Medications for Back Pain and Neck Pain

Medications tailored to alleviate back pain and neck pain play a pivotal role in providing targeted relief and enhancing the quality of life for individuals dealing with these common yet distressing issues.

Each medication type carries distinct benefits and potential side effects, accentuating the importance of individualized treatment plans.

When Pain Medications are Used for Back and Neck Pain

Over-the-counter (OTC) medications, such as ibuprofen (Advil) and acetaminophen (Tylenol), are effective for treating acute mild-to-moderate pain, such as pain due to a pulled muscle injury.¹Tanna NK, Ong T. Pharmacological options for pain control in patients with vertebral fragility fractures. Osteoporos Sarcopenia. 2022;8(3):93-97. doi:10.1016/j.afos.2022.09.003^,2Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine. 2017;166(7):514. doi:10.7326/m16-2367

Prescription-strength medications, such as muscle relaxers and opioids, are recommended for the following cases¹Tanna NK, Ong T. Pharmacological options for pain control in patients with vertebral fragility fractures. Osteoporos Sarcopenia. 2022;8(3):93-97. doi:10.1016/j.afos.2022.09.003:

• Severe pain (greater than a 6 out of 10 on the numeric rating scale)
• Inadequate response to OTC medication
• Pain that interferes with daily activities, such as driving or working

If back or neck pain occurs in conjunction with numbness or weakness, it is advisable to seek emergency medical care to treat the underlying injury.

Factors that Affect the Type of Pain Medication for Back and Neck Pain

Essential factors that influence the choice of pain medication for back and neck pain include the type of pain, underlying medical conditions, potential drug interactions, and individual responses. 

Additionally, specific condition-related factors include¹Tanna NK, Ong T. Pharmacological options for pain control in patients with vertebral fragility fractures. Osteoporos Sarcopenia. 2022;8(3):93-97. doi:10.1016/j.afos.2022.09.003^,2Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine. 2017;166(7):514. doi:10.7326/m16-2367: 

• Type: neuropathic or nociceptive (non-neuropathic)
• Severity: mild, moderate, or severe
• Duration: acute, subacute, or chronic

Personalized consideration of these elements ensures the selection of the most suitable and effective treatment approach.

Using multiple types of pain medication for back and neck pain

In some cases, back and neck pain with multiple causes are treated with two or more types of medication. For example, post-surgical pain accompanied by muscle spasms are typically addressed through a combination of a non-steroidal anti-inflammatory drug (NSAID) and a muscle relaxant.³Horn R, Kramer J. Postoperative Pain Control. [Updated 2022 Sep 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544298/

Using more than one type of pain medication is also a therapeutic strategy to optimize pain relief and limit opioid use. The use of opioids is limited due to their potential safety risks associated with misuse and overuse.³Horn R, Kramer J. Postoperative Pain Control. [Updated 2022 Sep 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544298/

How Pain Medications for Back and Neck Pain Are Given

Pain medications produce whole-body (systemic) or local effects depending on their mode of delivery and how much of the drug is absorbed into the bloodstream. 

Pain medications that affect the whole body

Pain medications with systemic effects are absorbed into the bloodstream and affect nerve signaling throughout the body.⁴Campbell S, Smeets N. Drug Delivery: Localized and Systemic Therapeutic Strategies with Polymer Systems. Polymers and Polymeric Composites: A Reference Series. Published online October 15, 2018:1-56. doi:10.1007/978-3-319-92067-2_32-1 Examples include:

