Pain relievers are medicines that reduce or relieve headaches, sore muscles, arthritis, or other aches and pains. There are many different pain medicines, and each one has advantages and risks. Some types of pain respond better to certain medicines than others. Each person may also have a slightly different response to a pain reliever.

Over-the-counter (OTC) medicines are good for many types of pain. There are two main types of OTC pain medicines: acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs). Aspirin, naproxen (Aleve), and ibuprofen (Advil, Motrin) are examples of OTC NSAIDs.

If OTC medicines don't relieve your pain, your doctor may prescribe something stronger. Many NSAIDs are also available at higher prescription doses. The most powerful pain relievers are opioids. They are very effective, but they can sometimes have serious side effects. There is also a risk of addiction. Because of the risks, you must use them only under a doctor's supervision.

There are many things you can do to help ease pain. Pain relievers are just one part of a pain treatment plan.

Over-the-counter (OTC) pain relievers/fever reducers (the kind you can buy without a prescription) are safe and effective when used as directed. However, they can cause serious problems when used by people with certain conditions or taking specific medicines. They can also cause problems in people who take too much, or use them for a longer period of time than the product’s Drug Facts label recommends. That is why it is important to follow label directions carefully. If you have questions, talk to a pharmacist or health care professional.

What are pain relievers/fever reducers?

There are two categories of over-the-counter pain relievers/fever reducers: acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). Acetaminophen is used to relieve headaches, muscle aches and fever. It is also found in many other medicines, such as cough syrup and cold and sinus medicines. OTC NSAIDs are used to help relieve pain and reduce fever. NSAIDs include aspirin, naproxen, ketoprofen and ibuprofen, and are also found in many medicines taken for colds, sinus pressure and allergies.

How do I use pain relievers/fever reducers safely?

These products, when used occasionally and taken as directed, are safe and effective. Read the labels of all your over-the-counter medicines so you are aware of the correct recommended dosage. If a measuring tool is provided with your medicine, use it as directed.

What can happen if I do not use pain relievers/fever reducers correctly?

Using too much acetaminophen can cause serious liver damage, which may not be noticed for several days. NSAIDs, for some people with certain medical problems, can lead to the development of stomach bleeding and kidney disease.

What if I need to take more than one medicine?

There are many OTC medicines that contain the same active ingredient. If you take several medicines that happen to contain the same active ingredient, for example a pain reliever along with a cough-cold-fever medicine, you might be taking two times the normal dose and not know it. So read the label and avoid taking multiple medicines that contain the same active ingredient or talk to your pharmacist or health care professional.

• Speak up
• Ask questions
• Find the facts
• Evaluate your choices
• Read the label

If you've ever been treated for severe pain from surgery, an injury, or an illness, you know just how vital pain relief medications can be.

Pain relief treatments come in many forms and potencies, are available by prescription or over-the-counter (OTC), and treat all sorts of physical pain—including that brought on by chronic conditions, sudden trauma, and cancer.

Pain relief medicines (also known as "analgesics" and "painkillers") are regulated by the Food and Drug Administration (FDA). Some analgesics, including opioid analgesics, act on the body's peripheral and central nervous systems to block or decrease sensitivity to pain. Others act by inhibiting the formation of certain chemicals in the body.

Among the factors health care professionals consider in recommending or prescribing them are the cause and severity of the pain.

TYPES OF PAIN RELIEVERS

OTC Medications

These relieve the minor aches and pains associated with conditions such as headaches, fever, colds, flu, arthritis, toothaches, and menstrual cramps.

There are basically two types of OTC pain relievers: acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs).

Acetaminophen is an active ingredient found in more than 600 OTC and prescription medicines, including pain relievers, cough suppressants, and cold medications.

NSAIDs are common medications used to relieve fever and minor aches and pains. They include aspirin, naproxen, and ibuprofen, as well as many medicines taken for colds, sinus pressure, and allergies. They act by inhibiting an enzyme that helps make a specific chemical.

Prescription Medications

Typical prescription pain relief medicines include opioids and non-opioid medications.

Derived from opium, opioid drugs are very powerful products. They act by attaching to a specific "receptor" in the brain, spinal cord, and gastrointestinal tract. Opioids can change the way a person experiences pain.

Types of prescription opioid medications include

• morphine, which is often used before and after surgical procedures to alleviate severe pain
• oxycodone, which is also often prescribed for moderate to severe pain
• codeine, which comes in combination with acetaminophen or other non-opioid pain relief medications and is often prescribed for mild to moderate pain
• hydrocodone, which comes in combination with acetaminophen or other non-opioid pain relief medications and is prescribed for moderate to moderately severe pain

FDA has recently notified makers of certain opioid drugs that these products will need to have a Risk Evaluation and Mitigation Strategy (REMS) to ensure that the benefits continue to outweigh the risks.

