Most patients suffering with persisting pain take pain killers (or analgesics). A combination of different pain killers is often necessary for sufficient pain relief. There are different types of drugs which help to reduce pain through a variety of mechanisms, and often have synergistic effects.
A useful aspect of analgesic treatment is that it is painless and the effects are often long-term. Analgesics are available as tablets, liquids, nasal spray, suppositories, external creams and skin patches.

Taking analgesics for longer periods of time
Unlike for short-term pain after an injury or operation, pain killers for chronic pain need to be taken for longer periods of time. It is useful to take a long-term perspective of taking analgesics, as one would for medicines in other chronic conditions (like diabetes or high blood pressure, for example). It is important to find a combination that is effective and well tolerated, and to have a good plan how to take analgesics purposefully.


Tailored analgesics as part of a broader treatment plan
Successful long-term pain relief with medicines requires an individually tailored combination.
Your general health and other illnesses need to be taken into account when selecting suitable analgesics. 

A good long-term strategy needs to be established
- how and when to take tablets at what dose
- when to change doses
- when to try to wean off some of the drugs.

This should include good education how to recognise and deal with side effects and how to adapt your treatment if the pain gets better or worse.
A tailored management of medicines, involving GP's and other treating colleagues, is part of the treatment plan established during your medical pain specialist appointment.

If you’re interest in more details, please read on about some common types of analgesics used for chronic pain relief:

Paracetamol
- Strengths: lowest risk of side effects, can help with a wide variety of pains (not only headaches!), makes other painkillers more effective (synergistic effects), no development of tolerance; does not cause drowsiness or mental side effects. 
- Limitations: for mild to moderate pain only, overdose can damage liver


Anti-inflammatories
(such as Ibuprofen, Diclofenac, Naproxen, Cox-2-Inhibitors like Celecoxib, Etoricoxib and many others; some are available as external creams, gels or suppositories).
- Strengths: can be more potent than paracetamol, often useful in inflammation like arthritis, synergistic effects combined with paracetamol. Do not cause drowsiness or mental side effects. 
- Limitations: tend to have more side effects than paracetamol, particularly if taken over longer periods, such as stomach pain, heart burn, indigestion, stomach and duodenal ulcers and bleeding, can effect kidney function or asthma.


Opioids
morphine-like drugs: weaker opioids (codeine, dihydrocodeine, tramadol), and strong opioids (morphine, fentanyl, oxycodone, buprenorphine and others)
- Strengths: often powerful pain relief, synergistic effect with paracetamol (so should normally be taken alongside)
Limitations: good effect is often short-term only; side effects like feeling sick, sleepiness, constipation, rare risk of becoming dependent or addicted; needs slow wean-off to avoid withdrawal symptoms. can have long-term side effects on immune and hormone system; can interfere with ability to drive, work and focus.
More about opioids can be found here (Link to British Pain Society leaflet).


Anti-depressants
Amitriptyline, Nortriptyline, Imipramin, Trazodone, Venlafaxine Mirtazapine. "Newer" anti-depressants (SSRI's such as Fluoxetine, Sertraline and others seem to lack these additional pain-relieving properties.
- Strengths: Can have powerful pain relieving effects when standard painkillers fail, e.g. in nerve pain of hypersensitive pain; help to control central sensitisation; additional benefit if sleep interrupted by pain; only one daily dose
- Limitations: side effects like drowsiness and mental changes, particularly at the beginning of treatment; can take several weeks until effect is felt; needs to be taken regularly over longer periods to be effective. Can interfere with ability to drive, work and focus.


Anticonvulsants
Gabapentin, Pregabalin and some others
- Strengths: powerful nerve pain relief and desensitisation, often with less side effects than anti-depressants; help to control central sensitisation;
- Limitations: Side effect at the beginning of treatment like dizziness, drowsiness, long-term weight gain; take a while to develop full effect; need to be slowly weaned off at the end of treatment. Can interfere with ability to drive, work and focus.


External medicines
Anti-inflammatory cream or gels, Lidocaine (local anaesthetic) patches or cream, Capsaicin cream.
These have quite different pharmacological effects and are suitable for certain forms of localised pain, e.g arthritis of a few major joints or local nerve-related pain.
Strengths: less systemic side effects than tablets; can have strong soothing effects on local hypersensitivity or burning from nerve-related pain.
Limitations: largely local effect only, unsuitable for wide-spread pain; sometime can cause skin reactions; anti-inflammatory creams/gels often less effective than tablets.



Managing long-term painkillers

Taking pain relief medicines for long-lasting or recurring pain needs to be tailored to individual circumstances. You should always follow recommendations of your GP or Pain Specialist. Nonetheless, common principles apply which often can make your medicines more effective and reduce side effects.



As a general rule follow a step-wise approach taking painkillers based on the World Health Organisation Pain ladder:

Step 1 	Start with Paracetamol 
Step 2 	Add an anti-inflammatory (unless you can’t tolerate it) and/or a weak opioid 
Step 3 	replace weak opioid with a stronger one 
At any stage: consider adding one or more adjuvants, particular if there is neuropathic pain or central sensitisation   




Adapt painkillers to your situation
If you take long-term analgesics more or less regularly it's a good idea to adapt dose(s) to changing pain levels. So when better reduce doses stepwise and if worse increase doses for a while up to a limit agreed with your doctor. 

