Medicines and procedures
Learn about the various types of musculoskeletal pain medicines and procedures available that may form part of your co-management plan
This module is designed to complement discussions on your pain management that you have with your doctor. The information here should not be used as a stand-alone treatment guide, nor should medications be used as a stand-alone treatment.
You should make an appointment with your doctor to discuss:
- any chills and fevers, sweaty episodes, raised temperatures, unexpected weight loss, weakness of your muscles or change in urine and bowel habits
- if your mood is lower than usual or you feel anxious or are sleeping poorly. This medical module provides information on some traditional medical options for pain management. Although much time and money is spent trying to provide the ‘perfect’ pain reliever, as yet, it hasn’t been found. It is better to consider medical options as ‘helping some people – some of the time’, rather than a magic bullet or procedure that cures all pain.
If you have persistent pain and are using an active management approach, including paced activity and functional everyday movement and exercise, your pain and function typically improve. However, if you experience significant ongoing pain that limits your return to activities, then discussing possible medications or procedural options with your doctor is important.
About pain medications
The name ‘pain killers’ tends to give the wrong idea. Pain medications called ‘analgesics’ or pain modifiers, and most pain procedures, only tend to help about 1 person out of 4 improve their pain by 50% (or more), compared to a placebo or dummy treatment. So if a pain medication is given to 4 people, one person will get 50% or more relief (compared to placebo). Hence, the name ‘pain modifier’ is more realistic than ‘pain killer’. It is best to keep your expectations low!
All medications and procedures have a placebo (or ‘I will please’) effect: this shows the power of our body to control pain naturally, and is a good thing. Placebos have a positive effect, as our bodies are ‘wired’ to release our natural pain modifiers.
If you do get a positive benefit from pain medications or procedures, make sure you continue to advance your paced activity and keep moving with pain. This approach helps to prevent a recurrence of your pain.
The goal of pain modifying medications is to allow you to get active, to improve your physical function, mood, sleep and your ability to manage your pain.
Sometimes your doctor may advise combining medicines. This is because different drugs work at different places in your body and in different ways. Combining drugs can mean you require lower doses of each, with less risk of side effects while ensuring pain relief.
How effective are medications for musculoskeletal pain?
The Number (of patients) Needed to Treat (NNT) is what is used to explain how likely a medication is to “work”. This compares how the medication reduces pain by half (50%) compared to a placebo (e.g. a sugar tablet or ‘dummy’).
An NNT of 2 means that 1 patient in 2 treated with the pain-reliever will get a reduction in pain (by at least 50%), compared to a placebo. A NNT of 4 means that 1 patient in 4 will achieve pain relief, and so on.
How harmful are medications?
The Number Needed to Harm (NNH) is what is used to explain how likely a medication is to give side-effects. An NNH of 8 means that 1 in every 8 people taking the medication will experience a side effect, compared to placebo, because of the medication.
What medication your doctor recommends may depend on whether you have any other medical issues. You want to choose the medication that has:
- the highest chance of helping (so that means a low NNT)
- the lowest chance of side-effects (that means a high NNH)
- the lowest chance of addiction
For more information, see our summary table with the NNT and NNH of pain modifier medications.
Do the same pain medications help all types of pain?
No. The medication choices you discuss with your doctor and pharmacist will depend on the type(s) of your pain1. Once you have good information, it is up to you to decide whether, ‘on balance’, the medication does you more good than harm.
There are 3 broad pain types:
- ‘Nociceptive’ pain – this is common with acute pain when there is tissue damage liked a torn muscle or sprained ankle
- ‘Nociceptive Inflammatory’ pain – which is usually worse in the mornings, for example, like rheumatoid arthritis pain
- ‘Neuropathic’ pain – often burning, shooting, electric shock-like pain, with hypersensitivity so that even a light touch is painful. People often get this type of pain when they have shingles, sciatica, trigeminal neuralgia, or diabetic neuropathy
The immune system can also contribute to pain. More evidence is emerging to support the role of the immune system in pain. This is sometimes referred to as ‘alloplastic’ pain or glial mediated immuno-responsive pain. Major advances have occurred in understanding how glia and immune cells in the nervous system can contribute to pain. One of the key messages from this understanding is the importance of reducing life stressors (physical, psychological and environmental) and threats (fear, anxiety, worry) to improving your pain and wellbeing.
For more information, see our pain types management module.
Helpful questions to ask your doctor and pharmacist
When you go to see your doctor or pharmacist, ask about the evidence for the medications you are recommended. Below is a list of example questions you may ask to find out more information about your options such as:
- what medication options are suitable for my pain condition?
- how long the medication takes to work?
- what are the potential benefits?
- what are the likely side effects?
- is the medication addictive?
- what ways can I take my pain medication?
- how will pain modifiers work with my other medicines?
Different ways you can take medications
Medications now come in many different forms such as tablets, capsules or liquid (taken orally), patches or creams (put on the skin), capsules (to put under the tongue), or suppositories (put in the rectum).
See our fact sheet for more detailed information on different forms of medications and ways to take medications.
How often should I use my pain medication?
