Standard analgesics for chronic pain
Various painkillers, known as analgesics, have been proven to be effective in the treatment of chronic pain. They are used depending on the intensity and origin of the pain. In the case of severe chronic pain, opiates or opioids are often the drugs of choice. In order to ensure effective treatment and to minimize possible undesirable reactions, the medicinal pain therapy must be accompanied permanently and closely by a competent physician or a trained pain therapist.
Some studies suggest that cannabis medication can be a complement or alternative to opiates and opioids for certain types of pain1.
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An overview of different pain medications
Pain medications fall into several categories and subcategories. First, medicine distinguishes between "non-opioids" and "opioids "2.
- Paracetamol: For mild to moderate pain, moderate to severe pain (as adjunctive therapy to opioids), and for temporary reduction of fever.
- NSAIDs (nonsteroidal anti-inflammatory drugs, for example, ibuprofen and diclofenac): For mild to moderate pain, pain associated with inflammation, and to temporarily reduce fever.
Opioids contain opium-like active ingredients such as those found in the dried milky sap of the opium poppy. The main active and naturally occurring constituents - known as opiates - are morphine, codeine and thebaine3. Synthetic opioids act on both the peripheral and central nervous systems by binding to the opioid receptors2. It is also through these receptors that the side effects, some of which are severe, are triggered.
Opioids are divided into "weak" and "strong" opioid analgesics.
The weak opioids include the painkillers tilidine and tramadol as well as codeine, which is used as a cough suppressant.
The best-known active ingredients of the strong opioids include:
Which pain medications are appropriate for treating chronic pain?
Adequate pain management is as important as it is complex. The treating physicians must include many aspects in their decisions, constantly question their treatment methods and readjust them if necessary. In doing so, it is important to take into account all of the patient's illnesses and conditions. Interactions with other medications and the patient's personal circumstances also play a major role in the selection of the appropriate medication. The therapy is very individual.
In the long-term treatment of mild to moderate chronic pain, paracetamol is often the analgesic of first choice, as it is a safe and effective drug when used correctly. If the drug is taken for a longer period of time, undesirable side effects may occur. Mainly problematic here are bleeding in the digestive tract and high blood pressure (see below). NSAIDs can also be used for chronic pain treatment, but can cause numerous undesirable side effects. Risks exist in particular for the cardiovascular system, the digestive tract, and the kidneys. Therefore, regular monitoring is highly recommended for chronic patients taking NSAIDs on a regular base.
Opioids are commonly used to treat severe chronic pain. However, the use of opioids is controversial due to the risk of dependence, tolerance, and serious side effects2.
Side effects of treatment with opioids
The side effects of opioids are wide-ranging. They may include2,4:
- Nausea and vomiting
- Development of tolerance
- Respiratory depression
- Inhibition of the cough reflex
- Pupillary changes
- Drowsiness and feeling light-headed
- Loss of appetite
- Dejection / euphoria
- Stiffening of skeletal muscles
- Physical dependence
To avoid habituation, it is recommended to vary with different opioids. To avoid withdrawal symptoms after prolonged use, the medication should be phased out slowly.
Special case of co-analgesics - off-label use in pain therapy
Some drugs that were not developed as pain medications in their true sense nevertheless possess analgesic properties. In some cases, physicians additionally decide to prescribe such drugs. This happens especially when there are one or more indications that correspond to the actual field of application. The so-called co-analgesics include:
- Antidepressants: the drugs used to treat depression block the reuptake of certain neurotransmitters in descending pain-inhibiting nerve pathways and thus enhance pain modulation. The analgesic effects of antidepressants are used primarily for neuropathic pain conditions, fibromyalgia, chronic musculoskeletal pain, migraine, and tension headaches2.
- Anticonvulsants: they are used to treat epilepsy because they decrease the release of neurotransmitters or the activity of neurons. Therefore, it is used for nerve pain and fibromyalgia2.
- Glucocorticoids: these hormones, which include cortisone, for example, have an anti-inflammatory effect, thus inhibiting the development of inflammation and the associated perception of pain. In addition, they eliminate tissue water accumulation (edema) and thus relieve pressure on pain-sensitive structures2.
- Regulators of calcium metabolism5,6,7,8: Calcitonin and bisphosphonates can be used for pain relief in spinal fractures, bone tumors, osteoporosis, and neuropathic pain. Calcitonin has also been shown to have analgesic effects in phantom limb pain.
Holistic pain therapy – What else can help patients?
In addition to drug therapy, psychological support for pain suffering patients is also essential. Persistent pain puts a strain on the psyche of those affected. In addition, their living conditions often inevitably change: some pain patients can no longer go about their daily lives, including their jobs, social contacts and hobbies. Exchanges with other sufferers can also be helpful in accepting the new life situation - support groups provide the necessary space.
Nutrition counseling and dietary changes can also help patients. For example, there are indications that specific diets can be helpful in the treatment of rheumatoid arthritis as a supplement to anti-inflammatory pain therapy with medication9.
The issue of exercise also plays a role in chronic pain. Depending on the clinical picture, it is considered health-promoting to pursue sports adapted to the health condition. Patients should always discuss which type of sport is considered appropriate at which point in time with the person providing medical support for the pain therapy.
In this context, pain patients may also benefit from physical and occupational therapy.