• Oral medications. Pain medications taken orally (by mouth) include immediate-release, delayed-release, and extended-release forms that differ in how long the pain-relieving effect of the drug lasts.⁴Campbell S, Smeets N. Drug Delivery: Localized and Systemic Therapeutic Strategies with Polymer Systems. Polymers and Polymeric Composites: A Reference Series. Published online October 15, 2018:1-56. doi:10.1007/978-3-319-92067-2_32-1
• Injections. Medications administered through an intravenous (IV) or intramuscular (IM) injection have a quicker onset of action compared to oral routes. Injectable delivery modes are typically reserved for emergency/urgent care, hospital, or home health settings.⁵Kim J, De Jesus O. Medication Routes of Administration. [Updated 2023 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568677/
• Transdermal patch. A patch is applied directly to the skin and stays in place for several hours (ranging from 8 to 72 hours). Pain medication is slowly released from the patch, absorbed through the skin, and eventually absorbed into the bloodstream. Transdermal patches are recommended in cases of chronic pain.⁴Campbell S, Smeets N. Drug Delivery: Localized and Systemic Therapeutic Strategies with Polymer Systems. Polymers and Polymeric Composites: A Reference Series. Published online October 15, 2018:1-56. doi:10.1007/978-3-319-92067-2_32-1^,6Leppert W, Malec-Milewska M, Zajaczkowska R, Wordliczek J. Transdermal and Topical Drug Administration in the Treatment of Pain. Molecules. 2018;23(3):681. Published 2018 Mar 17. doi:10.3390/molecules23030681
• Nasal spray. Medication is administered into the nostrils and absorbed into the bloodstream through the blood vessels in the nasal cavity. This delivery method is helpful for individuals with difficulty swallowing; the non-steroidal anti-inflammatory drug ketorolac is available as a nasal spray.⁵Kim J, De Jesus O. Medication Routes of Administration. [Updated 2023 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568677/

Oral pain medications are most commonly used due to their convenience and cost-effectiveness.⁴Campbell S, Smeets N. Drug Delivery: Localized and Systemic Therapeutic Strategies with Polymer Systems. Polymers and Polymeric Composites: A Reference Series. Published online October 15, 2018:1-56. doi:10.1007/978-3-319-92067-2_32-1

Pain medications that produce localized effects

Pain medications with local effects have little to no absorption into the bloodstream and exert their effects on the specific area of the body to which they are administered.⁴Campbell S, Smeets N. Drug Delivery: Localized and Systemic Therapeutic Strategies with Polymer Systems. Polymers and Polymeric Composites: A Reference Series. Published online October 15, 2018:1-56. doi:10.1007/978-3-319-92067-2_32-1 Examples include:

• Topical medications. Topical pain medications are applied directly to the skin and are absorbed into the surrounding muscle tissue. This delivery route is adequate for most mild-to-moderate pain but has little to no effect on pain caused by injury to bones.⁴Campbell S, Smeets N. Drug Delivery: Localized and Systemic Therapeutic Strategies with Polymer Systems. Polymers and Polymeric Composites: A Reference Series. Published online October 15, 2018:1-56. doi:10.1007/978-3-319-92067-2_32-1^,6Leppert W, Malec-Milewska M, Zajaczkowska R, Wordliczek J. Transdermal and Topical Drug Administration in the Treatment of Pain. Molecules. 2018;23(3):681. Published 2018 Mar 17. doi:10.3390/molecules23030681
• Epidural injection. Epidural injection involves delivering pain medication into the epidural space around the nerves in the spine, and the drug diffuses into the spinal fluid to reduce inflammation and pain around the spine.⁷Knezevic NN, Candido KD, Vlaeyen JWS, Van Zundert J, Cohen SP. Low back pain. Lancet. 2021;398(10294):78-92. doi:10.1016/S0140-6736(21)00733-9
• Intrathecal injection. The intrathecal route involves delivering medication directly into the fluid surrounding the spinal cord, typically through an implanted pain pump. This route is also used in post-surgical settings to provide nerve-blocking medication, such as lidocaine, and reduce opioid use.⁸Qiu Y, Zhang TJ, Hua Z. Erector Spinae Plane Block for Lumbar Spinal Surgery: A Systematic Review. J Pain Res. 2020;13:1611-1619. Published 2020 Jul 1. doi:10.2147/JPR.S256205

Most topical pain medications are available over the counter, but injectable forms require administration by a qualified healthcare professional. 

Local administration of pain medications have a lower risk of sedation and gastrointestinal side effects. However, administration directly into the spine is associated with risks for potential neurologic complications (eg, stroke and spinal cord injury).⁹Cohen SP, Greuber E, Vought K, Lissin D. Safety of Epidural Steroid Injections for Lumbosacral Radicular Pain: Unmet Medical Need. Clin J Pain. 2021;37(9):707-717. doi:10.1097/AJP.0000000000000963 

Risks of epidural injection of corticosteroids

The epidural injection of corticosteroids is associated with several serious risks due to systemic absorption of the medication. These risks include¹⁰King W, Miller DC, Smith CC. Systemic Effects of Epidural Corticosteroid Injection. Pain Medicine. 2017;19(2):404-405. doi: 10.1093/pm/pnx173:

