How Do Painkillers Work?

Painkillers lessen irritation of nerves or block the transmission of pain messages from a painful part of the body up to the brain. Most painkillers don’t treat the cause of the pain–a disc pressing on a nerve which goes to the leg producing “sciatica,” for example. The “pinched” nerve is still causing pain impulses to travel up to the brain, but pain killers lessen the amount of pain impulses of which we are aware.
There are several distinct pain pathways controlling the delivery of pain messages to the brain, each pathway blocked by different types of drugs. To further complicate matters, various areas of the nervous system–from a nerve in the leg to one in the spine or even the brain–respond to different painkillers. Therefore, it is not surprising that patients with certain kinds of severe, chronic pain may require various types of painkillers to adequately block pain impulses from reaching the brain.

Which Drugs Should Be Used, How and When Are They Given, and for What Length of Time?

The choice of pain reliever depends on the type of and severity of the pain. Mild pain may respond well to acetaminophen (Tylenol) whereas more severe pain may require a mild or even moderate narcotic for adequate pain control. Narcotics may be more effective when combined with other drugs, such as acetaminophen (Tylenol), aspirin, ibuprofen (Motrin, Advil), naproxifen (Aleve) and similar drugs. Generally, acetaminophen should be tried before using other drugs in its family, because it’s effective and safer than members of the same group are.

Steroids may be effective in controlling certain kinds of pain, usually associated with inflammation of nerves or muscles, as well as certain kinds of bone and joint pain. However, these potent drugs have serious side effects and usually should only be used for short periods, once in a while.

Other drugs such as certain antidepressants, anti-seizure medications, and certain heart drugs may help control pain from damaged nerves even better than narcotics. In some cases, these drugs may be used in conjunction with narcotics.

The method of delivering the drug (by mouth, intravenously, or other route) and the frequency of taking the medication depends on the patient, type and severity of pain, and prognosis of the painful disorder. Someone who is actively working and leading an active life should be managed with pills, while a sick patient in a hospital may require more cumbersome but more effective intravenous medication. Some medication is given as it is needed – depending on the severity of the pain and its fluctuation with daily activities or spontaneously over time. Other patients with severe, unremitting pain need around the clock medication – whether it be in pill form, intravenous, or other route.

Pain medication should be used as long as it is needed to control pain. If pain medication can adequately control chronic pain without undue side effects, patients may elect not to pursue any other treatment. This decision will depend on the cause of the pain and how it may influence the future of the patient, the age and physical state of the patient, and various social and psychological factors.


Because of the myths surrounding the use of narcotics, this type of drug merits some discussion. Narcotics are the most effective painkillers for most moderate-to-severe pain. Yet they are associated with an overblown fear of addiction on the part of patients, their friends and families, physicians, and government officials. Because of this fear, narcotics are either not prescribed when needed, or prescribed so that the narcotic wears off between doses or the strength of narcotic is inadequate for the pain being treated.

Recreational drug use is dangerous and harmful, but it is time to end false moral judgements that keep sick people from the medicine they need. A narcotic like Percocet may control your pain and help you enjoy a productive life. If it does, you should take it. There will be initial side effects. Such a drug may cause some sleepiness or nausea for the first few days, but you will adjust and these symptoms will disappear. You may experience constipation, but it can be managed effectively with over the counter medication and diet control.

It is true that you would depend on the drug, but that would not mean you were addicted to it. Approximately 5% of patients with chronic pain (lasting longer than 6 weeks) become addicted to drugs. Less than 1% of cancer patients do. Those who become addicted manipulate drugs for psychological purposes – to put themselves in a better mood, to cope or to help them sleep or wake up. Most patients who take narcotics take them because without it they will experience severe pain. It’s the medication they need, just as patients who take digitalis take it because it’s the medication they need for their hearts. Patients in pain should not deny themselves relief-giving narcotics because they fear they will become shameless addicts. It is nobler to be a productive person taking a controlled-dosage, prescribed narcotics than to be a debilitated, pain-filled person who has refused proper medication.

Pain-relieving medication, including narcotics, is prescribed after comprehensive evaluation, including high quality radiological and other studies for appropriate patients.  Chronic medication use, especially of narcotics, is not appropriate in patients who can be treated successfully by other means, essentially liberating them from the pain management system.

My purpose is to keep my patients working productively and to help them enjoy their family, friends, and their personal interests. It is also to help them thrive on the least amount of medication they can properly take. I say that if you can live on a regimen of properly prescribed narcotics for the rest of your life and this enables you to pick up your kids, drive a car, go to work, and or play a sport, you should accept and use properly prescribed narcotics.

Statistical Sources:

“Chronic Pain In America: Roadblocks to Relief” Dec. 1998

“Roper Starch Worldwide Survey” sponsored by the American Pain Society

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Emile M. Hiesiger, M.D.

The Corinthian
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