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Analgesic is a general name for types of painkillers that do not cause unconsciousness.<ref>{{Cite web|url=https://www.merriam-webster.com/dictionary/analgesic#medicalDictionary | title = Definition of ANALGESIC|website=Merrian-Webster Dictionary|language=en|access-date=2018-10-01}}</ref> A large variety of '''analgesics''' are used in [[ME/CFS]] to help relieve both [[chronic pain|chronic]] and acute [[pain]]. They are also used to treat pain associated with comorbid illnesses such as [[Irritable bowel syndrome|IBS]] or [[fibromyalgia]].<ref name=":5" /><ref name="ICP2011primer" /><ref>{{Cite journal | last = Bested | first = Alison C. | last2 = Marshall | first2 = Lynn M. | date = 2 November 2015 | title = Review of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: an evidence-based approach to diagnosis and management by clinicians|url=http://www.acfsonlus.org/wp-content/uploads/2018/01/reveh-2015-0026.pdf|journal=Reviews on Environmental Health|language=en|volume=30|issue=4|pages=|doi=10.1515/reveh-2015-0026|issn=2191-0308|via=}}</ref> [[File:ME-CFS-painkillers.png|alt=M.E./Chronic Fatigue Syndrome pain medications. Anti-inflammatories, TCAs and SNRIs, Muscle Relaxants, Anti-convulsants and others.|thumb|400x400px|M.E./Chronic Fatigue Syndrome pain medications.]] Analgesics act in a variety of ways on the peripheral and central nervous systems and can be taken in combination or alone. Determining which analgesic is appropriate involves considering both the severity and type of pain presented. The patient's response to previous analgesics may also be considered. ==Types of Painkillers== ===Acetaminophen=== '''[[Acetaminophen]]''', also known as paracetamol or Tylenol, is used to treat mild to moderate pain and fever. It is classed as a mild analgesic and does not reduce inflammation.<ref name=":2">{{Cite web|url=https://medlineplus.gov/ency/article/002123.htm | title = Over-the-counter pain relievers: MedlinePlus Medical Encyclopedia|website=medlineplus.gov|language=en|access-date=2018-10-02}}</ref> Acetaminophen can be taken by mouth (tablets or liquid), rectally (as suppositories), or intravenously, and is typically taken every four and six hours as needed.<ref name=":0">{{Cite news | url=https://www.drugs.com/monograph/acetaminophen.html | title = Acetaminophen Monograph for Professionals - Drugs.com|work=Drugs.com|access-date=2018-10-01|language=en-US}}</ref> Extended release acetaminophen can be taken every 8 hours.<ref name=":1">{{Cite news | url=https://www.drugs.com/dosage/acetaminophen.html | title = Acetaminophen Dosage Guide with Precautions - Drugs.com|work=Drugs.com|access-date=2018-10-02|language=en-US}}</ref> Typical uses include [[headache]]s, [[myalgia|muscle aches]], colds and [[sore throat]]s, back pain, toothaches), and to reduce fever. It is usually available over-the-counter without a prescription. Taking too much acetaminophen, or taking more than one product containing it can cause severe liver damage or death.<ref name=":0" /><ref name=":1" /> Some pain medications combine acetaminophen with other drugs, for instance with NSAIDs (Anacin, Excedrin), or [[opioid]]s (Hycet, [[Percocet]], [[codeine|co-codamol]]), for stronger pain relief.<ref name=":2" /><ref name=":1" /> ==== Acetaminophen for pain in M.E. ==== Acetaminophen can be used as a baseline drug for pain; it has a weak effect but few side effects.