Affected opioid drugs, which include brand name and generic products, are formulated with the active ingredients fentanyl, hydromorphone, methadone, morphine, oxycodone, and oxymorphone.

FDA has authority to require a REMS under the Food and Drug Administration Amendments Act of 2007.

Types of non-opioid prescription medications include ibuprofen and diclofenac, which treat mild to moderate pain.

USE AS DIRECTED

Pain medications are safe and effective when used as directed. However, misuse of these products can be extremely harmful and even deadly.

Consumers who take pain relief medications must follow their health care professional's instructions carefully. If a measuring tool is provided with your medicine, use it as directed.

Do not change the dose of your pain relief medication without talking to your doctor first.

Also, pain medications should never be shared with anyone else. Only your health care professional can decide if a prescription pain medication is safe for someone.

Here are other key points to remember.

With acetaminophen:

• Taking a higher dose than recommended will not provide more relief and can be dangerous.
• Too much can lead to liver damage and death. Risk for liver damage may be increased in people who drink three or more alcoholic beverages a day while using acetaminophen-containing medicines.
• Be cautious when giving acetaminophen to children. Infant drop medications can be significantly stronger than regular children's medications. Read and follow the directions on the label every time you use a medicine. Be sure that your infant is getting the infants' pain formula and your older child is getting the children's pain formula.

With NSAIDs:

• Too much can cause stomach bleeding. This risk increases in people who are over 60 years of age, are taking prescription blood thinners, are taking steroids, have a history of stomach bleeding or ulcers, and/or have other bleeding problems.
• Use of NSAIDs can also cause kidney damage. This risk may increase in people who are over 60 years of age, are taking a diuretic (a drug that increases the excretion of urine), have high blood pressure, heart disease, or pre-existing kidney disease.

With opioids:

• Use of opioids can lead to drowsiness. Do not drive or use any machinery that may injure you, especially when you first start the medication.The dose of an opioid pain medication that is safe for you could be high enough to cause an overdose and death in someone else, especially children.

KNOW THE ACTIVE INGREDIENTS

A specific area of concern with OTC pain medicines is when products sold for different uses have the same active ingredient. A cold and cough remedy may have the same active ingredient as a headache remedy or a prescription pain reliever.

To minimize the risks of an accidental overdose, consumers should avoid taking multiple medications with the same active ingredient at the same time.

All OTC medicines must have all of their active ingredients listed on the package. For prescription drugs, the active ingredients are listed on the container label.

Talk with your pharmacist or another health care professional if you have questions about using OTC medicines, and especially before using them in combination with dietary supplements or other OTC or prescription medicines.

MISUSE AND ABUSE

Misuse and abuse of pain medications can be extremely dangerous. This is especially so in regard to opioids. These medications should be stored in a place where they cannot be stolen.

According to the National Institutes of Health, studies have shown that properly managed medical use of opioid analgesic compounds (taken exactly as prescribed) is safe, can manage pain effectively, and rarely causes addiction.

But the abuse of opioids is a significant public safety concern. Abusers ingest these drugs orally, and also crush the pills in order to snort or inject them.

Commonly abused opioid pain medicines include prescription drugs such as codeine, and the brand-name products Oxycontin (oxycodone), Vicodin (hydrocodone with acetaminophen), and Demerol (meperidine).

Addiction is just one serious danger of opioid abuse. A number of overdose deaths have resulted from snorting and injecting opioids, particularly the drug OxyContin, which was designed to be a slow-release formulation.

USE OPIOIDS SAFELY: 3 KEY STEPS

1. Keep your doctor informed. Inform your health care professional about any past history of substance abuse. All patients treated with opioids for pain require careful monitoring by their health care professional for signs of abuse and addiction, and to determine when these analgesics are no longer needed.
2. Follow directions carefully. Opioids are associated with significant side effects, including drowsiness, constipation, and depressed breathing depending on the amount taken. Taking too much could cause severe respiratory depression or death. Do not crush or break pills. This can alter the rate at which the medication is absorbed and lead to overdose and death.
3. Reduce the risk of drug interactions. Don't mix opioids with alcohol, antihistamines, barbiturates, or benzodiazepines. All of these substances slow breathing and their combined effects could lead to life-threatening respiratory depression.

Acetaminophen is a safe and effective pain reliever that benefits millions of consumers. However, taking too much could lead to serious liver damage. The drug is sold under brand names such as Tylenol and Datril, but it is also available in many cough and cold products and sleep aids, and is an ingredient in many prescription pain relievers. The Food and Drug Administration warns consumers that all over-the-counter pain relievers should be taken with care to avoid serious problems that can occur with misuse.

