In this chapter, we focus on pain treatment through medication (pharmacological treatment for pain, called analgesics). There is however also a wide range of non-pharmaceutical approaches towards pain, often used in combination with pain medication. We briefly list a number of them.
Non-pharmacological approaches and specific interventions
Specific interventions for pain include:
- Relaxation therapy
- Exercises, mobilization and physiotherapy
- Acupuncture
- TENS (Transcutaneous Electrical Nerve Stimulation)
- Spinal cord stimulation
- Nerve root decompression
- Laminectomy
- Fusion
The best known intervention is physiotherapy aiming at improving relaxation and stabilisation of limbs and other parts of the body.
TENS (Transcutaneous Electrical Nerve Stimulation) and spinal cord stimulation make use of an electronic device that generates light electric impulses in the nervous system to “overshoot” the natural pain transmitting signals.
Surgical procedures, such as on the spine, aim to:
- Reduce pressure on a nerve by trimming the disc back in line with the vertebra (nerve root decompression)
- Stabilise unstable segments in the spine by fixing vertebrae into each other (fusion) or removing a part of bone (laminectomy).
Nevertheless, most patients suffering from pain are treated with painkilling drugs or ‘analgesics’.
Medication for pain - Classification of analgesics
Medications to treat pain are called “analgesics”. The World Health Organisation (WHO) guidelines for the treatment of cancer pain use a three-step approach towards pain. This approach is also frequently used for non-cancer pain. Different types of analgesics are classified on each of the three steps of this ‘ladder’. Pain therapy should start from the lowest level and gradually climb up if pain control is insufficient.
1. The WHO step I analgesics are the so-called non-opioids, mostly drugs which have some anti-inflammatory properties as well. Some of these analgesics are available without prescription, like aspirin and paracetamol. Nevertheless, side effects can occur when you take these drugs, so make sure you consult the package insert and do not exceed the maximum daily dose allowed to control your pain.
Analgesics with a typical anti-inflammatory action, also called NSAIDs (non-steroidal anti-inflammatory drugs) or antiphlogistic drugs, include ibuprofen and diclofenac. These drugs suppress the nociceptors and thereby diminish the intensity of the signal sent towards the central nervous system. Because of their anti-inflammatory action, they are often used first-line in rheumatoid disorders. But as NSAIDs can impair the gastric lining and can lead to significant gastric discomfort and even stomach ulcers, newer anti-inflammatory agents that result in less discomfort (called COX2-inhibitors) have been developed.
Step I analgesics are frequently used in occasional pain, like toothaches, headaches or a dislocation.
2. WHO step II analgesics: Analgesics with intermediate strength, so-called weak opioids, are on the second level. They have an effect on the transmission of the pain signal, mostly at its end point: the interpretation of the signal in the brain. Examples are codeine, tramadol and tilidine. Weak opioids are often used for musculoskeletal and visceral pain not responding to step I analgesics, sometimes also in combination with these drugs.
3. WHO step III analgesics: Level III contains the most powerful painkillers available, the strong opioids such as morphine, fentanyl, oxycodone or hydromorphone. If these drugs are taken for chronic pain conditions they should be given in a regular dosing scheme in order to prevent re-occurrence of pain and they should be taken as sustained release formulations, e.g. tablets taken once or twice daily or pain patches.
Step II and III drugs can be combined efficiently with step I non-opioid analgesics.
In case of insufficient pain control or intolerance, other drugs can be used in addition to conventional analgesics. Although they are not primarily designed to alleviate pain, these products often strengthen the effect of painkilling drugs. Because of their additive effect, they are often referred to as “adjuvant therapy”. Examples are drugs, normally used to treat epilepsy or depression. Corticosteroid injections are used in some chronic pain conditions like osteoarthritis.
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Item code: NPR/08-0056
Date of Preparation: July 2009
