recommend a small reduction in all pain medication at least every year; this is to check if the medication is still effective. Often the medication can be reduced or stopped if the symptoms do not worsen – read point 3 above for advice on reducing the dose.
What are the advantages and disadvantages of pain medications?
If medication reduces your pain levels, allows you to do things that would otherwise be more difficult and has few side effects, it is probably working well.
Unfortunately, some people get only minimal help or have unpleasant side effects from medications. The chance of problems rises with higher doses over longer periods of time. It is therefore important that the dose is as low as possible and that the medication is stopped if it is not effective. You should never take more medication than is advised or prescribed.
Some medications may impact your ability to drive safely or operate machinery. There is a link to information on driving at the end of this page.
How do you know if your medication is working or causing any problems?
It can be difficult to know how much help or how many side effects pain medication is providing, particularly after taking it for many months or years.
Many people feel nervous about changing what they take but the only way to find out the effect of medication, is to try a different dose. We would always recommend doing this with guidance from a medical professional.
If you still have considerable pain, despite taking medication, reducing the medication can significantly improve side effects - some of which you may not even have noticed, as they happen gradually over time. For example, poor concentration, exhaustion, low mood, anxiety and weight gain may be associated with your pain or medical conditions but could also be worse as a result of medications you are taking. You might find that reducing the medication makes life a little easier, not more difficult.
Our patients often say that when they reduce their medication, they have a bit more energy and are able to think about trying other management strategies from the jigsaw puzzle. As the benefits of the medication have often reduced over time, surprisingly the pain hardly changes.
Changes can be made in a slow and gentle way and most people will be able to manage this well. It can be helpful to write a diary of the things you can do and the way you feel before the change in your medication dose and then again after you have made the change. This can help you and your clinician to decide on the correct dose.
Opioids
Opioids are one type of pain medication, including morphine, codeine, buprenorphine, fentanyl and oxycodone.
Many pain medications become less effective over time, but opioid medications have particular characteristics.
Over time, the benefits of an opioid medication are likely to reduce, for 3 reasons:
- Tolerance - initially the medication may help your pain but over time, this effect reduces. After a while, in order to feel like you have taken the medication, you will need a higher dose.
- The nature of pain changes – in the early stages there may be injury or damage which responds well to opioids, however persistent pain is usually caused by abnormal nerve function and opioids do not treat this well.
- Opioid medications can worsen pain. Hyperalgesia describes an increased sensitivity to pain which can happen when opioids are taken regularly. The pain worsens as the dose increases.
In all 3 scenarios, the pain worsens over time and the temptation is to increase the dose. Soon the higher dose becomes ineffective and the pain may worsen further.
While the increased dose does not help, the problems associated with the medication are increasing and most people notice withdrawal symptoms if they miss or delay a dose. Some people will crave the relaxation or euphoric effects of the medication.
Research suggests that high doses of opioids (the equivalent of over 120 mg morphine per day) are likely to cause more side effects than benefit. There may be an increased risk of accidental overdose while taking high doses of opioids for persistent pain, especially when combined with other sedative medication.
Medication reviews
If you would like a medication review, you should discuss this with your prescriber.
Our service is available for specialist advice if needed and can help with advice for complicated pain and medication regimes. We can provide expert input from the most appropriate members of our multidisciplinary team to consider non-medication ways to manage pain. Speak to your specialist or your GP if you think this might help you.
Further information
For more information, please visit the following websites.
Drugs and driving: the law
Website: www.gov.uk/drug-driving-law
Pain Concern
Website: https://painconcern.org.uk/product-category/leaflets/