Never stop long-term painkillers abruptly  - you will develop very unpleasant or dangerous withdrawal symptoms.

If you take multiple analgesics don't change them all in one go but one after the other. Start with the one giving you most side effects or one you got used to (e.g. Opioids). 
Agree with your prescribing doctor an escalation plan for flare-ups: which dose to increase and for how long, or optional stronger pain killers to be added (or replace weaker ones) for a limited while.  
 Long-term adjuvants (see below) should be changed slowly, not on a day-to-day basis. For these and opioids there should be wean-off trials in regular intervals (e.g. every three to six months) when doses are reduced slowly (to avoid withdrawal symptoms or rebound effects) with change in pain intensity monitored. If your pain is getting worse and remaining worse return to the dose taken so far. It is then established that this drug is still effective and should be continued until the next wean-off trial. If on the other hand the pain intensity does not change with a lower dose then you should continue to slowly wean off as the drug may not have a sufficient effect any more. It may be re-started after a break. 




Step 1 - Start with Paracetamol 
The usual standard dose is 1g (two 500mg tablets) taken every six hours. This amounts to 4g per day, which is safe for even longer periods, unless you suffer with liver or severe kidney disease.
Paracetamol is one of the safest painkillers, which only rarely causes side effects compared to other painkillers. It can enhance effects of stronger painkillers like “opioids” (see below).
Do not exceed 4 gram (8 tablets) per day or serious liver damage may result. Be aware that many “combination” painkillers (cocodamol, codydramol, Tramacet® etc) also contain paracetamol. If you take any of these watch the total dose you take and don’t add  any extra Paracetamol.
Paracetamol alone is often not sufficient to control long-lasting moderate or severe pain, but should be taken together with stronger painkillers as it augments their effect. 
Long-term regular use of Paracetamol can cause headaches. You should watch out for this and if you feel that this is a gradually increasing problem you should discontinue Paracetamol for at least while (several weeks or months). 




Step 2 - Add an anti-inflammatory… 
If Step 1 is insufficient, an anti-inflammatory (NSAID) like Ibuprofen, Diclofenac, Naproxen, Celecoxib etc. should be added.
These tend to cause more side effects, particularly affecting the stomach/bowel. However, most patients tolerate them fairly well. It seems safer to take anti-inflammatories periodically (e.g. quite regularly for periods of weeks or a few months)  and then discontinue for a break of at least 2-4 weeks.
Another safer option is to apply a local anti-inflammatory cream/ gel instead of tablets if your pain is in a few places only. Don’t use both tablets and external cream. 
In any event, taking anti-inflammatories for longer than a few days should be discussed with and regularly reviewed by your doctor.
Like with Paracetamol long-term use of anti-inflammatories can cause headaches. You should watch out for this and if you feel that this is a gradually increasing problem you should discontinue your drug for at least a while.
If you suffer or have suffered with stomach/ bowel problems, asthma, kidney problems or had a heart attack or stroke, NSAIDS should be taken with caution. These drugs should be avoided if you have difficult to control high blood pressure, heart problems or a stroke history, and if you're older than 65 years.
It has emerged over the last few years that taking anti-inflammatories for longer periods can increase risk of stroke, heart attack and cardiovascular disease. Concerning these risks some anti-inflammatories (e.g. Naproxen) appear to be a little safer than others (e.g. Diclofenac, Ibuprofen) for long-term use.



 … and/or a mild opioid 
Opioids (or opiates) are morphine-like pain killers.
Examples of milder ones are
codeine (as in cocodamol = codeine+paracetamol)
dihydrocodeine (DF113; codydramol = dhc+paracetamol)
tramadol (Tramacet ® = tramadol+paracetamol)
Opioids can be powerful painkillers, but they don’t work equally well for everyone and for all types of pain. It is reasonable to try a mild opioid for a limited while if you suffer with moderate to severe pain to see whether you respond to this treatment - not every one does.
See more about opioids in the next chapter:
 



