Prescription pain medications

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woman getting pills from doctor

Prescription medications are those prescribed by a doctor in specific doses. They are not available over the counter.

Click the links below to learn more about the various types of prescription medications for chronic pain:

Tip: The tables below are best viewed in landscape mode if you are accessing this page on a smartphone, tablet or other mobile device.​

Prescription NSAIDs

General points to note

  • Generally, NSAIDs are best used in short courses to manage flare-ups of pain related to inflammation.
  • NSAIDs available by prescription include diclofenac, meloxicam and celecoxib.
  • Although there are many types of NSAIDs, only take one type at a time.
  • Because each medication in this group is slightly different, one might work more quickly for you or have different side effects than others.
  • For short flares of pain, a medication that acts quickly and gets out of your system right away might be best. For episodes of pain that last a long time, you may do better with a longer-lasting medication.
  • Before starting any NSAID, tell your doctor if you have a bleeding disorder, asthma or kidney problems or if are undergoing chemotherapy or have ever had a stomach ulcer.

Side effects

  • One of the most common side effects of NSAIDs is stomach upset. Usually, you can avoid this by taking the correct dose and taking the medication with food, even just a glass of milk or some crackers.
  • When used regularly for a long time, or in high doses, NSAIDs can cause kidney problems and stomach ulcers. This can lead to dangerous bleeding and perforations. If you experience blood in bowel movements or severe stomach pain while taking NSAIDs, see your doctor or nurse practitioner right away and stop taking the medication.
  • In very rare cases, NSAIDs can cause bleeding problems. If you are taking NSAIDs, you may need to stop them for a period if you need to have surgery.
  • If you have migraines, don’t take NSAIDs on more than 15 days of the month, as they can make headaches worse.

Tricyclic antidepressants

General points to note

  • Tricyclic anti-depressants (TCAs) were first developed to treat depression but were then found to offer relief for neuropathic (nerve) pain.
  • Much smaller doses of TCAs are given for pain relief than for treating depression.
Generic name Brand names Comments Side effects
Amitriptyline ElavilOften causes sleepiness; can help treat pain and sleep problems at the same time
Possible
  • Dry mouth
  • Dry eyes
  • Constipation
  • Dizziness when standing after lying down
  • Can sometimes cause weight gain
Rare
  • Can worsen symptoms in those with irregular heart beat
Nortriptyline Apo-nortriptylineLess likely to make you sleepy than other TCAs
Short-term (for a few days only)
  • Dry mouth
  • Dry eyes
  • Constipation
  • Dizziness when standing after lying down
  • Can sometimes cause weight gain
Rare
  • Can worsen symptoms in those with irregular heart beat
Desipramine Apo-desipramineAlternative to amitriptyline and nortriptyline if neither works for your pain
Short-term (for a few days only)
  • Dry mouth
  • Dry eyes
  • Constipation
  • Dizziness when standing after lying down
  • Can sometimes cause weight gain
Rare
  • Can worsen symptoms in those with irregular heart beat

Side effects

  • The short-term side effects listed above are usually not troublesome and tend to go away after a few days.
  • If your doctor thinks that TCAs might be helpful, they may recommend that you have an electrocardiogram or ECG before you start them. This test measures the electrical activity of your heart, or your heart rhythm, to check that it is regular and that it is safe to start the medications.

Serotonin and norepinephrine reuptake inhibitors (SNRIs)

General points to note

  • SNRIs were originally developed to treat depression and anxiety, but scientists have found that they are also helpful for pain.
  • SNRIs work by helping to slow down communication of pain signals between nerves.
  • If you also suffer from depression or anxiety, it can be helpful to take a single medication that treats both problems instead of two separate medications.
Generic name Brand names Comments Side effects
DuloxetineCymbaltaCan cause nausea, which is improved by taking it with food
  • Nausea
  • Drowsiness
  • Dizziness
  • Dry mouth
VenlafaxineEffexorSome people become drowsy with this medication, but some become agitated or anxious. If it tends to make you sleepy, take it at night. If it disrupts your sleep, try taking it in the morning.
  • Drowsiness
  • Dizziness
  • Headache
  • Nausea

Side effects

  • Do not take these medications if you have liver problems.

