Episode 30: Review of Medication for Chronic Pain in 2026

Most patients with chronic pain will use medications to control their symptoms. Join Dr. Karmy for an overview of the most commonly used medications for chronic pain management. 

In this episode, Dr. Karmy will review the risks, the benefits, and my approach to the use of these medications.

If you have any questions for Dr. Karmy, feel free to email us at karmychronicpain@gmail.com

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Transcript

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It is totally up to the patient whether or not they want to continue taking a given medication, and usually when they make that decision, they weigh the benefits. In other words, by how much is my pain better? Is it better by 10%, 20%, 50%? And the side effects. Welcome to Chronic Pain Chronicles with Dr. Karmy, where today we explore the different types of medications for chronic pain management. I'm Raveena your host and advocate for informed balanced conversations about living and treating chronic pain. With nearly one in five people experiencing chronic pain at some point in their lives, understanding safe and effective treatment options is more important than ever. In this episode, Dr. Karmy discusses a range of medications from Tylenol and anti-inflammatories to nerve pain medications, antidepressants, and muscle relaxants. What's safest? What actually works, and what should patients realistically expect? Joining us is Dr. Karmy, a chronic pain specialist with over 20 years of clinical experience who will walk us through how these medications work, who they help, and how to think about them as part of a larger treatment plan. This is Dr. Karmy for chronic Pain, Chronicles, and today I wanted to discuss some of the medications we use in chronic pain management. I am not going to focus on opioids or narcotic medications because I did an episode covering that, and I'm not going to discuss in depth, uh, medications for headaches because I have interviewed Dr. Goldstein a neurologist covering this group of medications. This is about everything else I did not cover. So let me start by answering a couple of commonly asked questions. First of all, what is the safest medications we have in chronic pain? And the safest medication is Tylenol or Extra Strength Tylenol. Although there's no medications that have zero risk attached, uh, Tylenol and Extra Strength Tylenol have relatively few side effects. It doesn't typically make you drowsy or dizzy. It, uh, doesn't cause bleeding from your stomach. It is also cheap and widely available without prescription. So there's many things to like about extra strength Tylenol, especially in seniors. But as everything else in life, uh, it does have some risks. It can damage liver, but typically in doses far higher than are used by patients. Most importantly doesn't help everybody. Some of our other medications are more effective for nerve pain or for pain associated with inflammation. However, if Tylenol or Tylenol Extra strength works well, that's actually often the safest solution. What about Tylenols with numbers? Tylenol number one. Tylenol number two, Tylenol number three, Tylenol number four. Well, they actually a different medication. They do have some Tylenol in them, but the other ingredient is a narcotic codeine, which in the body is converted to morphine. It is one of the weaker narcotics. But it often has some of the same risks, including addiction and constipation. Uh, Tylenol number one is available without a prescription, but all the other Tylenols require prescription. Generally speaking, do not recommend these medications for long-term use. And they're not as safe as Tylenol without the numbers. The next, question I should address, at least in passing is, narcotic medications. I know, I promise not to talk about them, so I'm not going to dwell on them, but there is this misconception that they incredibly effective at treating pain. Yes, they can be helpful in the short run, but for chronic pain, they're not terribly effective because people develop tolerance quite quickly. And to be honest, for excruciating pain, they don't work all that well, so its reputation as incredibly powerful medications is a little bit overhyped, so when people ask me, which is the most effective medication, just give me something that works, something that's really strong. Unfortunately, there's no such thing. Some patients respond to one medication, some patients respond to another, and. One cannot predict who's going to respond to which medications until people try them. The next, most commonly used medication group is anti-inflammatories. There are some that are over the counter, like Advil or Aleve. And, uh, then there's some prescription medications such as Arthrotec, Celebrex, Mobic, , and Vimovo. These tend to work a little bit better than Tylenol. This is in part because in addition to reducing pain, they can reduce inflammation. Also, although all these medications belong to the same group. It's common for patients to respond to one of them but not the other. So sometimes rotating through a few makes sense. One message I wanted to get across is that just because something is over the counter doesn't mean that it is safe. ibuprofen or Advil and Aleve, which is actually Naproxen, are over the counter, but just like all other anti-inflammatory medications, they can cause stomach ulcers, bleeding from the stomach that can damage kidneys. They can cause for blood pressure to go up. So one has to use them with caution. Often people will take a second medication to protect the lining of the stomach because of the risk of stomach ulcers and bleeding. These medications probably should not be taken by patients who take blood thinners, and especially anticoagulant blood thinners because the risk of bleeding go up sevenfold. And , the other thing I wanted to mention is that these medications come into form. They come in oral form, where you take as a tablet, they actually come as a suppository, rectal suppository. And they also come as topical preparations. In other words, liquid or cream that you just drop into the skin, all else being even. Topical anti-inflammatories are safer than, oral ones because for the most part, the medication stays in the muscles and the joints and only very little gets into the circulation if you use anti-inflammatories in topical form. In terms of prescriptions, the most common topical anti-inflammatory I use is Pennsaid, which is, diclofenac in liquid form. It seems to work a little bit better than Voltaren creams that are over the counter. Now let's move on to some of the medications that are strictly used on prescription that are not available over the counter. They tend to be more helpful for pain coming from muscles and nerves. They don't reduce inflammation. And as a very general, statement, a lot of them can make patients drowsy and dizzy. So falling is a risk, especially in the older people. Confusion is a risk, especially in the older people with these medications. The first group would be muscle relaxants. There's actually is one that's over the counter called Robaxacet and there's two that, are, on prescription Baclofen and Flexeril. Baclofen is the only one that's covered under government plans, such as the plan for people over 65 or on ODSP. Then we have medications that would be classified as antidepressants, but they're actually used, not so much for depression, but for pain control. In some cases, you may want antidepressant effect because often patients with chronic pain will also have depression and, this way you are sort of killing two birds with one stone. The older medications, nortriptyline and amitriptyline, and I found them to be quite effective. The only issue with amitriptyline is that it can cause a great deal of weight gain. The newer medications called SNRIs, serotonin, norepinephrine uptake inhibitors, Cymbalta or duloxetine, and effexor or venlafaxine. Duloxetine, or Cymbalta tends to be used more for widespread pain and osteoarthritis. While Effexor tends to be used more for headaches and then the final group is medications that are normally used for seizures or anticonvulsant, but again in the case of chronic pain patients they used because they can help with nerve and muscle pain. The two most commonly used are gabapentin and pregabalin, or each has a different name. Gabapentin is also called Neurontin. Pregabalin is also called Lyrica. Again, they can be effective medication. Some people will respond better to one. Some people respond better to the other. Unlike Tylenol in an anti-inflammatory medications, anti-depressants and anticonvulsants So seizure medications take a long time to kick in. With Tylenol typically, you will know if it works or not, within half an hour. With anti-inflammatories, it might take a little bit longer, maybe 45 minutes, but with, medications like, amitriptyline, nortriptyline, Effexor, gabapentin, pregabalin, you have to take them for two to four weeks before you see the benefit. So typically they can steady rather than once in a while when the pain gets worse. So you take them each and every day. No matter what, and if it happens to help after two to four weeks, maybe you notice that your pain doesn't come as often or when it comes, it's not quite as severe. Let me make another comment about effectiveness. Chances for any one medication helping an individual patient is not very high. It's maybe one in five, at least in my experience. And also when medications do help, you don't expect them to take the pain down to zero. Typically the pain becomes 10 to 20 to 30% better, but it's certainly not gone. Also, the medications I find tend to help more with pain addressed and perhaps sleep. Not so much for improved function. If you want to improve your function, you have to use that pain reduction to push your exercise program to build stronger and more flexible muscles. The other point I wanted to make that every medication you take is a little bit of an experiment because they don't heal anything, and as soon as you stop the medications, most of the time the pain will be back to square one. It is totally up to the patient whether or not they want to continue taking a given medication, and usually when they make that decision, they weigh the benefits. In other words, by how much is my pain better? Is it better by 10%, 20%, 50%? And the side effects. If the medication reduces the pain by 10%, but it makes the patient very sleepy to the point that they can barely function. Generally speaking, it's not a win because, the whole goal of taking medications is not to fix anything. It's to improve function. Thank you. Thank you for listening to this episode of Chronic Pain Chronicles with Dr. Karmy, a podcast that explores chronic pain from a physician's perspective while keeping patients at the center of the conversation. Our podcast aims to break down the most effective and commonly used approaches to managing chronic pain from interventional treatments like nerve blocks to emerging regenerative medicine therapies. We'll also dive deeper into the science behind chronic pain explore why it develops and examine where the field of pain management is heading in the years to come. Our goal is simple to provide clarity, evidence-based insight, and realistic expectations for those navigating life with chronic pain. I'm Raveena Aujla Until next time. When it comes to your health, always consult with your own physician or healthcare provider for personalized advice and guidance. The information provided in this podcast is for educational and informational purposes only, and should not be considered medical advice or a substitute for professional medical care.