Medical cannabis as an opiate substitute?
Since the "Cannabis as Medicine" law came into effect in 2017, doctors are allowed to prescribe cannabis medication to their patients under certain conditions. Chronic pain is the most common indication for cannabis therapy10.
Mode of action of medical cannabis as a substitute for opioids
The broad spectrum of effects of the cannabis plant is thought to be mainly due to the interaction of the natural active ingredients (phyto-cannabinoids) with the endocannabinoid system (ECS).
The ESC is an endogenous communication system equipped with various receptors. The human body also produces cannabinoids (endocannabinoids) on its own, which can elicit certain responses when needed.
The ECS is involved in keeping important physiological functions such as pain perception, appetite, energy, mood, memory, immune responses and more in balance. This may explain why cannabis can play a role not only in relieving pain symptoms, but also in improving other symptoms that are very important to quality of life.
How is medical cannabis used as an opiate substitute in pain management?
In practice, cannabis is used as a medicine to treat chronic pain in a complementary rather than a substitute manner. This means that medical cannabis is initially taken in addition to existing medication for pain management.
Some patients report that medical cannabis has allowed them to take fewer opioids and has also reduced side effects. This has led to an improved quality of life11.
Which pain medications for long-term therapy?
Which painkillers are best for chronic pain management is always decided by physicians on a case-by-case basis. It is important to treat each patient individually, taking into account the patient's life circumstances, (pre-)illnesses and possible interactions with other medications. Opioids are often used for severe pain. However, there is a risk of dependence and serious adverse effects. Therefore, medical cannabis could be a supplement or even a substitute for opioids.
What do you do in pain management?
During pain therapy, a team of different experts works together with the pain patient to alleviate the patient's chronic pain and to maintain or improve the quality of life. On the one hand, this is done through drug therapy: pain treatment and other symptoms of the disease, for example depression, are the focus. On the other hand, psychotherapy, occupational therapy and physiotherapy are often an integral part. In addition, nutritional counseling or exercise therapy can be useful.
How useful is pain therapy?
Pain therapy makes sense if the person concerned is suffering from the symptoms of their chronic illness. Early pain management can also lead to a decrease in secondary symptoms caused by the pain, such as anxiety or sleep disorders.
Disclaimer / legal information
This article is for informational purposes only and does not replace medical advice from a doctor. The content is not intended to motivate self-diagnosis or self-treatment, nor to tempt people to change their current medical treatment on their own. Canify Clinics does not make any recommendations or promote any diagnostic methods or treatments. If you wish to change your treatment, this should always be discussed with a doctor. Furthermore, Canify Clinics cannot guarantee the accuracy, timeliness and balance of the content. Therefore, neither the authors of the texts nor Canify Clinics accept any liability for damages resulting from the independent use of the information described here.
- 1McDonagh, M. S. et al. Cannabis-Based Products for Chronic Pain : A Systematic Review. Ann Intern Med175, 1143–1153 (2022).
- 2Milani, D. A. Q. & Davis, D. D. Pain Management Medications. StatPearls (2022).
- 3Chemie.de; “Opium”
- 4Gelbe Liste Online; “Oxycodon - Anwendung, Wirkung, Nebenwirkungen | Gelbe Liste”
- 5Ito, A. & Yoshimura, M. Mechanisms of the analgesic effect of calcitonin on chronic pain by alteration of receptor or channel expression. Mol Pain13, (2017).
- 6Tzschentke, T. M. Pharmacology of bisphosphonates in pain. Br J Pharmacol178, 1973–1994 (2021).
- 7Yazdani, J. et al. Calcitonin as an analgesic agent: review of mechanisms of action and clinical applications. Brazilian Journal of Anesthesiology69, 594 (2019).
- 8Yousef, Ayman A, and Amr M Aborahma. The Preventive Value of Epidural Calcitonin in Patients with Lower Limb Amputation. Pain medicine (Malden, Mass.) vol. 18,9 (2017).
- 9Athanassiou, P., Athanassiou, L. & Kostoglou-Athanassiou, I. Nutritional Pearls: Diet and Rheumatoid Arthritis. Mediterr J Rheumatol31, 319 (2020).
- 10Abschlussbericht der Begleiterhebung nach § 31 Absatz 6 des Fünften Buches Sozialgesetzbuch zur Verschreibung und Anwendung von Cannabisarzneimitteln https://www.bfarm.de/DE/Bundesopiumstelle/Cannabis-als-Medizin/Begleiterhebung/_node.html;jsessionid=C8FE79E517C28C0C0ACFEEDEA12CA3A2.internet282
- 11Boehnke, K. F., Litinas, E. & Clauw, D. J. Medical Cannabis Use Is Associated With Decreased Opiate Medication Use in a Retrospective Cross-Sectional Survey of Patients With Chronic Pain. J Pain17, 739–744 (2016).
- 12Kuhathasan, N., Minuzzi, L., MacKillop, J. & Frey, B. N. An investigation of cannabis use for insomnia in depression and anxiety in a naturalistic sample. BMC Psychiatry22, (2022).
- 13Bilbao, A. & Spanagel, R. Medical cannabinoids: a pharmacology-based systematic review and meta-analysis for all relevant medical indications. BMC Med20, (2022).