Acetaminophen can cause liver injury through the production of a toxic metabolite. The body eliminates acetaminophen by changing it into substances (metabolites) that the body can easily eliminate in the stool or urine. Under certain circumstances, particularly when more acetaminophen is ingested than is recommended on the label, more of the harmful metabolite is produced than the body can easily eliminate. This harmful metabolite can seriously damage the liver.

The signs of liver disease include abnormally yellow skin and eyes (jaundice), dark urine, light-colored stools, nausea, vomiting, and loss of appetite. The signs can be similar to flu symptoms and may go unnoticed for several days if consumers believe their symptoms are related to their initial illness. Serious cases of liver disease may lead to mental confusion, coma, and death.

To avoid accidental overdosing, it's very important not to take more than the recommended dose on the label. Also, you should not take acetaminophen for more days than recommended, or take more than one drug product that contains acetaminophen at the same time. Consumers should be aware that taking more than the recommended dose will not provide more relief.

If you're taking a prescription pain medicine, check with your doctor first before taking OTC acetaminophen. The prescription pain medicine may contain acetaminophen. Acetaminophen is also available in combination with other OTC drug ingredients. So, you need to check the labels of other OTC drug products for the ingredient. In some cases of accidental acetaminophen overdose, it appears that consumers used two or more acetaminophen-containing products at the same time.

Some individuals appear to be more susceptible to acetaminophen-induced liver toxicity than others. People who use alcohol regularly may be at increased risk for toxicity, particularly if they use more than the recommended dose. Further research needs to be conducted in alcohol users to determine what factors make some alcohol users more susceptible to liver injury than others.

Parents should be cautious when giving acetaminophen to children. For example, the infant drop formula is three times more concentrated than the children's suspension. It's important to read drug labels every time you use a drug and to make sure that your child is getting the children's formula and your infant is getting the infants' formula.

Consumers should also know that there is a potential for gastrointestinal bleeding associated with the use of aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen. Aspirin is sold under brand names such as Bayer and St. Joseph's. Ibuprofen is sold under names such as Advil and Motrin. Naproxen is sold under the name Aleve. There are generic versions available for all of these products, as well.

The risk for bleeding is low for those who take these products intermittently. For those who take the products on a daily or regular basis, the risk is increased, particularly for those over 65 years of age or those who take corticosteriods (such as prednisone). Those who use hormone therapy (estrogens and progestins) for post-menopausal symptoms or birth control do not have an increased risk for bleeding.

In addition, consumers should ask health care providers about NSAID use if they have kidney disease or are taking diuretics (fluid pills).

The FDA is proposing new labeling that will inform consumers of the risk of liver toxicity from products containing acetaminophen, the risk of GI bleeding from the use of products containing NSAIDs, and factors that may increase these risks. The proposed new labeling will also better inform consumers about the ingredients contained in these products. In the meantime, read labels carefully, be sure you are getting the proper dose, and check with your health care provider to be sure that you can use these drugs safely.

The liver is a remarkable, if underappreciated, organ. It turns the nutrients in our diets to substances the body can use and converts toxins into harmless substances or makes sure they are removed from the body

When the liver is working well, our metabolism hums along in equilibrium. But drugs and dietary supplements can sometimes wreak havoc with that system, leading to dangerous liver problems. The Food and Drug Administration (FDA) is working to prevent drug-induced liver injuries.

“Any drug may cause dangerous liver problems but, fortunately, such problems only occur rarely,” says John R. Senior, M.D., an FDA gastrointestinal medical reviewer and consultant in hepatology, which includes study of the liver. “It is challenging to predict how drugs will affect the liver because each patient is different in how they respond to a given drug. Our goal is to prevent the toxicity of drugs.”

Acute liver failure is a rapid deterioration of the organ’s ability to function. Data suggest that prescription and over-the-counter drugs (OTC) and dietary supplements cause more acute liver failure cases than all other reasons combined.

FDA has identified several instances of liver damage caused by dietary supplements. For example, the agency has issued public health warnings and sent warning letters to companies marketing supplements for weight loss and muscle building. In one instance, a Texas-based company agreed to recall and destroy certain dietary supplement products after discovering a link between the supplement and cases of liver failure and non-viral hepatitis.

No Easy Way to Identify the Vulnerable

Finding even a few cases of serious liver toxicity in clinical trial subjects exposed to a drug can be a reason for discontinuing the trial. Also, cases of serious liver toxicity have prompted FDA to request sponsors to withdraw their approved drugs from the market.