<ref name=":5">{{Cite book | url =http://www.investinme.org/Documents/PDFdocuments/Canadian_ME_Overview_A4.pdf | title = Myalgic encephalomyelitis, chronic fatigue syndrome : a clinical case definition and guidelines for medical practitioners : an overview of the Canadian consensus document | last = | first = | date = 2005 | publisher=Carruthers & van de Sande|vauthors=Carruthers BM, van de Sande MI|isbn=097393350X|location=Vancouver, B.C.|pages=|oclc=71361905}}</ref> ===[[Nonsteroidal anti-inflammatory drug|NSAIDs]]=== [[NSAIDs|Nonsteroidal anti-imflammatory drugs]] are a class of drugs which provide both analgesic (pain-killing) and antipyretic (fever-reducing) effects, and anti-inflammatory effects in higher doses. They range from mild to strong pain relief.<ref name="ICP2011primer">{{citation | last1 = Carruthers | first1 = BM | authorlink1 = Bruce Carruthers | last2 = van de Sande | first2 = MI | authorlink2 = Marjorie van de Sande | last3 = De Meirleir | first3 = KL | authorlink3 = Kenny de Meirleir | last4 = Klimas | first4 = NG | authorlink4 = Nancy Klimas | last5 = Broderick | first5 = G | authorlink5 = Gordon Broderick | last6 = Mitchell | first6 = T | authorlink6 = Terry Mitchell | last7 = Staines | first7 = D | authorlink7 = Donald Staines | last8 = Powles | first8 = ACP | authorlink8 = A C Peter Powles | last9 = Speight | first9 = N | authorlink9 = Nigel Speight | last10 = Vallings | first10 = R | authorlink10 = Rosamund Vallings | last11 = Bateman | first11 = L | authorlink11 = Lucinda Bateman | last12 = Bell | first12 = DS | authorlink12 = David Bell | last13 = Carlo-Stella | first13 = N | authorlink13 = Nicoletta Carlo-Stella | last14 = Chia | first14 = J | authorlink14 = John Chia | last15 = Darragh | first15 = A | authorlink15 = Austin Darragh | last16 = Gerken | first16 = A | authorlink16 = Anne Gerken | last17 = Jo | first17 = D | authorlink17 = Daehyun Jo | last18 = Lewis | first18 = DP | authorlink18 = Donald Lewis | last19 = Light | first19 = AR | authorlink19 = Alan Light | last20 = Light | first20 = KC | authorlink20 = Kathleen Light | last21 = Marshall-Gradisnik | first21 = S | authorlink21 = Sonya Marshall-Gradisnik | last22 = McLaren-Howard | first22 = J | authorlink22 = John McLaren-Howard | last23 = Mena | first23 = I | authorlink23 = Ismael Mena | last24 = Miwa | first24 = K | authorlink24= Kunihisa Miwa | last25 = Murovska | first25 = M | authorlink25= Modra Murovska | last26 = Stevens | first26 = SR | authorlink26 = Staci Stevens | title = Myalgic encephalomyelitis: Adult & Paediatric: International Consensus Primer for Medical Practitioners | date = 2012 | isbn = 978-0-9739335-3-6 | url = http://www.investinme.org/Documents/Guidelines/Myalgic%20Encephalomyelitis%20International%20Consensus%20Primer%20-2012-11-26.pdf }}</ref> Commonly used NSAIDs include [[aspirin]], [[ibuprofen]], [[naproxen]], [[diclofenac]], [[celecoxib]], [[meloxicam]], [[mefenamic acid]], and [[nabumetone]]. ====[[COX-2 inhibitors]]==== COX-2 inhibitors are NSAIDs that directly target cyclooxygenase-2 (COX-2), an enzyme responsible for inflammation and pain. Some COX-2 inhibitors used in [[ME/CFS]] include [[celecoxib]] and [[meloxicam]]. ==== NSAIDs for pain in M.E. ==== [[ibuprofen|Ibuprofen]], [[naproxen]], and [[celecoxib]], a [[COX-2 inhibitors|COX-2 inhibitor]]. Ketorolac is a NSAID which can be used for up to 5 days, for example after surgery, and is available as tablets, by intramuscular injection or IV.