What is a pain specialist?

Duloxetine is a type of antidepressant medicine called an SNRI (serotonin–noradrenaline reuptake inhibitor) that is also used to treat some kinds of long‑lasting pain, especially nerve pain such as burning, shooting or stabbing sensations. It works by helping to ‘turn down the volume’ of pain messages in the brain and spinal cord, and may also improve sleep and mood. The benefit usually builds up gradually over a few weeks, and the dose is often adjusted slowly to reduce side effects such as nausea, dry mouth or dizziness. Duloxetine is not addictive, but it should not be stopped suddenly without medical advice. Further information (patient‑friendly websites): https://www.nhs.uk/medicines/duloxetine/ https://fpm.ac.uk/sites/fpm/files/documents/2023-02/duloxetine-leaflet-2022-v3.pdf

Amitriptyline is an older antidepressant (a tricyclic) that, in low doses, is commonly used to treat persistent nerve‑related pain and to help prevent some types of headache and migraine. It is also useful in post stroke pain and chemotherapy induced nerve damage. It can help reduce the intensity of pain, improve sleep and lower the distress associated with living with chronic pain, even if you are not depressed. The dose is usually started very low at night and increased slowly to minimise side effects such as drowsiness, dry mouth or constipation. It may take a few weeks before you notice a clear benefit. Further information (patient‑friendly websites): https://www.nhs.uk/medicines/amitriptyline-for-pain/ https://patient.info/medicine/amitriptyline-elavil

Pregabalin is a medicine that calms over‑active nerves and is often used to treat nerve pain, such as burning, shooting, stabbing or ‘electric shock’ pains. It may help people whose nerve pain has not responded well to other treatments, and it can also improve sleep and day‑to‑day functioning. Common side effects include dizziness, sleepiness, blurred vision and ankle swelling, so the dose is usually increased gradually. It should not be stopped suddenly without medical advice, as this can make you feel unwell. Further information (patient‑friendly websites): https://www.nps.org.au/consumers/pregabalin-for-nerve-pain https://www.britishpainsociety.org/static/uploads/resources/files/FPM-Pregablin_2.pdf

Tramadol is a strong painkiller from the opioid family, used for moderate to severe pain when simpler pain relievers are not enough. It works in the brain and spinal cord to dampen pain messages, but it can also cause side effects such as nausea, dizziness, sleepiness, sweating and constipation. With regular use, your body can become used to tramadol, and stopping it suddenly may cause withdrawal symptoms. Because of these risks, it is usually used at the lowest effective dose, for the shortest possible time, and reviewed regularly by your doctor. Further information (patient‑friendly websites): https://www.nhs.uk/medicines/tramadol/ https://www.e-lactancia.org/media/papers/Tramadol-DS-ActavisUK2017.pdf

Codeine is a milder opioid painkiller that is often combined with paracetamol for short‑term relief of moderate pain, such as after an injury or an operation. It changes how the brain and nervous system respond to pain, but it can cause drowsiness, constipation and nausea. With regular or high‑dose use there is a risk of tolerance, dependence and addiction, and stopping suddenly can cause withdrawal symptoms. For most people, codeine should only be used for short periods and under medical guidance, rather than as a long‑term daily treatment for chronic pain. Further information (patient‑friendly websites): https://www.nhs.uk/medicines/codeine/ https://www.tga.gov.au/sites/default/files/consumer-fact-sheet-codeine-containing-medicines-harms-changes-patient-access.pdf Further information (patient‑friendly websites): https://www.nhs.uk/medicines/tramadol/ https://www.e-lactancia.org/media/papers/Tramadol-DS-ActavisUK2017.pdf

