Chronic Pain – A Three-Tiered Approach

Chronic Pain – A Three-Tiered Approach

Pain serves a purpose; it exists to alert us to potential or existing damage to the body. It can arise from injury or disease. After the brain has received and processed the pain message and coordinated a suitable response, pain has served its function. Endorphins, the body’s natural pain killer, are meant to derail further pain messages from the same source. However, these natural pain killers may not dampen a continuing pain message sufficiently. Certain conditions lead to chronic pain which does not resolve. The time limit used in definitions of chronic pain ranges from three to six months but most use a flexible definition which considers pain chronic when it endures beyond a normal period of healing. Unfortunately, people with autoimmune conditions are often all too familiar with chronic pain. Much has been done in the field of pain management to assist these patients. It has become clear that the best approach is often one that incorporates a multidisciplinary approach, with the greatest relief being achieved using a combination of treatment options. In this three-part article we will look at a multitude of options for pain relief and ways to improve chronic pain. These options can be classified into three broad categories: noninvasive, non-drug pain management, noninvasive pharmacologic pain management and invasive pain management.

Part 2: Noninvasive Pharmacologic Pain Management


Drug Therapy

Non-prescription over the counter medications can offer relief from milder forms of pain. These range from Tylenol (acetaminophen) to nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen and naproxen. These drugs tend to help with muscle aches and stiffness and NSAIDs offer some reduction in inflammation. Medication offering the same benefits can be given as creams and ointments that can be applied to the affected area.

If over the counter medication does not offer sufficient relief, your treating physician may prescribe something stronger. Prescription pharmacological options fall into a number of different categories.

Muscle Relaxants

Muscle relaxants are used to reduce skeletal muscle spasms or muscle spasticity. Muscle spasms or cramps are sudden, involuntary contractions of a muscle or group of muscles. They can be caused by too much muscle strain and lead to pain.  Muscle spasticity, on the other hand, is a continuous muscle spasm that causes stiffness, rigidity, or tightness that can interfere with normal walking, talking, or movement. Muscle spasticity is caused by injury (either physical or driven by disease) to parts of the brain or spinal cord involved with movement. Antispasmodics are used to treat muscle spasms, and antispastics are used to treat muscle spasticity. Some antispasmodics, such as tizanidine, can be used to treat muscle spasticity. However, antispastics should not be used to treat muscle spasms. Although antispasmodics can be used to treat muscle spasms, research indicates that they do not work better than nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen. Given that they have additional side effects when compared with NSAIDs or acetaminophen they should be used with caution for short periods as prescribed by your doctor. Common side effects include, drowsiness, dizziness, headaches, nervousness and low pressure upon standing. Certain antispastics, such as Baclofen, work by blocking nerve signals from the spinal cord that cause muscles to go into spasm. Others such as Dantrolene act directly on skeletal muscle in order to relieve the spasm. Most frequently for spasms resulting from inflammation, a drug such as Diazepam (Valium) is given and works by increasing the activity of a specific neurotransmitter.


Prescription NSAIDs (such as Celebrex) work by blocking the production of certain substances in the body, prostaglandins, that cause inflammation and pain. Prostaglandins have other effects in the body. They help maintain the mucosal lining of the stomach and intestines, promote blood clotting, and help the kidneys function normally. Due to the fact that prostaglandins have many roles in the body, taking NSAIDs to suppress the production of prostaglandins can have both positive and negative effects. Long-term use may cause gastrointestinal ulcers, and may slightly raise the risk of heart attack. Research that longer-term use of NSAIDs will also result in tolerance and they will therefore be less effective overtime. It is advised to use these drugs as little as possible and it may be more beneficial to switch and alternate between NSAIDs and acetaminophen to reduce side effects and decrease the likelihood of developing tolerance.

Narcotic Medications

Narcotic medications include strong pain killers (codeine, fentanyl, oxycodone to name but a few). These work by altering how we perceive pain by weakening pain signals sent to the brain. In addition, these drugs can have an emotional impact leading to feelings of improved well-being. It is worth noting that a recent study in The Journal of Pain found that doctors have been overprescribing opioids for chronic musculoskeletal pain. The data collected over 8 years showed that drugs were more often prescribed than physical therapy, counseling or other nondrug interventions. This is directly at odds with what experts recommend, including the recommendations in the CDC guidelines for prescribing opioids for chronic pain. Therefore, while these medications can certainly offer some relief for chronic pain suffers it is important that they are prescribed and utilized correctly, they should form part of a multipronged approach to pain management and should never be the sole crutch on which patients rely. This will help to avoid negative side effects including liver and kidney damage, problems with addiction and reduced efficacy and tolerance over time.


Corticosteroids are generally used in the application of pain management for their anti-inflammatory properties. These agents, produced by the adrenal cortex, are broadly used in epidural, joint, peripheral nerve and various types of soft tissue injections. Corticosteroids can be classified as anti-inflammatory (glucocorticoids), androgenic/estrogenic, and salt-retaining (mineralocorticoids). The primary mechanism of action of corticosteroids is at the cellular level with anti-inflammatory properties resulting from inhibition of phospholipase, alterations in lymphocytes, inhibition of cytokine expression and stabilization of the cellular membrane. Of particular concern with corticosteroids is that when used without caution, transient and permanent tissue damage can result. Even when given within recommended guidelines, adverse reactions are fairly common. High doses and/or chronic intake of corticosteroids are more likely to precipitate their known side effects than a single low dose injection. Some of the more common reported problems are fluid and electrolyte imbalances, muscle weakness, bone demineralization leading to osteoporosis, gastrointestinal irritation and disease, and difficulty sleeping.


Although antidepressants were developed to treat depression and anticonvulsants were developed to treat seizures, it has been found that both can be effective in combating certain types of chronic pain. Antidepressants that have been exhibited analgesic (pain reducing) properties include amitriptyline (Elavil), trazodone (Desyrel), and imipramine (Tofranil), often prescribed to treat musculoskeletal pain. Anticonvulsants that offer pain relief associated with nerve damage include phenytoin (Dilantin), carbamazepine (Tegretol) and Lyrica (Pregabalin). 

Although some of medication discussed is available over the counter, it is important to discuss any medication use with your treating physician. Your doctor will be able to assist with which medication combinations can be safely used and which to avoid. They will also discuss potential side effects that occur and what you should do in the event that you experience any of them. Please see our April edition of the ANRF Chronicle is you missed part one of this series as it discusses non-invasive, non-drug pain management options. For patients with chronic pain it is likely that a combined approach will yield the best pain relief.


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Article Author
Arthritis National Research Foundation

The Arthritis National Research Foundation's mission is to provide initial research funding to brilliant, investigative scientists with new ideas to cure arthritis and related autoimmune diseases. Writing articles about the patients affected and the science being done to find a cure shows why we need to come together to #CureArthritis!

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