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Chronic pain: Medication decisions

Content Nonsteroidal anti-inflammatory drugs (NSAIDs) Acetaminophen COX-2 inhibitors Antidepressants and anti-seizure medications Opioids Pain medications at a glance

Pain medications at a glance

Medication type How they work First line option for Benefits Risks
NSAIDs Block COX-1 and COX-2 enzymes involved in pain and inflammation
  • Mild to moderate pain accompanied by swelling and inflammation
  • Arthritis pain and pain resulting from muscle sprains and strains, back and neck injuries, overuse injuries, and menstrual cramps
 When taken as directed, generally safe for short- and long-term use
  • May cause nausea, stomach pain, stomach bleeding or ulcers
  • When taken in high doses, can lead to kidney problems, fluid retention and high blood pressure
  • Increased risk of side effects for older adults
Acetaminophen Unknown, but possibly blocks a COX-3 enzyme Mild to moderate pain Acetaminophen Unknown, but possibly blocks a COX-3 enzyme
COX-2 inhibitors Block COX-2 enzymes Rheumatoid arthritis, osteoarthritis, menstrual cramps and injury-related pain As effective as NSAIDs without damaging stomach lining at regular doses
  • Respiratory infection, headache and dizziness
  • When taken in high doses, can lead to stomach bleeding, kidney problems, fluid retention and high blood pressure
  • Increased risk of side effects for older adults
Antidepressants Interfere with certain chemical processes that cause you to feel pain
  • Neuropathic pain, chronic daily headaches, fibromyalgia
  • May be considered for chronic low back pain
  • Can be in doses much lower than what is currently used to treat depression
  • Side effects generally mild
  • Drowsiness possible with tricyclic antidepressants
  • Can take several weeks to produce desired effects
  • May worsen depression and cause suicidal thoughts in a small number of people
Anti-seizure medications Quiet pain signals from damaged nerves Postherpetic neuralgia, diabetic neuropathy, fibromyalgia Side effects generally mild
  • May cause dizziness, drowsiness, nausea, reduced coordination and weight changes
  • May worsen depression and cause suicidal thoughts in a small number of people
Opioids Activate feel-good neurotransmitters, called endorphins, that suppress pain and boost a sense of well-being
  • Acute pain, such as pain that follows surgery or a bone fracture
  • Typically prescribed for maximum of three days
 Powerful relief during short periods of severe pain
  • Tolerance, dependence, misuse, addiction and overdose, which may begin to develop within one week of use
  • Responsible for the majority of accidental overdose deaths in the U.S.

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