Medication Management
Medication Management
Medication management for chronic pain involves the careful, physician-supervised use of pharmacologic therapies to control pain, improve function, and enhance quality of life. At IPC, medication management is always part of a comprehensive treatment plan that includes interventional procedures, physical therapy referrals, and lifestyle modifications.
Conceptual illustration
Medically reviewed by Joshua L. Hare, DO, Founder & Medical Director
Updated October 2026
Conditions Treated
Neuropathic pain, fibromyalgia, chronic musculoskeletal pain, inflammatory pain conditions, and any other chronic pain condition where pharmacologic management is indicated as part of a multimodal treatment plan. Non-opioid medication plans are available for patients who want to avoid opioids.
| What it is | A medication plan built around your type of pain, reviewed and adjusted at regular follow-up visits |
|---|---|
| Joint and back pain | Acetaminophen and NSAIDs are considered first-line treatments,[1] with topical forms for pain in one area |
| Nerve pain | Usually starts with gabapentin or pregabalin, often alongside other medicines |
| Antidepressants for pain | SNRIs and TCAs such as duloxetine and nortriptyline, used for their effect on pain signals |
| Opioids | Second-line options for managing severe, persistent pain, prescribed with regular monitoring |
| How a trial runs | Started at a low dose and raised gradually; each medicine gets 2 to 4 weeks to show what it can do |
Talk with our team
Request a callback
The team calls you back within one business day, Monday to Thursday.
Insurance we acceptWhy the Plan Depends on the Kind of Pain
Different kinds of pain respond to different medicines. Chronic musculoskeletal back pain is managed differently from diabetic neuropathy:[1] pain from joints, muscles and discs is typically nociceptive in nature and responds to a stepwise plan, while pain from a damaged or irritated nerve calls for a different set of drugs, and neuropathic pain often necessitates a multimodal approach.[1]
Treatment responses vary widely among individuals, so the plan begins with an evaluation. Your first visit includes a full review of every medicine you take, a urine drug screen, and a check of the state prescription drug monitoring program. From there the choice of medicine follows the diagnosis, and non-opioid plans are available for patients who want to avoid opioids.
When pain and depression occur together, simultaneous treatment of both has been shown to yield greater reductions in pain severity,[1] and chronic pain can worsen preexisting depression, which is one reason several pain medicines are also antidepressants.
Anti-Inflammatories for Joints, Muscles and the Back
NSAIDs such as ibuprofen, naproxen, meloxicam and celecoxib work by inhibition of the enzyme cyclooxygenase (COX),[2] which the body needs to make prostaglandins, the chemical signals behind inflammation and pain. COX comes in two forms. COX-1 helps keep the stomach lining, kidney function and platelets working normally; COX-2 rises during inflammation. COX-2 selective NSAIDs (such as celecoxib) were designed to provide anti-inflammatory relief without compromising the gastric mucosa.[2]
If one does not suit you, another may. No single NSAID has demonstrated clear superiority; therefore, trialing different agents is recommended before considering opioids.[1]
Applied to the skin, an NSAID acts mainly where it is placed, which generally means fewer whole-body side effects than the same drug taken by mouth. Topical NSAIDs have demonstrated efficacy in treating acute musculoskeletal pain, including strains and sprains,[1] and in knee arthritis they have shown superior effectiveness to placebo.[1]
NSAIDs also carry real risks, so they are prescribed with your medical history in view. They can affect the gastric mucosa, renal system, cardiovascular system, hepatic system, and hematologic system:[2] stomach ulcers and bleeding, higher blood pressure and kidney strain, a higher risk of heart attack and blood clots, and rarely liver injury. They are relatively contraindicated in patients with cardiovascular disease, renal impairment, gastrointestinal ulcers, or those receiving anticoagulation therapy,[1] and they are not used during the third trimester of pregnancy, after coronary bypass surgery, in kidney failure, or after an allergic reaction such as hives or asthma triggered by an NSAID or aspirin.
Gabapentin and Pregabalin for Nerve Pain
The initial pharmacological treatment of neuropathic pain typically involves gabapentin or pregabalin.[1] Both are calcium channel alpha-2-delta ligands:[1] they quiet overactive nerve signaling, and they are commonly prescribed for conditions such as postherpetic neuralgia, diabetic neuropathy, and mixed neuropathies.[1] Pregabalin carries FDA approval for neuropathic pain associated with spinal cord injury, diabetic peripheral neuropathy, postherpetic neuralgia and fibromyalgia, and it could be most appropriate when addressing both severe pain and sleep disturbance concurrently.[3]
The dose starts low because the early weeks are when side effects show. Pregabalin's are mild to moderate intensity, dose-dependent, and occurred within the first 2 weeks[3] in most reports, and the common ones are somnolence, dizziness, blurred vision, difficulty with concentration/attention, dry mouth, edema, and weight gain. Gabapentin's include dizziness, sleepiness, fatigue, unsteadiness, swelling of the legs and nausea.
Some combinations are not safe. With opioids, gabapentin has been linked to respiratory depression and sedation, occasionally fatal.[4] Pregabalin taken with opioids, benzodiazepines or alcohol should also be avoided, because the drugs intensify each other's effects. Concurrent use of gabapentin and pregabalin is contraindicated.[4] Long-term use of pregabalin can result in physical dependence,[3] a risk that is higher in people already on opioid medicines or with a history of substance use, and either drug stopped abruptly can cause withdrawal symptoms, including withdrawal seizure with gabapentin. Both are tapered off rather than stopped.
