Medication Approach to Chronic Pain

August 14, 2007 – 00:00

A Patient's Guide to: Medication Approach to Chronic Pain


Pain is the most common reason for visiting a doctor. Treatment for pain consists of non-drug therapy and drug therapy. Examples of the non-drug therapies are physical therapy, relaxation exercises, injections, and massage. Most patients with chronic pain will need to use both non-drug and drug therapies to get the best pain relief possible.

This guide will help you understand

  • how healthcare providers choose medications
  • how pain affects the decision
  • what is polypharmacy
  • what are the possible medication side effects

Analgesic Ladder

The World Health Organization (WHO) developed the analgesic ladder. It is designed to help healthcare providers manage cancer pain with medications in a systematic way.

Step 1 of the Analgesic Ladder

The WHO recommends a non-opioid (non-narcotic) medication as the first step. This can be given with an adjuvant medication. Adjuvants are medications that can give additive pain control when used with the primary pain medication. Common adjuvants include certain antidepressants, antiepileptics, and topical medications.

Non-opioid pain medications include acetaminophen (Tylenol®) and the non-steroidal antiinflammatory drugs (NSAIDs). NSAIDs include drugs such as aspirin, ibuprofen (Advil®, Motrin®) naproxen (Aleve®), Naprosyn®), piroxicam (Feldene®), meloxicam (Mobic®), celecoxib (Celebrex®), and many others.

Step 2 of the Analgesic Ladder

If pain is not controlled with a Step 1 medication, then one should proceed to Step 2. This would be adding or changing the medication to include a weak opioid. Weak opioids include the drugs such as hydrocodone or oxycodone with acetaminophen, ibuprofen, or aspirin. Common brand names are Lortab®, Vicodin®, Vicoprofen®, Bancap HC, Percocet®, and Percodan®.

Step 3 of the Analgesic Ladder

If the weak opioid is not enough, then a strong opioid should be tried. Examples of strong opioids are morphine (Kadian®, MS Contin®, Avinza®), oxycodone (OxyContin®), fentanyl (Duragesic® patches), oxymorphone (Opana®), and methadone (Dolophine®.)

Problems with the WHO Analgesic Ladder

The WHO analgesic ladder has been a helpful guide to slowly step patients up as they need stronger medications. There has been some debate over where some medications fit on the ladder.

Tramadol (Ultram®)

Tramadol is a synthetic analogue of the opioid codeine. The Drug Enforcement Agency (DEA) did not classify it as a controlled substance. This means that some see it as a Step 1 non-opioid drug. Others view it as a Step 2 opioid drug. It can be helpful for mild or moderate pain. It is one of the few medications that show benefit in patients with fibromyalgia.

The term weak opioid is a confusing term. Combining a low dose of an opioid with acetaminophen, ibuprofen, or aspirin, improves efficacy (gives the desired effect). Adding hydrocodone and oxycodone to other substances make them weak opioids. This is because there are dose limits to these products. The dose of the combined product is not limited by the opioid. It is limited by the non-opioid component. Exceeding the daily-recommended dose greatly increases the risk of dangerous side effects from the non-opioid component. Hydrocodone and oxycodone are low dose strong opioids without the added acetaminophen, ibuprofen, or aspirin.


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