Consider regular non-addictive medications if you have:
- pain every day, 7 days a week, 24 hours per day
- pain on most days of the week.
Consider using non-addictive medications ‘as needed’, if you experience:
- pain on some days of the week
- pain on occasional days
- pain following specific events.
Remember that paced movement, activity and mood management is the treatment. Medications are used to help you do these activities. Medications are not a treatment in their own right.
There are four main groups of pain medications
What may be appropriate for you will depend on your musculoskeletal pain conditions1 and any other co-morbid health conditions. Different types of medicines may be indicated to help manage your pain. It is important to ask your doctor or pharmacist about the evidence (science) for benefit and risks for each.
Group One: Traditional pain medications called analgesics
Analgesics include paracetamol, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Tramadol (Tramal™, Zydol™, Tramahexal™, Durotram ™); and combinations such as Panadeine (paracetamol 500mg and codeine 8mg), Panadeine Forte (paracetamol 500mg and codeine 30mg).
While simple analgesia may be appropriate at times, especially for pain flare ups, the most recent high level evidence indicates that paracetamol alone is not effective in the treatment of acute low back pain2 and provides minimal short term benefit for people with osteoarthritis3. Recent evidence on lower limb osteoarthritis4 shows that exercises (such as strengthening exercise) compared with no exercise helps to significantly reduce pain. For hip or knee osteoarthritis, the size of the benefit (knowm as ‘effect size’) is much larger (more benefit) than using short term paracetamol.
These can be tried for usual acute pain or nociceptive pain, inflammatory pain and some of these medications might help neuropathic pain. For more detail on this group of medication, download our fact sheet on Analgesics.
Group two: Anti-neuropathic medications
These medications can be tried for neuropathic pain5 to reduce or “calm down” nerve activity and reduce pain hypersensitivity associated with conditions like shingles, diabetic pain, sciatica, fibromyalgia and headaches.
These medications are often prescribed if you have burning or shooting pain (nerve injury or ‘neuropathic pain’). They help 1 out of 3 people with neuropathic pain. They don’t tend to help usual acute nociceptive pain or Inflammatory pain (except for tramadol). For more detail on this group of medication, download our summary on Anti-Neuropathic Medications fact sheet.
Group three: Other options
- Fish Oil: 12gm per day is the ‘anti-inflammatory’ dose and might be worth a trial for 3-6 months (then reduce to half this dose). The dose that is for ‘good for your heart’ is 2-3 capsules/day. For pain associated with rheumatoid arthritis, there is some evidence for modest benefit from fish oil for joint swelling and pain, duration of morning stiffness, global assessments of pain and disease activity7
- Glucosamine: although not consistently recommended based on current clinical guidelines, some clinicians may suggest using this. In this case, the usual dose for patients with Osteoarthritis (OA) is 1.5 gm (1500mg) per day. While there is some evidence that glucosamine may provide benefit for you if you have knee osteoarthritis6 the evidence is mainly lacking for other conditions
Group four: Opioid pain modifiers
Opioid means the medication has an action ‘like opium’ which comes from the Poppy plant. Only about 1 in 5 patients obtain effective pain relief with opioid pain medications, without major side effects.
Codeine-related deaths are increasing in Australia as the consumption of codeine-based products increases8. Codeine is often thought of as a weak opioid, however recent research shows that deaths attributed to accidental overdoses in Australia were more common (48.8%) than intentional deaths (34.7%). For these deaths, there were high rates of comorbid mental health problems like depression or anxiety (53.6%), substance use (36.1%) and chronic pain (35.8%). This research found that for every two opioid-related deaths in 2009, there was one codeine-related death, and most of these (83.7%) were the outcome of toxicity due to combined drug use.
Opioids are discussed separately here, as there are health concerns associated with long term use. For more detail on this group of medication, download our fact sheet on Opioid Medications.
There is an opioid calculator app to help work out morphine equivalents as these differ between medicine. This helps to ensure safer use of this medicine. See this short clip about opioids: ‘Understanding Pain: Brainman stops his opioids.’