• Adrenal suppression
• Avascular necrosis of the hip
• Osteoporosis
• Increased blood sugar, especially in diabetic patients
• Immunosuppression
• Mood changes

This list is not comprehensive, and the potential risk of these effects is increased with repeated epidural injections, especially at short intervals.¹⁰King W, Miller DC, Smith CC. Systemic Effects of Epidural Corticosteroid Injection. Pain Medicine. 2017;19(2):404-405. doi: 10.1093/pm/pnx173

See Epidural Steroid Injections Risks and Side Effects

Acetaminophen

The exact mechanisms of acetaminophen are unknown, but research suggests that it blocks cyclooxygenase enzymes in the central nervous system to lower the production of prostanoids (the chemicals that cause pain and fever) and reduce the brain’s perception of pain.¹¹Gerriets V, Anderson J, Nappe TM. Acetaminophen. [Updated 2022 Sep 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482369/

Acetaminophen (Tylenol) effectively reduces pain and fever in most individuals but has no significant effect on inflammation.¹¹Gerriets V, Anderson J, Nappe TM. Acetaminophen. [Updated 2022 Sep 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482369/

See Acetaminophen Potential Risks and Complications

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs inhibit the action of cyclooxygenase enzymes in the central and peripheral nervous system to block the production of prostanoids throughout the whole body.¹²Bindu S, Mazumder S, Bandyopadhyay U. Non-steroidal anti-inflammatory drugs (NSAIDs) and organ damage: A current perspective. Biochem Pharmacol. 2020;180:114147. doi:10.1016/j.bcp.2020.114147

These medications are considered first-line therapy for back pain when no significant risk factors are present, such as gastric ulcers or cardiovascular disease. All NSAIDs are generally considered equally effective for treating pain, and the common drugs in this class include¹Tanna NK, Ong T. Pharmacological options for pain control in patients with vertebral fragility fractures. Osteoporos Sarcopenia. 2022;8(3):93-97. doi:10.1016/j.afos.2022.09.003^,2Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine. 2017;166(7):514. doi:10.7326/m16-2367: 

• Ibuprofen
• Naproxen
• Meloxicam
• Celecoxib
• Diclofenac

NSAIDs are also available in topical creams for local pain relief, including diclofenac (Voltaren) and trolamine salicylate (Aspercreme).¹³Voltaren Arthritis Pain. Package Insert. GlaxoSmithKline Consumer Healthcare Holdings (US) LLC; 2023^,14Aspercreme. Package Insert. Chattem, Inc; 2023.

See Potential Risks and Complications of NSAIDs

Muscle Relaxers

Muscle relaxers act on receptors in the central nervous system and directly within muscle tissue to reduce spasticity (tightness) and stop the spontaneous or involuntary contraction of muscles (such as jerks, twitches, or cramps) that cause spasms.¹⁵Witenko C, Moorman-Li R, Motycka C, et al. Considerations for the appropriate use of skeletal muscle relaxants for the management of acute low back pain. P T. 2014;39(6):427-435.

In cases of lower back pain, these medications are considered second-line therapy when NSAIDs are ineffective.¹³Voltaren Arthritis Pain. Package Insert. GlaxoSmithKline Consumer Healthcare Holdings (US) LLC; 2023 Common muscle relaxers used include:

• Baclofen (Lioresal)
• Carisoprodol (Soma)
• Cyclobenzaprine (Flexeril)
• Methocarbamol (Robaxin)
• Tizanidine (Zanaflex)

Treatment with muscle relaxers is typically limited to short-term (2 to 3 weeks) due to the risk of potential side effects.¹³Voltaren Arthritis Pain. Package Insert. GlaxoSmithKline Consumer Healthcare Holdings (US) LLC; 2023

See Side Effects and Risks of Muscle Relaxers

Anticonvulsants (Anti-Seizure Medications)

Anticonvulsants act similarly to gamma-aminobutyric acid (GABA), a natural chemical in the brain that helps calm the nervous system down and reduce nerve pain.¹⁶Yasaei R, Katta S, Saadabadi A. Gabapentin. [Updated 2022 Dec 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493228/