Senior explains there’s no easy way to identify the people who might be vulnerable. “The drug-disease relationship is not so simple,” he says. “Identifying drugs that may cause liver injury only solves half the problem. The other half: Drugs that appear to be safe in pre-clinical studies still may be harmful to some patients.”

Meanwhile, we have an aging population that is more dependent on drugs. “The more medications you take, the more likely you are to have trouble,” Senior says.

A few drugs are toxic to the liver only when used in excess. One example is acetaminophen.

“Acetaminophen when used as labeled is generally considered to be safe. But overdoses of acetaminophen are the most common cause of drug-related liver injury, whether these occur accidentally or otherwise,” says Mark Avigan, M.D., a medical reviewer at FDA with a background in gastroenterology and hepatology. “With acetaminophen overdoses, some people get a more severe reaction than others.”

Acetaminophen is an active ingredient in hundreds of OTC and prescription medicines commonly used to treat musculoskeletal pain and fever, allergies, coughing, colds, flu, and even sleeplessness. Overdoses leading to serious liver injury have resulted from consumers inadvertently taking both OTC and prescription drugs containing acetaminophen.

Inadvertent overdoses with prescription drugs that contain acetaminophen and a narcotic have been responsible for a significant proportion of all the cases of acetaminophen-related liver failure in the United States, some of which have resulted in liver transplant or death.

FDA has taken steps to keep consumers safe. In early 2014, FDA requested withdrawal of over 120 applications for combination prescription acetaminophen drug products containing more than 325 mg acetaminophen per dosage unit. The agency also has reminded pharmacists and physicians to stop prescribing and dispensing combination prescription acetaminophen products containing more than 325 mg. It is FDA’s understanding that as a result, all manufacturers have discontinued marketing combination prescription drug products that contain more than 325 mg of acetaminophen.

Some antibiotics and nonsteroidal anti-inflammatory medications also have been tied to liver damage.

Hepatitis, a liver inflammation, can have several potential causes. Drugs may induce a form of hepatitis that closely resembles viral hepatitis (liver inflammation caused by viral infection).

Signs and Symptoms

How can you recognize the signs of liver problems?

Avigan says you might feel tired and have a poor appetite. In more extreme cases, your eyes and skin become yellowish (jaundice) and your skin becomes very itchy. “Your skin itches because the liver is not properly clearing toxins from the body,” he says.

When patients taking a drug they have not used before get those symptoms, they should seek immediate medical attention and stop using that drug if it is identified as the cause, Avigan cautions.

If the symptoms surface and the patient has been taking a medication for a long time, there could be another cause. Senior says it’s difficult to be certain that the symptoms were caused by a drug and not something else. Obesity and excessive consumption of alcohol also can damage the liver.

Considering Risks and Benefits

Patients should discuss the risks and benefits of any drug with their doctors when they start treatment, Avigan says. They should also discuss dietary supplements with their clinician before taking them.

Some life-saving drugs are the only options for very sick patients.

“Before approving or denying approval of a drug, we evaluate its risks and work to identify its liver injury potential, even if only one in 10,000 people will be badly affected,” Avigan says. “With some drugs, for example for cancer patients, the benefits of treatment might far outweigh the risks.”

The liver can regenerate even when 65% of it is destroyed or surgically removed, as in a cancer treatment. This versatile organ is often capable of adapting and becoming tolerant of various foreign agents, including drug products. But if the liver isn’t healthy, complications from drug interactions can be even worse.

May 28, 2014

If you've ever rubbed a topical pain reliever—a cream, gel or other product applied to the skin—on a sore muscle or joint, you're familiar with the sensation of warmth or coolness that soon follows.

But if, instead, you experience burning pain or blistering, you must seek medical attention immediately.

The Food and Drug Administration (FDA) is warning that some consumers have reported receiving serious skin injuries while using certain over-the-counter (OTC) pain relievers applied to the skin to relieve mild muscle and joint pain.

The injuries, while rare, have ranged from mild to severe chemical burns with use of such brand-name topical muscle and joint pain relievers as Icy Hot, Bengay, Capzasin, Flexall, and Mentholatum.

OTC topical pain relievers for muscles and joints include creams, lotions, ointments and patches. In many cases, burns where the product was applied occurred after just one application, with severe burning or blistering occurring within 24 hours. Some had complications serious enough to require hospitalization.

"There's no way to predict who will have this kind of reaction to a topical pain reliever for muscles and joints," says Jane Filie, M.D., a medical officer in FDA's Division of Nonprescription Regulation Development (DNRD).