Six rules to help you stay safe and get the best out of your medications
Rule one: Start low, go slow
- start at the lowest dose, and slowly increase the dose every 3rd day until you are taking the dose the doctor recommended. This helps reduce side effects
- some medications work on the day you take them; others take 2 or 4 weeks to work. Ask your doctor or pharmacist for this information for each medication you are prescribed
- assess if the tablets help reduce your pain
Rule two: Trial each new medication for four weeks
- ask your doctor how long it takes for this medication to have a maximal positive effect
- ask your doctor how long it takes for that medication to have a negative effect or side-effect
- if there are more positives than negatives (within the 4 weeks), then continue the medication
- if there aren’t many positives, then discuss with your doctor slowly reducing and ceasing the medication
Rule three: Timing of taking medications
- if tablets are likely to make you sleepy, take them at the end of the day’s work: either at 6-7pm if they take a few hours to work, or at bedtime if you feel sleepy shortly after taking them
- take tablets in the morning that are likely to increase your alertness, rather than at night
- ask your doctor what is the most likely ‘alertness’ effect for any medications you are prescribed
Rule four: Assess if the medication helps achieve your goals
- it is important that prior to starting any medications that you already have an established routine, which includes pain management approaches covered in the other training modules such as pacing and goal setting, movement with pain an approaching pain
- you need to assess over the 4 weeks if the medication improves your activity and function and reduces your pain whilst you are doing activities
- the positive effect of a medication may be time-limited if your body gets used to them. This is called ‘tolerance’ for medications that are related to morphine (also called opioids). Their use, if recommended, should be short term only
Rule five: Combining medications
- only start (or stop) one tablet at a time, assess the effect over 4 weeks
- doctors might try combinations from different groups of pain medications
- ask your doctor if there are likely interactions with you usual medications
Rule six: Stopping tablets
- stopping tablets that are taken over a longer period (e.g. more than 4 weeks) is the reverse of Rule One. Reduce them slowly over a few days, or a few weeks if you body has got used to them
- ask your doctor prescribing the medications if they are habit-forming: as this may cause tolerance and addiction
- ask your doctor prescribing the medications if side effects are likely if the medications are suddenly stopped
Remember that medications are used so you can progress the skills you have learnt in our other pain management modules.
If procedural interventions are being considered, it is necessary to discuss the following details with the doctor performing the procedure. This doctor will also perform a clinical examination of you prior to discussing procedural options.
The doctor will be able to discuss the use of imaging (X-ray beam with Image Intensifier, CT scan or Ultrasound), and the risks and benefits of the procedures directly with you.
You should expect:
- to be examined by the doctor performing the procedure
- that the procedure is performed in a low risk (safe and sterile) facility
- that a follow-up appointment is organised with the doctor who performed the procedure. At this follow-up you can discuss the outcomes of the procedure, and what this means in the context of your overall management program
Diagnostic procedures: The aim here is to find out if your pain is coming from one specific part of your body, or if the nerve carrying the pain messages is blocked by the “numbing fluid” or Local Anaesthetic (LA) fluid that the doctor will put through a needle.
- the Local Anaesthetic (LA) should be starting to work within 30 minutes and lasts a few hours
- if your pain is “almost gone” during this LA phase (30 minutes to 4-6 hours), this indicates that a significant component of your pain may be coming from that part of the body, or be carried by the nerve that has been temporarily blocked
- often a medium to long term steroid is used, which works for a few weeks to a few months. This doesn’t start to work for 24-48 hours, and doesn’t reach its full effect until 2 to 4 weeks
- common side-effects are red facial flushing, higher blood sugars if you are a diabetic; less common is changes in mood and blood pressure
- just prior to the procedure, write down the location of your pain, and what level it is (we often use a 10cm line with markings from 0-10 as a pain score – where “0” is no pain and “10” is the worst pain you can imagine)
- make sure you record these pain scores (and pain location) before, immediately after, at 4 hours, then at 1, 7, and 14 days
- continue doing your usual activities (in a paced fashion) so you know how much pain you have compared to usual.
See our fact sheet for more information on diagnostic procedures and therapeutic procedures. You can find consumer summaries for though Cochrane Summaries. Alternatively, if you need to speak to your GP or health care professional, please seek further assistance.
Chronic Non-Cancer Pain Management Plan
painHEALTH - NNT and NNH of pain modifier medications
painHEALTH - Different forms of medications and ways to take medications
painHEALTH - Analgesics fact sheet
painHEALTH - Anti-Neuropathic pain medications
painHEALTH - Opioid pain medications
painHEALTH - NNT and NNH for diagnostic and therapeutic procedures
- Schug SA, Goddard C. Recent advances in the pharmacological management of acute and chronic pain. Ann Palliat Med 2014; 3(4): 263-75. [PubMed]
- Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet 2014; 384(9954): 1586-96. [PubMed]
- Machado GC, Maher CG, Ferreira PH, et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. Bmj 2015; 350: h1225. [PubMed]
- Uthman OA, van der Windt DA, Jordan JL, et al. Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. Bmj 2013; 347: f5555. [PubMed]
- Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet neurology 2015; 14(2): 162-73. [PubMed]
- Kongtharvonskul J, Anothaisintawee T, McEvoy M, Attia J, Woratanarat P, Thakkinstian A. Efficacy and safety of glucosamine, diacerein, and NSAIDs in osteoarthritis knee: a systematic review and network meta-analysis. Eur J Med Res 2015; 20: 24. [PubMed]
- Miles EA, Calder PC. Influence of marine n-3 polyunsaturated fatty acids on immune function and a systematic review of their effects on clinical outcomes in rheumatoid arthritis. Br J Nutr 2012; 107 Suppl 2: S171-84. [PubMed]
- Roxburgh A, Hall WD, Burns L, et al. Trends and characteristics of accidental and intentional codeine overdose deaths in Australia. The Medical journal of Australia 2015; 203(7): 299. [PubMed]
This module has been developed by Dr Stephanie Davies, MBBS, FANZCA, FFPMANZCA, Pain Medicine Specialist, WA Specialist Pain Services, Perth, Australia. The information in this module is based on current best evidence research and clinical practice.