The principle of multimodal analgesia
Pain travels by several routes: transduction in the tissues, transmission along the nerves, modulation in the spinal cord, perception in the brain. Multimodal analgesia means acting at several of these levels at once, using different means.
The benefit is twofold: better relief, and lower doses of each individual agent, and therefore fewer side effects. Combining a simple painkiller, a physical technique and a mind-body approach is almost always better than increasing the dose of a single medicine.
The three steps of the WHO analgesic ladder
| Step | Medicines | Indication |
|---|---|---|
| Step 1 | Paracetamol, non-steroidal anti-inflammatory drugs, aspirin, metamizole | Mild to moderate pain (1–4 out of 10) |
| Step 2 | Codeine, tramadol, dihydrocodeine, often combined with paracetamol | Moderate pain, or failure of step 1 (4–6 out of 10) |
| Step 3 | Morphine, oxycodone, hydromorphone, fentanyl, buprenorphine | Severe or refractory pain (7–10 out of 10) |
Pain medicines
Paracetamol. First choice for mild to moderate pain, and very well tolerated at usual doses. The maximum daily dose must be respected: an overdose causes serious liver damage, sometimes with no early symptoms at all. Watch out for combination products that already contain it.
Non-steroidal anti-inflammatory drugs. Ibuprofen, diclofenac, naproxen: highly effective for inflammatory pain, for colic and for period pain. Use the lowest dose for the shortest possible time, given the risks to the stomach, the kidneys and the heart. They are not advised in pregnancy or in kidney impairment.
Weak and strong opioids. They have a legitimate place in severe acute pain, in pain after surgery and in cancer pain. Their benefit in chronic non-cancer pain, by contrast, is limited and wears off over time. Constant effects: constipation, nausea, drowsiness, and a risk of tolerance and dependence. They are always stopped gradually.
Treatments for neuropathic pain. Ordinary painkillers work poorly here. First-line options are certain antidepressants (amitriptyline, duloxetine) and anti-epileptics (gabapentin, pregabalin), together with local treatments: lidocaine plasters and high-concentration capsaicin patches. The effect often takes two to four weeks and requires the dose to be increased gradually.
Non-drug approaches
These are not optional extras: in chronic pain they are often the best-evidenced treatments of all.
Graded physical activity
The treatment with the strongest evidence in chronic low back pain, osteoarthritis and fibromyalgia. The principle is slow, steady progression from a level you can genuinely sustain, without trying to “push through”.
Physiotherapy
Targeted exercise, strengthening, postural work, manual therapy and reconditioning. It also helps you relearn how to move without fear.
Transcutaneous electrical nerve stimulation (TENS)
A small unit delivers a low-intensity current through electrodes on the skin. It can be used at home, without medication, and gives modest but worthwhile relief for some people.
Cognitive behavioural therapy
It works on catastrophising, on avoidance and on the beliefs that keep pain going. Its effect on impact and function is proven, whether it is delivered face to face or remotely.
Hypnosis and mindfulness
Effective on the emotional component and on tolerance of pain, both in chronic pain and during painful procedures.
Heat, cold and relaxation
Heat relaxes muscle spasm; cold calms acute inflammation and flare-ups. Simple and safe, they give people something they can do straight away.
Pain neuroscience education
Understanding how the alarm system works measurably reduces both pain and fear of movement. It is a treatment in its own right, not just reassuring talk.
Looking after sleep
Sleep deprivation lowers the pain threshold from the very next night. Cognitive behavioural therapy for insomnia improves pain as well.
Interventional techniques
When the treatments above are not enough, targeted procedures may be offered in a specialist centre:
- Injections of a steroid or a local anaesthetic into a joint, into a bursa or close to a nerve root;
- Nerve blocks of a peripheral nerve or a plexus, for diagnosis or for treatment, usually under ultrasound guidance;
- Radiofrequency denervation of the facet joint nerves in selected low back and neck pain;
- Implanted spinal cord stimulation, reserved for carefully selected refractory neuropathic pain;
- Intrathecal pumps delivering the medicine directly to the spinal cord, mainly in cancer care.
Frequently asked questions
Is morphine an end-of-life treatment?
No. It is a powerful painkiller used in many acute and chronic situations, including in patients who go on to recover fully. This belief leads people to refuse useful treatment and to suffer needlessly.
Can paracetamol and an anti-inflammatory be taken together?
These two families work differently and are often combined on medical advice. You should never, however, combine two anti-inflammatories with each other, or exceed the paracetamol dose by adding up several products that contain it.
Does medical cannabis relieve pain?
The evidence shows a modest effect on some neuropathic pain, with side effects that are not trivial (drowsiness, dizziness, cognitive problems). Its legal status and its licensed uses vary from country to country; it is neither a first-line treatment nor a universal solution.
How long does a neuropathic pain treatment take to work?
Often two to four weeks, with a very gradual increase in dose. Stopping after a few days and concluding that it does not work is the commonest mistake.
Are complementary therapies worth trying?
Some of them — hypnosis, mindfulness and adapted yoga in particular — have favourable evidence for reducing the impact of chronic pain. Others have not been shown to work better than placebo. The key point is that they should not delay a necessary diagnosis or treatment.
Sources and references
- WHO — Guidelines for the pharmacological and radiotherapeutic management of cancer pain, 2018.
- NeuPSIG / IASP — pharmacological recommendations for neuropathic pain.
- Cochrane — systematic reviews of exercise, CBT and TENS in chronic pain.
- NICE — Chronic pain (primary and secondary) in over 16s (NG193), 2021.