More than 40 Reported Cases

According to FDA chemist Reynold Tan, Ph.D., there have been 43 reported cases of burns associated with the use of OTC topical muscle and joint pain relievers containing the active ingredients menthol, methyl salicylate and capsaicin. These cases were uncovered by FDA scientists during safety surveillance of FDA's adverse event reporting database and the medical literature.

This is a very small number of cases when compared to the number of people who purchase these products, Tan notes.

Menthol, methyl salicylate and capsaicin create sensations of local warmth or coolness, but should not burn.

According to the available data, a majority of the more severe burns occurred with the use of a menthol or menthol/methyl salicylate combination product. Most of these cases involved products that contain higher concentrations of menthol and methyl salicylate (greater than 3% menthol or 10% methyl salicylate). Few of the cases involved capsaicin.

Safety Do's and Don'ts

FDA has the following advice for consumers using OTC topical muscle and joint pain relievers:

• Don't apply these products onto damaged or irritated skin.
• Don't apply bandages to the area where you've applied a topical muscle and joint pain reliever.
• Don't apply heat to the area in the form of heating pads, hot water bottles or lamps. Doing so increases the risk of serious burns.
• Don't allow these products to come in contact with eyes and mucous membranes (such as the skin inside your nose, mouth or genitals).
• It's normal for these products to produce a warming or cooling sensation where you've applied them. But if you feel actual pain after applying them, look for signs of blistering or burning. If you see any of these signs, stop using the product and seek medical attention.
• If you have any concerns about using one of these products, talk to a medical professional first.

Pain medicines can be effective in reducing pain when used as directed. However, these medicines can also cause serious injury or death when misused or abused. They can also be addictive. It is important to talk to your healthcare provider about how to safely use pain medicines. Also, ask your healthcare provider about other options to treat pain.

Women experience pain differently than men

• Women report more pain than men.
• Some types of long-term (chronic) pain, like migraines and back pain, are more common in women.
• Women may become dependent on prescription pain medicines more quickly than men.
• Women are more likely to be prescribed prescription pain medicines, be given higher doses, and use them for longer time periods than men.

Types of Pain Medicines

Over-the-Counter (OTC) Medicines

OTC pain medicines are in many common products for headaches, colds, and menstrual (period) cramps. Common types of OTC pain medicines are acetaminophen and NSAIDs (Nonsteroidal Anti-Inflammatory Drugs), such as aspirin and low-dose ibuprofen.

Prescription Medicines

• Non-opioid medicines – Medicines that treat pain. Types of non-opioid prescription medicines include diclofenac and ibuprofen. While ibuprofen is also available over-the-counter, your healthcare provider may give you higher doses.
• Opioids – Medicines that may be effective for reducing moderate to severe pain, like after a surgery. Common opioids include oxycodone, hydrocodone, fentanyl, and morphine. 

Take steps to protect yourself and your loved ones.

• Ask your healthcare provider if you should take opioids or use other options to effectively manage your pain. Opioids are not right for everyone or every type of pain.
• Keep track of your pain. Make note when you feel pain, what it feels like, and where your body hurts. Share these notes with your healthcare provider.
• Don’t share prescription pain medicines. Keep pain medicines locked up and away from children and others.
• Don’t take pain medicines for longer than you are supposed to. Get the facts about your medicine. Find out how long you should take it. If you are taking other medications, ask your healthcare provider if pain medications are safe to take at the same time.
• Don’t drink alcohol or use medicines like antihistamines and benzodiazepines when you take certain pain medicines. Combining alcohol and different types of pain medicines or other drugs can cause you to stop breathing.
• Tell your healthcare provider if you have been addicted to medications, other drugs, or alcohol.
• Get rid of unused prescription pain medicines. Check the FDA website or ask your healthcare provider about the best way to get rid of unused medication.

Painkillers are only recommended in addition to active treatments such as exercises and movement – for example, to relieve severe back pain or to help you start moving more again. Because of the associated risks, though, they shouldn't be used over a long period of time.

Low back pain usually goes away on its own after a while. In most cases it's not clear what's causing the pain. It is then called "non-specific" back pain. If low back pain lasts a long time or keeps returning, it is often difficult to treat. Good-quality studies have so far found that only few treatments help. Staying active and moving enough are among the most effective things you can do yourself.

The medications used include over-the-counter and prescription painkillers, muscle relaxants and antidepressants. Because medication can have side effects – especially when taken over longer periods of time – it shouldn't be taken continuously, but rather only for a short while, for example when the pain is especially severe. What's more, painkillers only have a limited effect in the treatment of non-specific low back pain.