Tell us if you are pregnant or breastfeeding: pregabalin may cause fetal harm,[3] and because it has been detected in breast milk, an alternative is preferred while breastfeeding. Report unexplained muscle pain or weakness, since pregabalin has been associated with rhabdomyolysis,[3] and report mood changes, since gabapentin's rare severe reactions include suicidality, depression, Stevens-Johnson syndrome, anaphylaxis, angioedema.[4]
Antidepressants That Treat Pain
Some antidepressants change how the nervous system handles pain signals, which is why they are prescribed for pain in people who are not depressed. SNRIs and TCAs are effective for neuropathic pain, central pain syndromes, and chronic musculoskeletal pain, and they can reduce neuropathic pain intensity by up to 50%.[1]
Duloxetine is FDA-approved for diabetic peripheral neuropathic pain, for fibromyalgia, and for chronic musculoskeletal pain, including chronic low back pain and osteoarthritis-related pain in adults.[5] Oncology guidelines recognize it as the only agent for which evidence supports its use in the treatment of painful chemotherapy-induced peripheral neuropathy,[5] which matters for cancer pain, and it offers similar efficacy to other antidepressants in treating comorbid depression. Older tricyclics such as nortriptyline are also effective, although they may require 6 to 8 weeks for full therapeutic effect.[1]
Nausea is the most common adverse effect[5] of duloxetine, followed by dry mouth, drowsiness and dizziness, and some ease with continued treatment. The serious ones need watching. The label carries a boxed warning for an increased risk of suicidal thoughts and behaviors[5] in people aged 24 or younger, especially when starting. Duloxetine is avoided in patients with cirrhosis, chronic liver disease, or substantial alcohol consumption; it can raise blood pressure, increase bleeding with NSAIDs or blood thinners, and cause serotonin syndrome with tramadol, triptans and other serotonergic drugs; and it is not used in uncontrolled narrow-angle glaucoma or end-stage kidney disease. It can also lower sodium levels, particularly in older adults, and rarely causes serious skin reactions. Stopping suddenly can cause dizziness, nausea and electric-shock sensations, so it is reduced with a gradual taper over 2 weeks or longer.[5]
Lidocaine and capsaicin are topical options that sit alongside these. Adjunctive topical agents, such as lidocaine, are effective for managing neuropathic pain and allodynia,[1] particularly after shingles, and capsaicin cream may be considered for chronic neuropathic or musculoskeletal pain when other treatments have not been enough.
When Opioids Are Part of the Plan
Opioids are considered second-line options for managing severe, persistent pain or cancer-related neuropathic pain,[1] and they may be appropriate when other treatments have not worked or cannot be used, and when pain significantly impairs your quality of life. Starting one should be preceded by a comprehensive discussion of the potential risks, benefits, and available nonopioid alternatives,[1] along with your informed consent.
A stepwise approach is generally preferred to minimize both the duration and dosage of opioid analgesics, and short-acting opioids are generally preferred outside severe, disabling pain. Higher doses carry more risk: above 100 morphine milligram equivalents a day, patients are at significantly heightened risk for adverse effects, particularly respiratory compromise.[1]
Side effects include sedation, respiratory depression, constipation,[6] nausea, itching, hormone suppression, and with long-term use tolerance and, in some cases, opioid-induced hyperalgesia, a heightened sensitivity to pain. The StatPearls chronic pain review advises that for anyone on opioid therapy, prescribing naloxone (Narcan) and providing appropriate training are essential.[1] Keep it where a family member or friend knows to find it.
Some histories call for extra caution because they raise an increased risk of prescription misuse:[6] a family or personal history of substance abuse, young age, a history of legal problems, frequent contact with high-risk people or settings, past problems with employers, family or friends, risk-taking and thrill-seeking behavior, smoking and regular use of other dependence-forming substances, major depression or anxiety, multiple psychosocial stressors, childhood abuse, and previous drug or alcohol rehabilitation. Serotonergic opioids such as tramadol need caution with a seizure disorder, and methadone with long QT syndrome.
Patients on opioid therapy have routine follow-up visits that include a history and physical exam to monitor for adverse effects,[6] and many practices add state prescription drug monitoring programs, frequent visits with urine toxicology screens[6] and similar checks. At IPC, the first visit includes both a urine drug screen and a monitoring-program check.
The treatment explained
How Follow-Up Visits Work
A new medicine typically needs 2 to 4 weeks before its effect can be judged, the dose is started low and raised gradually, and side effects are tracked at each visit. Follow-up visits are scheduled regularly, and what you take is adjusted to your response, your side effects and your goals.
Some medicines are used long term; others serve as a bridge while another treatment takes hold. Bring every bottle to your visits, including over-the-counter pain relievers and supplements, because several of the interactions above involve medicines people do not think to mention.
References
Clinical sources for this page.
- Chronic Pain. StatPearls [Internet]. StatPearls Publishing; 2025. Back to first citation ↑
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). StatPearls [Internet]. StatPearls Publishing; 2023. Back to first citation ↑
- Pregabalin. StatPearls [Internet]. StatPearls Publishing. Back to first citation ↑
- Gabapentin. StatPearls [Internet]. StatPearls Publishing. Back to first citation ↑
- Duloxetine. StatPearls [Internet]. StatPearls Publishing; 2026. Back to first citation ↑
- Opioid Analgesics (archived chapter). StatPearls [Internet]. StatPearls Publishing. Back to first citation ↑
Five clinics
Book a visit
Our fellowship-trained physicians are accepting new patients at five clinics: Dalton, Ringgold, Cleveland, Farragut and Oak Ridge.