Anticonvulsants

General points to note

  • Anticonvulsants were first developed to treat seizures but also treat nerve-related pain because they have a calming effect on overactive pain nerves.
  • Some commonly prescribed anticonvulsants include gabapentin, pregabalin and topiramate.
Generic name Brand names Comments Side effects
GabapentinNeurontinTell your doctor if you have ever had kidney problems, as you may need a lower dose than usual.
  • Headaches
  • Drowsiness
  • Nausea
  • Dizziness
  • Fatigue
  • Reduced concentration
  • Weight gain (sometimes)
PregabalinLyricaTell your doctor if you have ever had kidney problems, as you may need a lower dose than usual.
  • Headaches
  • Drowsiness
  • Nausea
  • Dizziness
  • Fatigue
  • Reduced concentration
  • Weight gain (sometimes)
TopiramateTopamax, Qudexy XR, TrokendiThis medication can cause growth to slow down in children and teens. If you have not yet finished growing, have blood tests periodically to make sure this isn't a risk for you.
  • Headaches
  • Drowsiness
  • Nausea
  • Dizziness
  • Fatigue
  • Reduced concentration

Side effects

  • The common side effects listed above usually go away within a few days and can be minimized by increasing the dose slowly.

Corticosteroids

General points to note

  • Corticosteroids (steroids) work best to treat severe pain associated with nerve irritation and inflammation. They reduce pain by reducing the inflammation.
  • Corticosteroids can be given by injection at the site of pain and are often given as a mixture with local anaesthetic. The local anaesthetic blocks pain messages along the nerves, working very quickly and lasting for a few hours. The steroid often takes a week or so to have full effect. Corticosteroids can also be taken orally (by mouth) or applied as a prescribed topical cream.
  • Corticosteroids can cause side effects if taken orally for a long time. Side effects are unlikely if they are taken this way briefly or as a single injection.
Generic nameBrand namesCommentsSide effects
DexamethasoneDecadron, Hexadrol, Dexasone, Diodex, MaxidexCommonly given through injection and lasts longer than other corticosteroidsCan suppress hormones and cause weight gain
TriamcinoloneKenalog, Triacet, TridermCommonly used for joint injections and neuraxial blocksCan suppress hormones and cause weight gain
MethylprednisoneDepo-medrolCommonly used more for joint injections and neuraxial blocks

Side effects

  • Talk to your healthcare provider about any questions or concerns about taking corticosteroids.

Muscle relaxants

General points to note

  • Muscle relaxants cause tense muscles to relax and prevent muscle spasms, so easing pain.
  • Commonly used muscle relaxants are methocarbamol and baclofen.
  • You can buy some of these medications over the counter, but others require a prescription.
  • Often, these medications work well in the short term but lose their effect after as little as two weeks.
Generic nameBrand namesCommentsSide effects
CyclobenzaprineFlexeril 
  • Drowsiness
  • Dry mouth
  • Dizziness
  • Headache
BaclofenApo-baclofenCan be used for more than two weeks if necessary, and if they are improving your function.
  • Nausea
  • Drowsiness
  • Confusion
  • Dizziness
  • Fatigue
MethocarbamolRobax, Robaxin, RobaxacetWatch your overall medication intake; acetaminophen, NSAIDs or aspirin are sometimes included with this over-the-counter medication.
  • Drowsiness
  • Blurred vision
  • Headache
  • Nausea
  • Skin rash

Side effects

  • Do not drive while taking muscle relaxants until you know how they affect you.
  • Long-term use of muscle relaxants carries certain risks, such as addiction, so check with your healthcare team whether these medications are right for you.