Over-the-counter painkillers

Non-steroidal anti-inflammatory drugs (NSAIDS) such as diclofenac, ibuprofen and naproxen are the most commonly used medications for low back pain. They can often relieve the symptoms a little. Lower doses of these drugs are available without a prescription. NSAIDs can be taken as tablets or injected into muscle tissue. Injections aren't recommended nowadays, though, because they can cause bleeding or inflammation where the needle enters the skin. In rare cases they can also lead to serious complications such as abscesses or nerve damage.

NSAIDs can cause stomach ache and – if taken over long periods of time – increase the likelihood of developing a stomach ulcer. They also slightly increase the risk of developing certain heart problems. People who have kidney failure should talk to their doctor before taking NSAIDs. Because of the possible side effects, it's a good idea to carefully consider the pros and cons of the medications, make sure you don't take them for too long, and use them correctly.

Two other anti-inflammatory painkillers that have a similar effect are two COX-2 inhibitors called celecoxib and etoricoxib (also referred to as coxibs). These medications are not approved for the treatment of back pain, so they are only rarely used – for instance, if opioids are the only other option.

Acetaminophen (paracetamol)

The painkiller acetaminophen (paracetamol) is also sometimes used to treat low back pain. But studies have shown that it is no more effective than a placebo (fake medication).

When using this painkiller, it's important to make sure you take the right dose. An overdose of acetaminophen can damage the liver and also cause liver failure. So experts recommend not taking more than 4 grams (4,000 mg) per day. This is the amount in, for example, 8 tablets containing 500 milligrams each. When taken at the right dose, though, acetaminophen is well tolerated. It is not suitable for people with liver problems.

Metamizole ("Novalgin")

Metamizole is a fever-reducing and anti-inflammatory painkiller that is similar to the NSAIDs. Although it is often used for the treatment of low back pain, there are no studies on its effectiveness in this area. Medical societies consider it to be an alternative to opioids for severe low back pain.

The use of metamizole is controversial because it can have a rare but very serious side effect called agranulocytosis, where the number of certain types of white blood cells decreases so much that it can become life-threatening. Possible signs of agranulocytosis include fever, a sore throat and inflamed mucous membranes. But the risk of this side effect is estimated to be much less than 0.1%. Metamizole is prescription-only in Germany.

Opioids

If other treatments don't work well enough, low back pain can be treated with stronger, prescription-only painkillers known as opioids. The best-known opioid is morphine. Other opioids include buprenorphine, codeine, hydromorphone, oxycodone, tapentadol, tilidine and tramadol. Opioids vary in their strength. Morphine, for example, is a very strong opioid, while tramadol is a weaker one. They are also available as skin patches.

Opioids are very effective at relieving many different types of acute pain. But they aren't as good at relieving low back pain as commonly believed. In studies, opioids were shown to relieve the pain in only about 10 out of 100 people. They usually don't work any better than NSAIDs do.

Opioids can have side effects such as constipation, nausea, decreased sex drive, dizziness and tiredness, affecting your ability to drive vehicles. There is also a small risk of a life-threatening overdose. So it is very important to follow the doctor's instructions and not to increase the dose without talking to the doctor first. This is also true for skin patches containing opioids (e.g. fentanyl patches). People can become physically dependent on opioids too. According to studies in this area, it is estimated that this happens to about 6% of all people who use opioids over a long period of time.

Treatment with opioids is an option if other treatments haven't helped enough or if NSAIDs can't be used. Opioids generally shouldn't be used for longer than 12 weeks. If you use opioids, it can be a good idea to seek advice from a pain specialist who has a lot of experience with these drugs.

Muscle relaxants

Muscle relaxants are thought to relieve pain by reducing tension in the muscles. They are usually prescription-only sedatives that influence the central nervous system.

Muscle relaxants can relieve acute back pain in the short term. But they haven't been proven to help relieve chronic low back pain.

Muscle relaxants can have side effects like drowsiness or dizziness. This can affect your ability to drive, and also increase the risk of falls in older people. Taking these medications can be a problem for people who operate machinery, too. Muscle relaxants known as benzodiazepines can be addictive as well.

Due to these side effects, medical societies in Germany do not recommend using muscle relaxants for the treatment of back pain.

Antidepressants

Antidepressants are prescription-only drugs used to treat depression. Some of these medications have also been approved for the treatment of chronic pain. Most antidepressants haven't been proven to help in chronic low back pain. One exception is the drug duloxetine, which can relieve the symptoms a little.

Antidepressants have a number of side effects, including loss of appetite, nausea, a dry mouth and low blood pressure. They can reduce sexual desire too. Medical societies in Germany do not recommend using antidepressants for the treatment of back pain.