<ref name="CCC" /><ref>{{Cite news | url=https://www.drugs.com/pro/ketorolac.html | title = Ketorolac - FDA prescribing information, side effects and uses|work=Drugs.com|access-date=2018-10-02|language=en-US}}</ref> ===[[Opioids]]=== Opioids are drugs that bind to opioid receptors to produce [[morphine]]-like effects.<ref name="opioid1" /> They provide moderate to very strong pain relief. Some of these are [[codeine]], [[tramadol]], [[oxycodone]], [[vicodin]], [[hydrocodone]], [[fentanyl]] and [[morphine]]. Opioids are available in many different forms including tablets, slow-release tablets and patches.<ref name=":6" /> [[Opioids]] rarely result in addiction when taken by people in pain, but they can become less effective over time (opioid tolerance), dependency may develop, and withdrawal effects can occur when opiods are stopped or doses are decreased.<ref name=":6">{{Cite web|url=https://www.rcoa.ac.uk/node/21136 | title = Taking Opioids for Pain {{!}} Information for Patients | last = The Royal College of Anaesthetists | first = | date = 2016 | website = rcoa.ac.uk|language=en|archive-url=|archive-date=|access-date=2018-10-03}}</ref> Some side effects of opioids can be serious, initial use can cause sleepiness, [[dizziness]], [[nausea]] and affect driving; long term use of opioids can cause breathing problems at night and weight gain.<ref name=":6" /> A number of different opioids may be used in patients with [[ME/CFS|ME/CFS]], if pain is particularly severe.<ref name="canadianconsensus">{{Citation | last1 = Carruthers | first1 = Bruce M. | authorlink1 = Bruce Carruthers | last2 = Jain | first2 = Anil Kumar | authorlink2 = Anil Kumar Jain | last3 = De Meirleir | first3 = Kenny L. | authorlink3 = Kenny De Meirleir | last4 = Peterson | first4 = Daniel L. | authorlink4 = Daniel Peterson | last5 = Klimas | first5 = Nancy G. | authorlink5 = Nancy Klimas | last6 = Lerner | first6 = A. Martin | authorlink6 = Martin Lerner | last7 = Bested | first7 = Alison C. | authorlink7 = Alison Bested | last8 =Flor-Henry | first8 = Pierre | authorlink8 = Pierre Flor-Henry | last9 =Joshi | first9 = Pradip | authorlink9 = Pradip Joshi | last10 = Powles | first10 = AC Peter | authorlink10 = A C Peter Powles | last11 = Sherkey | first11 = Jeffrey A. | authorlink11 = Jeffrey Sherkey | last12 = van de Sande | first12 = Marjorie I. | authorlink12 = Marjorie van de Sande | title = Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols | journal = Journal of Chronic Fatigue Syndrome | volume = 11 | issue = 2 | pages = 7-115 | date = 2003 | pmid = | doi = 10.1300/J092v11n01_02 | url = http://www.investinme.org/Documents/PDFdocuments/CanadianDefinitionME-CFS.pdf }}</ref><ref name="ICP2011primer">{{citation | last1 = Carruthers | first1 = BM | authorlink1 = Bruce Carruthers | last2 = van de Sande | first2 = MI | authorlink2 = Marjorie van de Sande | last3 = De Meirleir | first3 = KL | authorlink3 = Kenny de Meirleir | last4 = Klimas | first4 = NG | authorlink4 = Nancy Klimas | last5 = Broderick | first5 = G | authorlink5 = Gordon Broderick | last6 = Mitchell | first6 = T | authorlink6 = Terry Mitchell | last7 = Staines | first7 = D | authorlink7 = Donald Staines | last8 = Powles | first8 = ACP | authorlink8 = A C Peter Powles | last9 = Speight | first9 = N | authorlink9 = Nigel Speight | last10 = Vallings | first10 = R | authorlink10 = Rosamund Vallings | last11 = Bateman | first11 = L | authorlink11 = Lucinda Bateman | last12 = Bell | first12 = DS | authorlink12 = David Bell | last13 = Carlo-Stella | first13 = N | authorlink13 = Nicoletta Carlo-Stella | last14 = Chia | first14 = J | authorlink14 = John Chia | last15 = Darragh | first15 = A | authorlink15 = Austin Darragh | last16 = Gerken | first16 = A | authorlink16 = Anne Gerken | last17 = Jo | first17 = D | authorlink17 = Daehyun Jo | last18 = Lewis | first18 = DP | authorlink18 = Donald Lewis | last19 = Light | first19 = AR | authorlink19 = Alan Light | last20 = Light | first20 = KC | authorlink20 = Kathleen Light | last21 = Marshall-Gradisnik | first21 = S | authorlink21 = Sonya Marshall-Gradisnik | last22 = McLaren-Howard | first22 = J | authorlink22 = John McLaren-Howard | last23 = Mena | first23 = I | authorlink23 = Ismael Mena | last24 = Miwa | first24 = K | authorlink24= Kunihisa Miwa | last25 = Murovska | first25 = M | authorlink25= Modra Murovska | last26 = Stevens | first26 = SR | authorlink26 = Staci Stevens | title = Myalgic encephalomyelitis: Adult & Paediatric: International Consensus Primer for Medical Practitioners | date = 2012 | isbn = 978-0-9739335-3-6 | url = http://www.investinme.org/Documents/Guidelines/Myalgic%20Encephalomyelitis%20International%20Consensus%20Primer%20-2012-11-26.pdf }}</ref> ==== Opioids for pain in ME/CFS ==== The [[International Consensus Criteria]] Primer for physicians and [[Canadian Consensus Criteria]] both state that opioids should only be used for severe pain, and with a management plan in place. No particular opioids are suggested.<ref name="ICP2011primer" /><ref name="CCC"/> ===[[Tricyclic antidepressant|Tricyclic Antidepressants]]=== [[Tricyclic antidepressant]] (TCAs) are a group of medications which are licensed for many different conditions besides depression, including [[chronic myofascial pain]], [[dysautonomia]] ([[amitriptyline]], [[nortriptyline]], [[desipramine]]), long-term pain ([[amitriptyline]], [[nortriptyline]], [[imipramine]]), [[fibromyalgia]] (amitriptyline), [[Irritable bowel syndrome|Irritable Bowel Syndrome]] (amitriptyline, nortriptyline, [[doxepin]], and others), [[migraine]] prevention (amitriptyline, nortriptyline), [[nerve pain|neuralgia]] (nerve pain), and [[sleep paralysis]].<ref name=":3">{{Cite news | url=https://www.drugs.com/drug-class/tricyclic-antidepressants.html | title = Tricyclic Antidepressants: List, Uses & Side Effects - Drugs.com|work=Drugs.com|access-date=2018-10-01|language=en-US}}</ref> TCAs include [[amitriptyline]], nortriptyline or [[clomipramine]] are commonly used in [[ME/CFS]] to treat chronic pain and to aid regular sleep. ==== TCAs for pain in M.E. ==== Most patients with M.E. are extremely sensitive to medication; the International Consensus Primer for Medical Practitioners recommends starting with a lower initial dose of TCAs, and that they should be used short term only.<ref name="ICP2011primer" /><ref name="CCC">{{Cite journal | last = Carruthers | first = Bruce M. | last2 = Jain | first2 = Anil Kumar | last3 = De Meirleir | first3 = Kenny L. | last4 = Peterson | first4 = Daniel L. | last5 = Klimas | first5 = Nancy G. | last6 = Lerner | first6 = A. Martin | last7 = Bested | first7 = Alison C. | last8 = Flor-Henry | first8 = Pierre | last9 = Joshi | first9 = Pradip| date = January 2003 | title = Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols|url=http://www.investinme.org/Documents/PDFdocuments/CanadianDefinitionME-CFS.pdf#page=10|journal=Journal of Chronic Fatigue Syndrome|language=en|volume=11|issue=1 | pages = 7–115|doi=10.1300/j092v11n01_02|isbn=0-7890-2207-9|issn=1057-3321|via=}}</ref> There is evidence that [[amitriptyline]], [[nortriptyline]] and [[doxepin]] are effective for pain caused by M.E.; like all TCAs benefits may not take effect for 2 to 4 weeks<ref name="CCC" /> The sedating effects of [[doxepin]] and [[amitriptyline]] may help patients with sleep problems remain asleep.