Anticonvulsants are used to treat back and neck pain caused by nerve damage or compression, such as from a herniated disc, and to manage chronic neuropathic pain conditions such as fibromyalgia.⁷Knezevic NN, Candido KD, Vlaeyen JWS, Van Zundert J, Cohen SP. Low back pain. Lancet. 2021;398(10294):78-92. doi:10.1016/S0140-6736(21)00733-9

The anticonvulsants used for managing back and neck pain include:

• Gabapentin (Neurontin)
• Pregabalin (Lyrica)

These medications are effective for short-term relief of neuropathic pain but provide only moderate relief for chronic pain.⁷Knezevic NN, Candido KD, Vlaeyen JWS, Van Zundert J, Cohen SP. Low back pain. Lancet. 2021;398(10294):78-92. doi:10.1016/S0140-6736(21)00733-9

It is also important to note that pregabalin is regulated as a controlled substance in the US, while gabapentin is a controlled substance in only a few states.  This regulation leads to specific limitations on the prescription of these medications due to the potential for abuse and addiction.¹⁷Controlled Substance Schedules. Usdoj.gov. Published 2019. https://www.deadiversion.usdoj.gov/schedules

Antidepressants with Pain-Relieving Effects

Some antidepressants alleviate pain by increasing the amounts of chemicals in the brain (serotonin and norepinephrine) needed for optimal nervous system functioning, including pain regulation. The medications in this class include¹⁸Bonilla-Jaime H, Sánchez-Salcedo JA, Estevez-Cabrera MM, Molina-Jiménez T, Cortes-Altamirano JL, Alfaro-Rodríguez A. Depression and Pain: Use of Antidepressants. Curr Neuropharmacol. 2022;20(2):384-402. doi:10.2174/1570159X19666210609161447:

• Duloxetine (Cymbalta)
• Venlafaxine (Effexor)
• Amitriptyline 

Antidepressants are effective for managing chronic neuropathic pain but do not significantly affect acute or non-neuropathic pain.¹⁹Queremel Milani DA, Davis DD. Pain Management Medications. [Updated 2023 Feb 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560692/ However, addressing and treating depression improves pain from any cause and overall functioning.¹⁵Witenko C, Moorman-Li R, Motycka C, et al. Considerations for the appropriate use of skeletal muscle relaxants for the management of acute low back pain. P T. 2014;39(6):427-435.

Corticosteroids 

Corticosteroids (sometimes called glucocorticoids) produce potent anti-inflammatory and immunosuppressant effects that reduce pain and discomfort caused by inflammation of the spinal nerves, such as from herniated discs or spinal arthritis.²⁰Haley SP, Stem LA. Corticosteroids for Low Back Pain. American Family Physician. 2023;107(3):230A230B. Accessed August 10, 2023. https://www.aafp.org/pubs/afp/issues/2023/0300/mbtn-corticosteroids-low-back-pain.html#:~:text=Corticosteroids%2C%20when%20used%20orally%2C%20intramuscularly

Epidural steroid injections for back pain

Epidural steroid injections are recommended for persistent back and neck pain that does not respond to other medications.⁷Knezevic NN, Candido KD, Vlaeyen JWS, Van Zundert J, Cohen SP. Low back pain. Lancet. 2021;398(10294):78-92. doi:10.1016/S0140-6736(21)00733-9

For most people, corticosteroid injections produce a rapid onset of pain relief and improved mobility that typically lasts from 6 weeks to 6 months. However, in rare cases, pain could worsen if injections are not continued.²¹Corticosteroids General Statement. AHFS DI (Adult and Pediatric). Hudson, OH: Lexicomp, 2023. http://online.lexi.com/. Epidural steroid injections are not approved by the FDA and are used off-label. 

Injectable corticosteroids include¹⁸Bonilla-Jaime H, Sánchez-Salcedo JA, Estevez-Cabrera MM, Molina-Jiménez T, Cortes-Altamirano JL, Alfaro-Rodríguez A. Depression and Pain: Use of Antidepressants. Curr Neuropharmacol. 2022;20(2):384-402. doi:10.2174/1570159X19666210609161447:

• Methylprednisolone
• Dexamethasone
• Triamcinolone

The pain-relieving effects of corticosteroid injections typically last from 6 weeks to 6 months, but the duration of pain relief is different for each person.⁷Knezevic NN, Candido KD, Vlaeyen JWS, Van Zundert J, Cohen SP. Low back pain. Lancet. 2021;398(10294):78-92. doi:10.1016/S0140-6736(21)00733-9