Cannabinoids

General points to note

  • A cannabinoid is a chemical in the cannabis plant (also called marijuana).
  • Natural cannabinoids (herbal cannabis) are extracted and dried from the plant and are smoked or vapourized.
  • It is legal for doctors in Canada to prescribe herbal cannabis for very ill people. However, it is not recommended for anyone under the age of 25 because of its harmful long-term effects on memory, thinking and judgment.
  • Man-made cannabinoids, also called pharmaceutical cannabinoids, are available in a pill or as a mouth spray only by prescription.
  • Pharmaceutical cannabinoids treat nausea, loss of appetite, pain and muscle spasm in patients with multiple sclerosis and cancer-related pain. Medical literature supports their use for these medical conditions.
  • Cannabinoids are very powerful medications and must be used very carefully under medical supervision.
Generic nameBrand namesComments​Side effects
NabiloneCesametThese are pills that are taken once, twice or three times daily, depending on your prescription. Common: Drowsiness, dizziness, memory loss, concentration difficulties

Occasional: Nausea and vomiting

Significant: Can worsen existing anxiety, depression, anger or paranoia or cause psychosis in young people with a family history of mental illness
THC/CBDSativexThis is medication that you spray on the inside of your mouth several times a day if needed. Common: Drowsiness, dizziness, memory loss, concentration difficulties
  
Occasional: Nausea and vomiting
  
Significant: Can worsen existing anxiety, depression, anger or paranoia or cause psychosis in young people with a family history of mental illness

Side effects and risks

  • When used as prescribed, pharmaceutical cannabinoids are fairly safe once doses are kept as low as possible to deliver pain relief with the fewest possible side effects.
  • Overdosing is rare, but cannabinoids may interact negatively with other medicines.

Opioids

General points to note

  • Opioids are among the oldest, strongest and best-known pain medications.
  • There are many types and strengths of opioids – morphine is a common example – but they are all chemically related to the same poppy plant that produces opium.
  • Your pain care team will only decide to start you on opioids after discussing their risks and benefits fully. They are not a first resort treatment and it is unclear how effective or safe they are for chronic pain.
  • As with any medication, opioids are given on a trial period, for example for three months. At the end of the trial, you and your pain management team would assess if your pain and function have improved enough to justify continuing the medication.
  • For more information on how opioids work, check out the video Best Advice for People taking Opioid Medication below from Mike Evans.
 
Generic ​nameBrand namesCommentsSide effects
CodeineTylenol #1,2,3 Atasol 8, 15, 30Some of these may include caffeine, which can disrupt sleep. Tylenol 3 can cause serious constipation. Common: Constipation and hard stools in half of all users, nausea, drowsiness

Less common but potentially serious: An urgency to pee, difficulty peeing, mood swings, vivid dreams, mild hallucinations, feeling disoriented, itching, excessive sweating, reduced levels of sex hormones (which can affect fertility) from long-term use
FentanylDuragesic, Ratio-fentanylShould not be used in people under the age of 18
HydromorphoneDilaudid Hydromorph ContinThese are very strong medications - about five times stronger than morphine.
MorphineStatex, MS Contin, M-Eslon, Kadian 
OxycodonePercocet, OxyContin, OxyNEO 
TramadolTell your doctor or nurse practitioner if you have ever had seizures or if you are taking an anti-depressant.

Side effects

Common side effects

  • Constipation can be eased with prescription laxatives, but it does not tend to clear up over time.
  • Because opioids cause drowsiness, do not drive until you know how they might affect you.

Less common but potentially serious side effects

  • The potentially serious side effects are listed in the table above. Other side effects relate to the dose of the medication.
  • Your doctor or nurse practitioner can monitor the levels of your sex hormones through a physical exam.
  • In high doses, opioids can sometimes make your pain worse instead of better.
  • Uncommonly, and if given in too high a dose, opioids can cause low blood pressure or slow and shallow breathing. People need to be carefully monitored for these negative side effects.
  • Tell your healthcare team if you have a breathing-related disease or condition so you can minimize the risks associated with the breathing side effects of opioids.

Healthcare professionals can provide guidance that will help you to manage these negative side effects.

Managing the risks of opioids

If opioids are prescribed for your treatment, the amount will depend on your weight and how much is needed for effective pain management. Anyone prescribed an opioid will also need to complete an ‘Agreement for Opioid Therapy’ form to help ensure the safety of opioid therapy. Your health will be monitored regularly, which may include urine testing to check that you are using your opioids as prescribed. If the prescription is interrupted for any reason and then restarted at the original dose, your body might lose its tolerance, which could result in overdose.