Treatment with injections

If other treatments don't help relieve low back pain, treatment with injections is often offered. This involves injecting various pain-relieving or numbing medications, including the following:

• Local anesthetics

• Steroids

• Botulinum toxin (Botox)

Some of these medications aim to stimulate the body’s natural healing processes if the problem is being caused by irritated nerve roots, tendons and ligaments, or to reduce inflammation or numb the pain. Different drugs are injected into different places: for instance, into muscle tissue, into the tissue directly surrounding nerves, ligaments or spinal disks, into the joints of the spine, or into a space in the spinal canal known as the epidural space.

There is no good-quality research on the effectiveness of the various kinds of injections in the treatment of non-specific low back pain. Although side effects are rare, they can lead to serious complications. For example, if an anesthetic is injected into the wrong place it can cause respiratory paralysis, making it hard to breathe. Injections near the spine can also lead to infections.

Because it's not clear how effective they are and because of the possible risks, it's not a good idea for people with non-specific low back pain to have treatment with injections. Medical societies in Germany do not recommend injections for this purpose.

What Are the Risks?

Mixing Alcohol and Pain Medicines Can Be Harmful

• Mixing alcohol and acetaminophen can cause acute liver failure
• Mixing alcohol and aspirin increases risk for gastric bleeding
• Alcohol increases analgesic, reinforcing, and sedative effects of opiates, elevating risk for combined misuse of alcohol and opiates as well as overdose.

If you’re taking medications to manage your pain, talk to your doctor or pharmacist about any reactions that may result from mixing them with alcohol.

Analgesic Doses of Alcohol Exceed Moderate Drinking Guidelines

• The greatest pain-reducing effects occur when alcohol is administered at doses exceeding guidelines for moderate daily alcohol use.*
• Tolerance develops to alcohol’s analgesic effects so that it takes more alcohol to produce the same effects. Increasing alcohol use to stay ahead of tolerance can lead to other problems, including the development of alcohol dependence.
• According to the Dietary Guidelines for Americans, drinking in moderation is defined as having no more than 1 drink per day for women and no more than 2 drinks per day for men.

Chronic Alcohol Drinking Makes Pain Worse

• Withdrawal from chronic alcohol use often increases pain sensitivity which could motivate some people to continue drinking or even increase their drinking to reverse withdrawal-related increases in pain.
• Prolonged, excessive alcohol exposure generates a painful small fiber peripheral neuropathy, the most common neurologic complication associated with alcoholism.

If you use alcohol to relieve your pain, it is important to learn about possible adverse health effects. Ask your health care provider if any alcohol use is safe for you.

How your health care provider interacts with you is important. Their style can shape how you feel about your treatment. A new study found that people experienced less pain when the treatment provider expected a pain reliever to work. This may have been due, in part, to the provider’s facial expressions.

The study didn’t use real doctors and patients. Participants were assigned to play these roles. Those playing the doctor were first asked to rate their experience of pain relief after applying two creams on their own arms. The creams were actually the same. But the “doctors” were given different levels of mildly painful heat with the two creams. That led them to believe that one was effective and the other wasn’t.

The doctors then tested the patients to see how they responded to the creams. Researchers analyzed the facial expressions of both participants. They found that the amount of pain displayed in the doctor’s facial expressions affected the patient’s overall pain rating. Patients experienced less pain when the treatment provider expected the pain reliever to work.

“When the doctor thought that the treatment was going to work, the patient reported feeling that the doctor was more empathetic,” says Dr. Luke Chang of Dartmouth College. “The doctor may have come across as warmer or more attentive. Yet, we don’t know exactly what the doctor was doing differently to convey these beliefs that a treatment works.”

Most people experience some kind of pain during their lives. Pain serves an important purpose: it warns the body when it’s in danger. Think of when your hand touches a hot stove. But ongoing pain causes distress and affects quality of life. Pain is the number one reason people see a doctor.

A class of drugs called opioids is often used to treat pain. One reason, explains NIH pain expert Dr. Michael Oshinsky, is that opioids work well for many people. Opioids can stop the body from processing pain on many levels, from the skin to the brain. Because they work throughout the body, he says, “Opioids can be very effective for multiple types of pain.”

But opioids also produce feelings of happiness and well-being. And they’re reinforcing: the more people take them, the more they crave them. This can lead to addiction, or continuing to take opioids despite negative consequences. Scientists have not yet been able to develop opioids that reduce pain without producing these addicting effects, Oshinsky explains.

The longer someone takes opioids, the more they may need to take to get the same effect. This is called tolerance. Having a high tolerance doesn’t always mean you’ll become addicted. But taking higher doses of opioids increases the risk for both addiction and overdose.

The U.S. is now in the grip of an opioid crisis. Every day, more than 100 Americans die from an opioid overdose. This number includes deaths from prescription opioids.