See Epidural Steroid Injections: Risks and Side Effects

SI joint injections for low back pain

Some research suggests that sacroiliac joint injections (injection directly into the space between the base of the spine and the hip bones) may be effective for managing lower back pain in suitable patients.⁷Knezevic NN, Candido KD, Vlaeyen JWS, Van Zundert J, Cohen SP. Low back pain. Lancet. 2021;398(10294):78-92. doi:10.1016/S0140-6736(21)00733-9

See Sacroiliac Joint Injections: Risks, Success Rates, and Long-Term Outcomes

Oral corticosteroids for back and neck pain

On rare occasions, like during episodes of psoriatic arthritis exacerbation or acute spinal cord injury, short-term prescriptions of oral corticosteroids may be recommended. However, long-term use of these medications is generally discouraged due to the risk of significant side effects and complications.²²Ocejo A, Correa R. Methylprednisolone. [Updated 2022 Dec 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544340/

Oral corticosteroids used for back and neck pain include:

• Prednisone
• Methylprednisolone (Medrol Dosepak)
• Dexamethasone

Gastrointestinal upset is common, so it is advisable to take the medication with milk or food to prevent these side effects.²¹Corticosteroids General Statement. AHFS DI (Adult and Pediatric). Hudson, OH: Lexicomp, 2023. http://online.lexi.com/.

Dosage considerations for steroids: A short course of oral steroids typically involves starting at a high dose, quickly tapering down to a lower dose, and eventually discontinuing the medication over approximately 1 to 2 weeks.²³Fleishaker DL, Mukherjee A, Whaley FS, Daniel S, Zeiher BG. Safety and pharmacodynamic dose response of short-term prednisone in healthy adult subjects: a dose ranging, randomized, placebo-controlled, crossover study. BMC Musculoskelet Disord. 2016;17:293. Published 2016 Jul 16. doi:10.1186/s12891-016-1135-3

Use of these medications for any length of time, especially at high doses, increases blood sugar, and individuals with diabetes should be closely monitored while taking corticosteroids.²⁴Shah M, Adel MM, Tahsin B, Guerra Y, Fogelfeld L. Effect of short-term prednisone on beta-cell function in subjects with type 2 diabetes mellitus and healthy subjects. PLoS One. 2020;15(5):e0231190. Published 2020 May 5. doi:10.1371/journal.pone.0231190 Long-term use has been shown to worsen bone health and impair natural healing processes.¹⁹Queremel Milani DA, Davis DD. Pain Management Medications. [Updated 2023 Feb 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560692/

Opioids

Opioids block the transmission of pain signals within the nervous system. They are highly effective for treating pain, but due to their impairing side effects (eg, sedation, cognitive impairment, and respiratory depression) and addiction potential, opioids are prescribed conservatively.²⁵Cohen B, Ruth LJ, Preuss CV. Opioid Analgesics. [Updated 2023 Apr 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459161/

Research suggests that opioids are most beneficial for moderate to severe non-neuropathic pain with low inflammation.²⁶Anekar AA, Hendrix JM, Cascella M. WHO Analgesic Ladder. [Updated 2023 Apr 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554435/

Opioids differ in their potency and strength, and the severity of pain generally determines which opioid is used.²¹Corticosteroids General Statement. AHFS DI (Adult and Pediatric). Hudson, OH: Lexicomp, 2023. http://online.lexi.com/. 

• Weak opioids, such as codeine, hydrocodone, and tramadol, are effective for moderate pain.²¹Corticosteroids General Statement. AHFS DI (Adult and Pediatric). Hudson, OH: Lexicomp, 2023. http://online.lexi.com/.
• Potent opioids, such as morphine, oxycodone, and hydromorphone, effectively manage severe and persistent pain.²¹Corticosteroids General Statement. AHFS DI (Adult and Pediatric). Hudson, OH: Lexicomp, 2023. http://online.lexi.com/.

The recommendations for safe opioid prescribing are constantly changing, but there is a consensus that all drugs in this class (regardless of potency) be used at the lowest effective dose for the shortest duration possible.²¹Corticosteroids General Statement. AHFS DI (Adult and Pediatric). Hudson, OH: Lexicomp, 2023. http://online.lexi.com/.