<ref name="CCC" /> Side effects may be severe, and include morning or daytime sleepiness, dry mouth, [[weight gain]], and increase dizziness and [[orthostatic intolerance]].<ref name=":3" /><ref name="CCC" /> Amitriptyline may also cause [[cognitive dysfunction]], e.g. '''brain fog'''.<ref name="CCC" /> [[Nortriptyline]] causes the least side effects, and [[amitriptyline]] is particularly effective for people with [[fibromyalgia]].<ref name="CCC" /> Some guidance states these drugs should be avoided in [[weight gain|overweight]] patients with ME.<ref name="ICP2011primer" /> ===[[Anticonvulsants]]=== '''Anticonvulsants''' are a group of medications that were originally used in the treatment of epileptic seizures, but are increasingly used for other purposes, including the treatment of [[nerve pain]].<ref name="Rogawski" /> Anticonvulsants commonly used for pain in [[ME/CFS]] include GABA analogs such as [[gabapentin]] (Neurontin) and [[pregabalin]] (Lyrica), and [[:Category:Fatty acids|fatty acid]]s such as [[tiagabine]] (Gabitril). ==== Anticonvulsants for pain in M.E. ==== ===[[Medical marijuana]]=== [[Medical marijuana]] (cannabis designed for medical use) is available in various forms is increasingly used to treat chronic pain, including neuropathic pain.<ref name="Jensen2015" /> [[CBD oil]], made from marijuana or hemp, is also gaining popularity as an analgesic.{{Citation needed}} CBD oil, which can be made from hemp is an alternative that is legal everywhere, and cannot create a high.{{Citation needed}} ==== Medical marijuana and CBD oil for pain in M.E. ==== ===Other pain medications=== Other analgesic treatments for chronic pain include [[lidocaine]] infusions, [[ketamine]] infusions, steroid injections such as [[cortisone]], and benzodiazepines such as [[diazepam]]. [[Low dose naltrexone]] has also been reported to reduce chronic pain in [[ME/CFS]] and [[fibromyalgia]]. A variety of [[:category:supplements|supplements]] and [[:category:herbs|herbs]] are also used to reduce pain.{{Citation needed}} Non-pharmacological pain relief include as [[TENS]], [[massage therapy]], and hot and cold treatments see [[:Category:analgesics|pain relief (analgesic)]]. == Muscle relaxants == ==== Muscle relaxants for pain in M.E. ==== [[Baclofen]], [[cyclobenzaprine]] and [[magnesium sulfate]] (prescription strength) have evidence for their use in M.E./CFS.<ref name="ICP2011primer" /><ref name="CCC" /> Baclofen may help [[muscle fasciculations]] and [[Muscle twitches|muscle spasms]], and magnesium sulfate can be used for [[Muscle pain|leg cramps]] at night.<ref name="ICP2011primer" /><ref name="CCC" /> ==Combinations== ===Adjuvants=== ==Application== ===Topical=== Topical pain medication is a form applied to the skin, typically as a cream or gel. Examples include [[ibuprofen]] and [[diclofenac]] gel (Volteral), and [[capsaicin]] 0.025% cream. Some topical pain medications are available over-the-counter. ==== Transdermal ==== Transdermal skin patches can be prescribed for severe pain, some may be left in place for a number of days while others may need to be applied by a medical professional only, and removed after an hour. Examples include [[capsaicin]] 8% patches, [[buproprion]] (an anti-depressant also used for nerve pain), [[lidocaine]] and [[Opioids|opioid]] patches. Weaker medicated heat or cold