Painkillers vs Pain Relievers, Treating the Cause or the Symptom

I had an interesting chat with one of my doctors recently about pain relief. After dealing with quite a bit of nerve pain and ultimately getting an MRI to help diagnose the reason, I had a few questions about how different pills worked. There are a number of drugs marketed for pain relief. But I wanted to know which, if any, might actually solve the root problem causing my pain instead of merely masking my discomfort.

Over-the-counter pain relievers:

The most common over the counter (OTC) drugs commonly used to treat pain are acetaminophen and the group of non-steroidal anti-inflammatory drugs (NSAID). The most common NSAID options are ibuprofen, aspirin, and naproxen. Additionally, there are over a dozen prescription NSAID medications, that appear to be distinguished mainly through marketing rather than performance.

Both acetaminophen and NSAIDs can reduce fever and relieve the pain of muscle aches and stiffness. NSAIDs, as their name implies, also work by reducing the inflammation or swelling that might actually be causing the pain. In addition, NSAIDs reduce or prevent the production of prostaglandins, which are fatty acid compounds associated with the transmission of pain signals. Acetaminophen works directly to disrupt the pain signals within the brain itself.

The dosage of NSAIDs has more to do with inflammation, however; the amount of pain relief changes very little with higher doses for short-term treatment. NSAIDs may cause stomach irritation or bleeding with higher doses and prolonged use may cause kidney problems. High doses of acetaminophen, however, may damage the liver. Before choosing NSAIDs or acetaminophen, it is important to check with a doctor or pharmacist about other medications a patient is taking because there are potential drug interactions to be aware of, especially with NSAIDs. Acetaminophen is often combined with other drugs, especially in "cold and flu" medications, so it is important to check the dosages of all medications if a patient is taking more than one containing the same ingredient.

Corticosteroids:

For specific types of pain caused by inflammation, such as joint pain, corticosteroids may be prescribed in either pill or injectable form. Common drugs of this type include methylprednisolone, prednisolone, and prednisone. While often very effective at relieving pain by helping to fix the underlying problem, these medications can cause sleeplessness, irritability, and suppression of the immune system.

Narcotics:

Narcotics work by actually changing the brain's perception or interpretation of pain. The effect is generally much stronger than that of either acetaminophen or NSAIDs alone.

Acetaminophen is also commonly combined with several types of narcotic drugs for enhanced pain relief. Codeine, hydrocodone, and oxycodone are the most common narcotics used for these prescription medications, but they do not all work equally well for every patient. Codeine, for example, requires a specific enzyme to convert it into morphine, and not all patients have that enzyme. Hydrocodone is a stronger pain medication than acetaminophen or NSAIDs, but it can also lead to dependency with extended use. Oxycodone also has the potential to lead to dependency but is even stronger than hydrocodone.

For short-term pain relief, it may be better to use an NSAID like ibuprofen and simply add a dose of a hydrocodone or oxycodone and acetaminophen combined medication as needed.

For acute or chronic pain, narcotics may be prescribed on their own and come in both immediate release and sustained release formulations. For quick, short-term relief of acute pain, buprenorphine, fentanyl, hydromorphone, meperidine, morphine, oxycodone, and oxymorphone are commonly used. Fentanyl is available in formulations that make it possible to absorb directly through skin contact, making it particularly effective and for which the FDA specifically approved the drug to treat cancer pain.

Chronic pain is often treated through the use of sustained-release medication, some of which may be administered through the use of a topical patch. Fentanyl, methadone, morphine, oxycodone, oxymorphone, and tapentadol are the most common of these sustained-release narcotics.

Because these drugs are opioids, they come with the risk of both sedation in the short-term and addiction in the long-term. A non-narcotic alternative for chronic pain relief is available with tramadol, however, it also has the potential for abuse. Still, for some patients, this might be a better alternative.

Other approaches:

For some difficult to treat types of pain, such as chronic nerve pain, it might be useful to consider anti-depressants. Several types of anti-depressants given at low doses have shown promise treating pain, but they require sustained use so that the medication can build up in the patient's body and become effective. Certain types of anti-convulsants used to treat seizures may also help treat pain associated with nerve damage. Lastly, for topical pain, an anesthetic such as lidocaine may be used. Anesthetics work by actually numbing the area to dull the sensation of pain at its source, but they offer only temporary relief.^1-5

Editor’s Note: We are extremely saddened to say that on October 21, 2018, Jeffrey Poehlmann passed away. Jeffrey’s advocacy efforts and writing continue to reach many. He will be deeply missed.