Methods Of Pain Relief Using Medications, Non-steroidal Anti-inflammatory Drugs, Acupuncture And TENS

Pain management which is also called pain medicine or algiatry is that branch of medicine employing an interdisciplinary approach to easing the suffering and improving the quality of life of those living with pain. The typical pain management team includes medical practitioners, clinical psychologists, physiotherapists, occupational therapists, and nurse practitioners. Pain usually resolves promptly once the underlying trauma or pathology has healed, and is treated by one practitioner, with drugs such as analgesics and (occasionally) anxiolytics. Effective management of long term pain, however, frequently requires the coordinated efforts of the management team.

Methods Of Pain Relief

Medicine treats injury and pathology to support and speed healing; and treats distressing symptoms such as pain to relieve suffering during treatment and healing. When a painful injury or pathology is resistant to treatment and persists, when pain persists after the injury or pathology has healed, and when medical science cannot identify the cause of pain, the task of medicine is to relieve suffering. Treatment approaches to long term pain include pharmacologic measures, such as analgesics, tricyclic antidepressants and anticonvulsants, interventional procedures, physical therapy, physical exercise, application of ice and/or heat, and psychological measures, such as biofeedback and cognitive behavioral therapy.

Pain Relief Medications

The World Health Organization (WHO) recommends a pain ladder for managing analgesia which was first described for use in cancer pain, but can be used by medical professionals as a general principle when dealing with analgesia for any type of pain.
In the treatment of chronic pain, whether due to malignant or benign processes, the three-step WHO Analgesic Ladder provides guidelines for selecting the kind and stepping up the amount of analgesia. The exact medications recommended will vary with the country and the individual treatment center, but the following gives an example of the WHO approach to treating chronic pain with medications. If, at any point, treatment fails to provide adequate pain relief, then the doctor and patient move onto the next step.

Mild Pain

Paracetamol (acetaminophen), or a non steroidal anti-inflammatory drug such as ibuprofen

Mild To Moderate Pain

Paracetamol, an NSAID and/or paracetamol in a combination product with a weak opioid such as Hydrocodone used in combination, may provide greater relief than their separate use.

Moderate To Severe Pain

Morphine is the gold standard of choice, followed by Oxycodone, Hydromorphone, Oxymorphone and Fentanyl in the form of a transdermal patch designed for chronic pain management. Diamorphine, Methadone and Buprenorphine are used less frequently.
Pethidine is not recommended for chronic pain management due to its low potency, short duration of action, and toxicity associated with repeated use. Amitriptyline is prescribed for chronic muscular pain in the arms,lower back,legs and neck. While opiates are often used in the management of chronic pain, high doses are associated with an increased risk of opioid overdose.
Opioids Opioid medications can provide a short, intermediate or long acting analgesia depending upon the specific properties of the medication and whether it is formulated as an extended release drug. Opioid medications may be administered orally, by injection, via nasal mucosa or oral mucosa, rectal, transdermal, intravenously, epidurally and intrathecally. In chronic pain conditions that are opioid responsive a combination of a long acting or extended release medication is often prescribed in conjunction with a shorter acting medication for breakthrough pain (exacerbations).

Non-steroidal Anti-inflammatory Drugs

The other major group of analgesics are Non-steroidal anti-inflammatory drugs (NSAID). This class of medications does not include acetaminophen, which has minimal anti-inflammatory properties. However, acetaminophen may be administered as a single medication or in combination with other analgesics (both NSAIDs and opioids). The alternatively prescribed NSAIDs such as ketoprofen and piroxicam, have limited benefit in chronic pain disorders and with long term use is associated with significant adverse effects. The use of selective NSAIDs designated as selective COX-2 inhibitors have significant cardiovascular and cerebrovascular risks which have limited their utilization.