patches are also available over-the-counter. ==== Oral ==== Tablets and capsules are the most common forms of pain relief. Some drugs are also available as liquids or in slow-release forms, for example [[opioids]]. ==== Suppositories ==== These pain medication are usually inserted into the rectum. Examples include [[acetaminophen]] (paracetamol( suppositories, and [[indometacin]] (a non-steroid anti-inflammatory). ==== Injections and IV Drugs ==== Intramuscular injections, subcutaneous injections and IV pain medication are typically only administered by medical professionals and may a much higher dose than over-the-counter forms of the same drug, for example acetaminophen on IV or codeine injections. == Learn more == * [https://medlineplus.gov/ency/article/002123.htm Over-the-counter pain relievers: MedlinePlus] * [http://www.investinme.org/Documents/Guidelines/Myalgic%20Encephalomyelitis%20International%20Consensus%20Primer%20-2012-11-26.pdf Myalgic Encephalomyelitis - Adult & Paediatric International Consensus Primer for Medical Practitioners], p13, p17 * [http://www.investinme.org/Documents/PDFdocuments/CanadianDefinitionME-CFS.pdf#page=10 Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Canadian Consensus Criteria], p53-p55 * [http://www.acfsonlus.org/wp-content/uploads/2018/01/reveh-2015-0026.pdf Review of M.E./CFS: an evidence-based approach to diagnosis and management by clinicians], table 5 * [https://www.nhs.uk/live-well/healthy-body/which-painkiller-to-use/ Which painkiller? - NHS] * [https://www.nhs.uk/conditions/fibromyalgia/treatment/ Fibromyalgia treatment - NHS] * [https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware Opioids Aware - A resource for patients and health professionals to support the prescribing of opioid medications for pain] ==See also== *[[Chronic pain]] *[[:Category:Antidepressants|Antidepressants]] *[[Nonsteroidal anti-inflammatory drug|NSAIDs]] *[[Medical marijuana]] *[[CBD oil]] ==References== <references> <ref name="Rogawski">{{citation | last1 = Rogawski | first1 = Michael A. | last2 = Löscher | first2 = Wolfgang | title = The neurobiology of antiepileptic drugs | journal = Nature Reviews Neuroscience | volume = 5 | issue = 7 | page = 553-564 | date = 2004 | pmid = 15208697 | doi = 10.1038/nrn1430 | url=http://www.nature.com/nrn/journal/v5/n7/abs/nrn1430.html }}</ref> <ref name="Jensen2015">{{citation | last1 = Jensen | first1 = Bjorn | last2 = Chen | first2 = Jeffrey | last3 = Furnish | first3 = Tim | last4 = Wallace | first4 = Mark | title = Medical Marijuana and Chronic Pain: a Review of Basic Science and Clinical Evidence | journal = Current Pain and Headache Reports | date = Sep 1, 2015 | volume = 19 | issue = 10 | doi = 10.1007/s11916-015-0524-x }}</ref> <ref name="opioid1">{{citation | last1 = Hemmings | first1 = Hugh C. | last2 = Egan | first2 = Talmage D. | title = Pharmacology and Physiology for Anesthesia: Foundations and Clinical Application: Expert Consult - Online and Print |year = 2013 |publisher = Elsevier Health Science |language = en |isbn = 1437716792 |page = 253 | url = https://books.google.com/books?id=s8CXrbimviMCs | quote = Opiate is the older term classically used in pharmacology to mean a drug derived from opium. Opioid, a more modern term, is used to designate all substances, both natural and synthetic, that bind to opioid receptors (including antagonists). }}</ref> </references> [[Category:Potential treatments]] [[Category:Analgesics]]
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