“We don’t need ‘better’ opioids. We need to move away from the reliance on opioids for developing pain treatments,” Oshinsky says.

NIH is funding research into new and more precise ways to treat pain. It’s also working to develop new treatments to combat opioid misuse and addiction.

Opioids Not Always Needed

Opioids are often prescribed for acute pain. Acute pain is short-term pain, the kind experienced after an accident or an operation. But other drugs may be just as effective for acute pain, even after surgery, explains Dr. Dena Fischer, a dental health expert at NIH. Some of these drugs, like acetaminophen or ibuprofen, don’t require a prescription.

People may think that prescription drugs work better for acute pain. But that’s often not the case, Fischer says. Using something other than an opioid first can be especially important to manage acute pain in fields such as dentistry, she adds.

Many people receiving opioid prescriptions from dentists are teens or young adults who have never been prescribed an opioid before.

“Research is starting to tell us that people who receive an opioid prescription as a teenager have a tendency to continue to take opioids for non-medical purposes in the long term,” Fischer says.

Healthcare providers who decide their patient needs an opioid are now being encouraged to give only a few pills at a time. People who receive shorter prescriptions are less likely to misuse their pills by taking more than prescribed or taking them after the pain is gone. This also cuts down the chance that the pills could be taken by others.

When Pain Is Chronic

Managing chronic pain is more complicated than treating acute pain. More than 25 million people in the U.S. alone live with chronic pain, which is pain that lasts more than three months.

Many things can cause chronic pain. For example, Oshinsky says, a muscle that was damaged in an accident may heal relatively quickly. But if a nerve was also hurt, it can continue to send pain signals long after the body has repaired the muscle.

Other types of chronic pain are driven by brain changes, explains Dr. David Williams, an NIH-funded pain researcher at the University of Michigan. When these changes happen, the brain continues to perceive pain even though the injury has healed.

For people with this type of chronic pain, sometimes called central pain, opioids and some other kinds of pain medications can actually make the pain worse.

Research has shown that talk therapies, such as cognitive behavioral therapy, can help many people with chronic central pain. These types of therapies “emphasize behaving in different ways or thinking in different ways that alter the perception of pain,” Williams explains. “Pain is a combination of a sensory and an emotional experience.”

Cognitive behavioral therapy can also help people with chronic pain manage related health problems, such as problems sleeping, feeling tired, or trouble concentrating. This can increase quality of life for people with chronic pain. It can also have overlapping effects.

“Pain processing and sleep and thinking and mood all share the same neurotransmitters in the brain,” Williams says. “So, by improving something like sleep, you’re also improving pain.”

Non-opioid drugs can help some people with chronic pain too, Oshinsky says. Many of these drugs were first developed to treat different health conditions, such as seizures, depression, or anxiety. But they can also change the way the brain processes pain.

Some people benefit from devices that stimulate the nerves directly to block pain signals from reaching the brain, Oshinsky adds. Different devices can work on different parts of the nervous system, from the nerves in the skin to the spinal cord.

People with certain types of pain have also been shown to benefit from exercise, acupuncture, massage therapy, or yoga.

Expanding the Options

The alternatives to opioids we have now don’t work for everyone’s pain. More non-opioid, non-addictive treatment options could help reduce the number of opioids prescribed each year.

Recently, NIH launched the Helping to End Addiction Long-Term (HEAL) Initiative to address the shortage of effective medications for chronic pain and other issues contributing to the opioid crisis.

Some of the research funded by HEAL will focus on understanding how chronic pain develops. A better understanding of how acute pain becomes chronic could reveal new treatment targets.

Researchers funded by HEAL also hope to learn how to predict who will develop chronic pain from acute pain. This information could be used to guide early pain management, Oshinsky explains. HEAL will fund research into new treatments for opioid misuse and addiction as well.

More options for pain management could help doctors better personalize pain treatment. “It could be a little more like precision medicine, where you try to identify what flavor of pain the patient has, and then match the treatments we have available to the needs of that patient,” Williams explains.

Dealing Safely With Pain

Things you can do if you’re prescribed an opioid:

• Ask if there are ways besides opioids to relieve your pain.
• Make sure your healthcare provider knows about all other medications you are taking.
• Let your healthcare provider know if you or others in your family have had any problems with addiction, such as with alcohol, prescription medications, or illicit drugs.
• Ask about the risks of taking an opioid.
• Ask how to take the opioid and how long you should take it.
• Never use alcohol when taking an opioid.
• Store opioids in a safe place out of sight and out of reach of children, preferably in a locked cabinet.
• Dispose of leftover prescription medicine quickly and properly.