Antidepressants And Antiepileptic Drugs

Some antidepressant and antiepileptic drugs are used in chronic pain management and act primarily within the pain pathways of the central nervous system, though peripheral mechanisms have been attributed as well. These mechanisms vary and in general are more effective in neuropathic pain disorders as well as complex regional pain syndrome.
Drugs such as Gabapentin have been widely prescribed for the off-label use of pain control. The list of side effects for these classes of drugs are typically much longer than opiate or NSAID treatments for chronic pain, and many antiepileptics cannot be suddenly stopped without the risk of seizure.

Other Adjuvant And Atypical Analgesic Agents

Other drugs are often used to help analgesics combat various types of pain and parts of the overall pain experience. In addition to gabapentin, the vast majority of which is used off-label for this purpose, orphenadrine, cyclobenzaprine, trazadone and other drugs with anticholinergic properties are useful in conjunction with opioids for neuropathic pain.
Orphenadrine and cyclobenzaprine are also muscle relaxants and are therefore particularly useful in painful musculoskeletal conditions. Clonidine has found use as an analgesic for this same purpose and all of the mentioned drugs potentiate the effects of opioids overall.

Physical Approach Physiatry

Physical medicine and rehabilitation (Physiatry) employs diverse physical techniques such as thermal agents and electrotherapy, as well as therapeutic exercise and behavioral therapy, alone or in tandem with interventional techniques and conventional pharmacotherapy to treat pain, usually as part of an interdisciplinary or multidisciplinary program.


Transcutaneous electrical nerve stimulation (TENS or TeNS) is the application of electrical current through the skin for pain control. The unit is usually connected to the skin using two or more electrodes. A typical battery-operated TENS unit is able to modulate pulse width, frequency and intensity.
Studies comparing TENS with placebo (sham TENS) in the treatment of chronic low back pain provide conflicting results, with 2 Class I studies and one Class II study showing no benefit, and 2 Class II studies showing benefit. Class I studies are stronger evidence, so it appears that TENS is ineffective for the treatment of low back pain. Two Class II studies demonstrate probable effectiveness in the treatment of painful diabetic neuropathy. More high quality research into the effectiveness of TENS is needed.


Acupuncture involves the insertion and manipulation of needles into specific points on the body to relieve pain or for therapeutic purposes. As per the article published in 2003 by the World Health Organization synthesizing the scientific research (controlled trials) of the time, concluded that acupuncture is helpful for the treatment of pain in some cases of acute epigastralgia, facial pain, headache, knee pain, low back pain, neck pain, pain in dentistry, postoperative pain, renal colic, and sciatica. The authors also concluded acupuncture has demonstrated effectiveness in other conditions for which further proof is needed.
An analysis of the 13 highest quality studies of pain treatment with acupuncture, published in January 2009 in the British Medical Journal, concluded there was little difference in the effect of real, sham and no acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles, and that further research is appropriate.

Cognitive And Behavioral Therapy

Mindfulness-based cognitive therapy, the use of stress reduction and relaxation, has been found to reduce chronic pain in some patients. Applied behavior analysis views chronic pain as a consequence of both respondent and operant conditioning, where a patient learns to display pain behavior in the presence of specific environmental antecedents and consequences. The model was first proposed by Fordyce in 1976.
Though cognitive-behavioral intervention can be an effective and economical means of treating chronic pain, the effects are rather modest and a substantial portion of patients gain no benefit.


Biofeedback based on behavioral principles has shown some success for chronic pain, demonstrating greater improvement in one study than peers undergoing cognitive-behavioral therapy and conservative medical treatment, though a different study showed improvements over wait-list controls but no difference between biofeedback and cognitive-behavioral therapy.


A 2007 review of 13 studies found evidence for the efficacy of hypnosis in the reduction of pain in some conditions, though the number of patients enrolled in the studies was small, bringing up issues of power to detect group differences, and most lacked credible controls for placebo and/or expectation.
The authors concluded that "although the findings provide support for the general applicability of hypnosis in the treatment of chronic pain, considerably more research will be needed to fully determine the effects of hypnosis for different chronic-pain conditions".

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