Medicine & Research

Prescription Pain Relief

By Ellen Whipple Guthrie, Pharm.D.

Pain is defined as an unpleasant sensory and emotional response to a stimulus associated with actual or potential tissue damage. While all pain is uncomfortable, it is important to realize that when it comes to MS-related pain, not all pain is alike.

Therefore, a “one drug treats all” option does not exist, according to Ben Thrower, M.D., senior medical advisor to MS Focus: the Multiple Sclerosis Foundation. Finding the best treatment for pain, he says, may involve a “trial and error” approach. It is important for patients to be empowered to discuss what is working and what is not working with their MS neurologists.

“We have learned a lot, not only about the prevalence of MS-related pain over the last decade, but also about the most effective ways to treat MS-related pain,” Dr. Thrower says. 

MS-related, neuropathic pain, which results from the demyelination of nerves, can be classified as either being acute or chronic. Acute pain comes on and goes away suddenly; it can be very intense, but is usually brief in duration. It is best described as burning, tingling, shooting, or stabbing pain. Chronic pain generally persists over time, with the pain being more intense at some times than others. 

Overall, antiepileptic medications and tricyclic antidepressants rank as the most commonly prescribed medications for MS pain syndromes. These products have been studied in numerous clinical trials; however, efficacy findings have not been consistent.

The role of opioids in treating MS-related neuropathic pain is very controversial. According to Dr. Thrower, opioids only decrease the perception of MS-related neuropathic pain compared to antiepileptic medications and tricyclic medications that treat the pain.

The efficacy of cannabinoids for the treatment of MS-related pain is also a controversial topic. In clinical trials, some patients treated with cannabinoids had improvements in MS-related pain;however, additional clinical trials are needed before cannabinoids are considered to be first-line therapies. Duloxetine (Cymbalta®) and pregabalin (Lyrica®) are both approved for diabetic neuropathic pain. Although not specifically approved as a treatment for MS-related pain, many MS neurologists consider these products to be good treatment options for MS-related pain. 

Secondary Pain

People with MS can suffer from pain that is not a direct result of demyelination of nerves or the disease process. For example, pain in MS can be secondary to spasticity – another common symptom – and successful management of the spasticity may decrease the occurrence and intensity of pain. Not surprisingly, pain secondary to spasticity is best treated with antispasticity medications, including baclofen (Lioresal®) or tizanidine (Zanaflex®). In some instances, pain resulting from spasticity can be reduced using over-the-counter nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin® or Advil®) or naproxen (Aleve®).

Likewise, MS patients experience many of the same aches and pains as do the general population (cramps, pulled muscles, osteoporotic pain). These types of pain that are not specific to MS are treated the same in patients who have and do not have MS.

The disease-modifying therapies are not a direct treatment of MS; however, adherence to therapy with disease-modifying therapies is associated with decreased progression of disease, which in turn can lead to decreased occurrence and/or intensity of MS-related pain.

Ellen Whipple Guthrie is an assistant clinical professor at the University of Georgia College of Pharmacy and a pediatric pharmacist at Children’s Healthcare of Atlanta. A medical advisor for the MSF, she is a member of the American Pharmaceutical Association, the Atlanta Academy of Institutional Pharmacists, and the Consortium of MS Centers.

 (Last reviewed 5/2012)