Even if you take opioids exactly as prescribed and without any of the side effects listed above, opioid use can have the following risks:

  • addiction
  • physical dependence
  • tolerance
  • overdose.

Addiction

Drug addiction is a psychological craving as well as physical dependence on the drug. People who are addicted to opioids feel unable to stop the medication even after it starts to cause them harm.

When doctors prescribe opioids for pain, they closely control the amount and pattern of use so that they can identify early on if problems are developing.

You may be more at risk of developing an addiction if:

  • your prescription recommends that you take an opioid every day
  • you, your parent or your sibling has had an addiction to any substance
  • you experienced early life trauma (neglect, emotional, physical or sexual abuse)
  • you are taking a fast-acting opioid (one that releases medication into your bloodstream quickly).

Please speak to your healthcare team if you or any family members are concerned about your risk of becoming addicted or have identified possible signs of addiction such as excessive craving or misuse of the medications.

Physical dependence

Physical dependence means that your body has become used to the effects of a drug. On its own, it is not the same as addiction.

Physical dependence can occur in as little as five days if you are taking opioids continuously. You will usually know the signs of physical dependence only if you suddenly stop the medication. These include uncomfortable 'withdrawal' symptoms such as feeling irritable, shivery and nauseated and having stomach pain.

You and your healthcare team can prevent withdrawal by planning to reduce your dose little by little if your need for pain relief reduces or if the medication is not working for you.

Tolerance

Tolerance happens when your body needs a higher dose of a drug to get the same effect. It commonly happens when people are treated with opioids for a long time. If tolerance occurs, your healthcare team might decide to switch you to a different opioid medication.

Overdose

Many people who take strong opioid medications have concerns about overdose. An overdose means taking so much medication that it causes your thinking and breathing to slow down. Overdoses can be very dangerous, even deadly.

The risk of overdose is quite low when opioids are taken over the long term. They have been used for centuries and healthcare professionals know how to prescribe them with a great degree of safety. That said, the following factors can make an overdose more likely to happen:

  • starting or increasing an opioid dose
  • interrupting and restarting an opioid prescription
  • taking an opioid with benzodiazepine (a medication to treat mood and sleep disorders) or other sedating medications (for example Gravol, Benadryl, antidepressants, gabapentin)
  • kidney disease
  • liver disease
  • sleep disorders, including sleep apnea.

To prevent the risk of overdosing:

  • talk to your healthcare team about your risk factors
  • take the medications exactly as prescribed by your healthcare team
  • monitor your medications frequently with your healthcare team
  • talk to your healthcare team about all the other medications, supplements, alcohol or other drugs that you may be taking in case there are any bad drug interactions.

Resources

For more information about managing your chronic pain with opioids, check out the “My Opioid Manager” book and smartphone app. This is a free resource for patients from the Toronto Rehabilitation Institute.

Sources

College of Family Physicians of Canada (2014). Authorizing Dried Cannabis for Chronic Pain or Anxiety. [Accessed April 22, 2016]

Electronic Medicines Compendium (2016).  Pregabalin. Medicines.org.uk [Accessed April 22, 2016]

Hospital for Sick Children Chronic Pain Clinic. What we do. SickKids.ca [Accessed April 22, 2016]​​​

Jeavons, M. (2009). Opioids: Safety and side effects. AboutKidsHealth.ca [Accessed April 22, 2016]

Michael G. DeGroote National Pain Centre, McMaster University (2010). Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. nationalpaincentre.mcmaster.ca [Accessed April 22, 2016]

Taddio, A. (2009). Adjuvant medications. AboutKidsHealth.ca [Accessed April 22, 2016]

Taddio, A., & Wang, L. (2009).  Opioids. AboutKidsHealth.ca [Accessed April 22, 2016]

Toronto Rehabilitation Institute (2011). Opioid Manager. opoidmanager.com [Accessed March 10, 2016]

US National Institute of Diabetes and Digestive and Kidney Diseases (2016). Muscle Relaxant Drugs[Accessed April 22, 2016]

US National Library of Medicine (2016). Venlafaxine. [Accessed April 25, 2016]

Last updated: May 2nd 2016