Non‑steroidal anti‑inflammatory drugs (NSAIDs) such as ibuprofen, naproxen and diclofenac reduce inflammation, fever and pain. They are often used for arthritis, back pain, muscle and joint injuries or period pain and can be very effective, especially in the short term. However, NSAIDs may irritate the stomach lining and, in some people, increase the risk of bleeding, kidney problems or heart and circulation problems. For this reason, they should generally be used at the lowest effective dose, for the shortest necessary time, and always with your doctor’s advice if you have other health conditions. People at higher risk of serious side effects from NSAIDs include patients who: are elderly (generally over 65 years of age); have a history of stomach or duodenal ulcers, bleeding from the gut, or inflammatory bowel disease; have heart or circulation problems such as ischaemic heart disease, previous heart attack or stroke, or heart failure; have chronic kidney disease or reduced kidney function; have poorly controlled high blood pressure or poorly controlled diabetes; are taking blood‑thinning medicines (for example warfarin, DOACs, or antiplatelet drugs such as aspirin or clopidogrel); are taking oral steroids, SSRIs or other medicines that affect the stomach or blood clotting; drink a lot of alcohol, are dehydrated or have other serious medical conditions. If you are in any of these groups, never start or continue an anti‑inflammatory medicine without checking with your doctor or pharmacist. Different anti‑inflammatory drugs carry different levels of risk for blood clots and bleeding. The simple diagram below gives a rough, general guide to how some commonly used medicines compare along this spectrum. Your doctor will choose the most appropriate option for you, taking into account your full medical history. Further information (patient‑friendly websites): https://www.nhs.uk/medicines/nsaids/ https://patient.info/treatment-medication/painkillers/anti-inflammatory-painkillers Further information (patient‑friendly websites): https://www.nhs.uk/medicines/tramadol/ https://www.e-lactancia.org/media/papers/Tramadol-DS-ActavisUK2017.pdf

Medicines like codeine, tramadol, tapentadol, morphine and oxycodone are opioids. They can be very helpful for short‑term severe pain, but with ongoing use they carry important risks, including tolerance (needing more for the same effect), dependence, constipation, hormone changes, low mood and, at higher doses, dangerous breathing suppression and accidental overdose. Because of these risks, long‑term opioid treatment for chronic non‑cancer pain is now used much more cautiously worldwide. Ketamine works in a different way, mainly by blocking NMDA receptors involved in pain processing and mood. At carefully controlled doses under medical supervision, ketamine does not usually cause dangerous breathing depression, and in some patients it can reduce pain sensitivity and improve mood where other treatments have failed. However, ketamine still has potential side effects (such as temporary increases in blood pressure, vivid dreams, dizziness and, with heavy long‑term misuse with doses greater than 10x that in clinical perioperative use, bladder and memory problems), so it is only used in selected patients and in a monitored setting.

In chronic pain medicine, ketamine infusions are sometimes used as a ‘third‑line’ option for nerve‑related or central sensitisation pain that has not responded to standard treatments. Low doses are infused slowly under monitoring, usually over several hours, and many patients describe their pain as feeling ‘turned down’ or less intrusive afterwards. The benefit may last days to weeks in some people, and infusions can sometimes be repeated as part of a wider pain management plan that also includes education, rehabilitation and psychological support. Further information (patient‑friendly websites): https://www.northerncarealliance.nhs.uk/patient-information/patient-leaflets/pain-service-ketamine https://www.mskcc.org/cancer-care/patient-education/about-your-ketamine-infusion-treatment

Ketamine has also been found to help some people with treatment‑resistant depression and severe mood disorders, especially where there have been suicidal thoughts or where several other antidepressants have not worked. It acts on glutamate pathways in the brain, which can rapidly improve mood and thought patterns in some patients, although the effect may wear off over time and repeat treatments or other supports are often needed. Ketamine for mood disorders is usually offered only in specialist centres, under the care of a psychiatrist, with close monitoring before, during and after treatment. Further information (patient‑friendly websites): https://www.blackdoginstitute.org.au/wp-content/uploads/2023/02/Ketamine-Fact-Sheet.pdf https://www.ketamind.co.za/patient-resources/kcsa-information-brochures-1/

Lignocaine (also called lidocaine) is a local anaesthetic medicine similar to the drug dentists use to numb your mouth. In chronic pain clinics it can be given as a slow intravenous infusion (into a vein) to help calm over‑active nerves and reduce certain types of nerve‑related pain. The infusion is given in hospital or a monitored clinic setting, usually over about an hour, and you will be observed closely during and after the treatment. Some patients experience worthwhile pain relief and are able to reduce other pain medicines, although this treatment does not work for everyone. Further information (patient‑friendly websites): https://www.uhcw.nhs.uk/health-information/lidocaine-infusion/ https://www.northerncarealliance.nhs.uk/patient-information/patient-leaflets/pain-service-lidocaine-intravenous-infusion