Step 3 - Strong opioids (replacing Step 2 mild opioids)
If your pain intensity remains severe (higher than five out of ten) on Step 1 and Step 2 medicines then strong opioids can be considered. Mild opioids as part of Step 2 should have achieved at least some relief. If mild opioids haven’t improved your pain at all then it is unlikely that stronger opioids will have a useful effect.
Examples of strong opioids are
morphine (e.g. Zomorph, Oramorph, Sevredol)
fentanyl (skin patches, lollipops, nasal spray, buccal tablets)
oxycodone
buprenorphine (skin patches or tablets).
There is no principle difference between opioid tablets/capsules and skin patches. The skin patches are just another way of getting the medication into your system through skin absorption rather than stomach). The patches don’t have a local effect, they work by releasing the opioid slowly into your system – so they can be put on healthy skin anywhere.
Typical side effects of all opioids at the beginning are feeling sick and drowsy; quite often, these tend to disappear after a little while. Being sick can be eased by taking additional anti-sickness medication for a short while after starting an opioid (like Cyclizine, Domperidone etc)
Another, more persisting long-term side effect is constipation. You will need to watch this and if getting constipated take early action such as changing your diet (drinking plenty of fluid >2l per day; fibre-rich diet such as fruit, vegetables, brown bread, oats etc); and/or take laxatives (Lactulose, Movicol, Senna etc). 
Other long-term side effects can be sweating, sleeplessness or restlessness, hormonal changes, libido changes and abnormal pain sensitisation. If you develop any of these, bring to the attention and discuss with your doctor. 
Many patients who find opioids helpful for their pain will note that they get used to the effect after a while (weeks to months). While it’s possible to increase the dose somewhat or take tablets/ patches a little earlier to compensate this should be done cautiously as it may start a cycle that can be hard to control and lead to dose escalation and dependence. It is safer and more rational to accept that an opioid will be useful for a while only (often a few months) and will gradually lose its effect. When it has, the opioid should be gradually weaned off. Discuss with your doctor wether to re-start for another cycle after a break of several weeks/ months.
You should always avoid stopping opioid medication abruptly as you will likely develop very unpleasant or dangerous withdrawal symptoms (sweating, restlessness, sleeplessness, headaches, diarrhoea, aches and soreness etc).
While genuine addiction to opioids in pain patients is rare it can happen and it is good to be aware of the issue. As explained above you will likely get used to the pain relief effect which is tolerance, not addiction. For more information look you may look at a British Pain Society publication about opioids here.
be aware of developing unhelpful and irrational habits and beliefs which can sometimes make people cling to their medication despite lack of sufficient pain relief. In general it is a good idea to regularly (e.g. every 3 or 6 months) and slowly attempt to wean off your opioid medication to establish whether it is still needed and continues to have a useful effect. This should be discussed in detail and agreed with your prescribing doctor before beginning opioid treatment.
Patients on Step 3 strong opioids should usually have a comprehensive treatment plan with targets. Measurable improvement in mobility and activity, pain intensity, mood etc should be agreed before starting these drugs. Failure to achieve the set targets (e.g. pain remains more intense than 5 on a scale of ten) is a sign of treatment failure. 
keep in mind that opioids are not a lasting solution but more like a temporary help - an opportunity for a break, to re-energise your life, to review your coping strategies, recharge your batteries, return to work, restart social contacts and start an exercise programme. Don't let this opportunity pass!    



Adjuvants
Adjuvants are “supporting” or “boosting” drugs that can relieve pain in other ways than standard pain killers. Often, the exact mechanism of pain relief is not entirely clear. Adjuvants can be particularly helpful for pain from nerve, spinal cord or brain injury, nerve damage or nerve inflammation.
In other forms of pain, they can “de-sensitise” the pain system or reset a reduced pain threshold.
They can be very effective even if standard pain killers fail. It tends to take a while for adjuvants to work fully (at least several days, sometimes weeks).
They need to be taken on a strictly regular basis (not as needed). Therefore, the initial trial period to judge their effect should be at least four, better eight weeks. If there is no noticeable effect after this trial period the adjuvant should be weaned off. Most adjuvants should be started at a low dose to minimise side effects and then need to be increased stepwise. If side effects don't stop after a while alternative drugs should be considered.
More detailed information on adjuvants will follow soon.




The information given on this website is meant to support a medical pain specialist appointment. It should not be taken as stand-alone universal advice and may be incomplete or unsuitable for your specific circumstances. It cannot replace medical assessment and advice, and should not be used as such. The website is operated from the UK and meant for UK residents. 
The information provided on this page reflects the professional opinion of the author and does not claim to be complete. Before taking any of the above medicines, always consult a suitably experienced medical practitioner. Effects and side effects of longer term medicines should be regularly reviewed. Some of these drugs are used for pain relief outside their license.

Copyright © 2015 by Dr Michael LuckmannTreatments.htmlhttp://www.britishpainsociety.org/book_opioid_patient.pdfAbout_pain.htmlAbout_pain.htmlhttp://www.paincommunitycentre.org/article/who-analgesic-ladder-0http://www.britishpainsociety.org/book_opioid_patient.pdfshapeimage_1_link_0shapeimage_1_link_1shapeimage_1_link_2shapeimage_1_link_3shapeimage_1_link_4shapeimage_1_link_5

Analgesics (pain killers)






Follow the World Health Organisations Pain Ladder approach











Adapt doses to changing pain levels



Don’t stop long-term analgesics abruptly




Agree an escalation and de-escalation plan for flare-up periods with your doctor





























Long-term regular use of Paracetamol and anti-inflamma-tories can cause headaches.








































Opioids don’t work well for everyone but might be worth a try if your pain is intense.
























Typical side effects at the beginning are drowsiness, nausea and constipation.










Many patients on opioids will develop tolerance






Don’t stop opioids abruptly - you will develop withdrawal symptoms




Genuine addiction is rare - be aware of the issue and of your attitude towards your medication




You should have and follow a comprehen-sive treatment plan while on opioids