Opioids for chronic pain (lasting 12 weeks or more)

Research demonstrates that when opioids are used in the long-term management of chronic pain, their effectiveness is moderate, and the risks of addiction and severe side effects often do not outweigh the limited benefit.⁷Knezevic NN, Candido KD, Vlaeyen JWS, Van Zundert J, Cohen SP. Low back pain. Lancet. 2021;398(10294):78-92. doi:10.1016/S0140-6736(21)00733-9

When considering opioids for long-term pain management, medications that provide a longer duration of pain relief and require less frequent dosing are preferred.²⁷Bhatnagar M, Pruskowski J. Opioid Equivalency. [Updated 2022 Sep 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK535402/ For example:

• Extended-release (ER) opioids, such as OxyContin (the ER formulation of oxycodone), slowly release the drug over several hours to provide consistent pain relief for 8 to 12 hours.²⁶Anekar AA, Hendrix JM, Cascella M. WHO Analgesic Ladder. [Updated 2023 Apr 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554435/
• Transdermal patches, including fentanyl and buprenorphine, release small amounts of the drug over multiple days and need to be reapplied every 3 to 7 days.²⁸Skaer TL. Dosing considerations with transdermal formulations of fentanyl and buprenorphine for the treatment of cancer pain. J Pain Res. 2014;7:495-503. Published 2014 Aug 19. doi:10.2147/JPR.S36446
• Opioids with a naturally long duration of action, such as methadone, provide sustained pain relief for up to 8 hours.²⁶Anekar AA, Hendrix JM, Cascella M. WHO Analgesic Ladder. [Updated 2023 Apr 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554435/

It is recommended to assess the continued need for opioid therapy at regular intervals (eg, every 3 months).²⁹Dowell D. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recommendations and Reports. 2022;71(3). doi: 10.15585/mmwr.rr7103a1

See Opioid Medication Potential Risks and Complications

Topical Pain Medications 

Topical pain medications reduce localized pain, such as from an arthritic joint or sore muscle, and are available over the counter as creams, gels, sprays, and transdermal patches.

Counterirritants for back and neck pain

Counterirritants produce a mild irritation or sensation on the skin (typically a hot or cold sensation), which tricks the nerves into sending non-painful signals and ultimately alleviates pain in the deeper tissue.³⁰Barkin RL. The pharmacology of topical analgesics. Postgrad Med. 2013;125(4 Suppl 1):7-18. doi:10.1080/00325481.2013.1110566911

Products containing ingredients such as camphor and menthol produce cooling sensations, while capsaicin and methyl salicylate produce warning effects.²²Ocejo A, Correa R. Methylprednisolone. [Updated 2022 Dec 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544340/ These products include:

• Icy Hot (menthol and methyl salicylate)
• Tiger Balm (menthol and camphor)
• Capzasin (capsaicin)

Counterirritants are effective for temporarily relieving pain, but they do not address the underlying cause or injury.²²Ocejo A, Correa R. Methylprednisolone. [Updated 2022 Dec 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544340/

Topical anesthetics for back and neck pain

Topical anesthetics temporarily block nerve signals in the area where it is applied and provide a numbing effect to relieve pain or discomfort.³¹Garmon EH, Huecker MR. Topical, Local, and Regional Anesthesia and Anesthetics. [Updated 2023 Apr 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430894/

Lidocaine is the most common active ingredient in topical anesthetics used for back pain and is available in OTC and prescription products, including³²Drugs@FDA: FDA-Approved Drugs. www.accessdata.fda.gov. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm: 

• Aspercreme Lidocaine 
• Icy Hot Lidocaine 
• Salonpas Lidocaine 

Most of these products are available as roll-on, creams, and patches.

OTC products contain between 2% and 4% lidocaine, but higher concentration products, such as Lidoderm (5% lidocaine), require a prescription.²⁴Shah M, Adel MM, Tahsin B, Guerra Y, Fogelfeld L. Effect of short-term prednisone on beta-cell function in subjects with type 2 diabetes mellitus and healthy subjects. PLoS One. 2020;15(5):e0231190. Published 2020 May 5. doi:10.1371/journal.pone.0231190

Safety Profile of Pain Medications 

The safety of pain medications varies depending on the drug's mechanism and the delivery method. Most pain medications are safe and well-tolerated when used at recommended doses for a short time; however, all medications have risks of side effects and serious adverse events.