Pain management doctors prescribe medications across several distinct categories, tailored to the type and severity of pain you’re experiencing. These range from over-the-counter anti-inflammatory drugs all the way to opioids, with a large middle ground of nerve-targeted medications, muscle relaxants, topical treatments, and injectable steroids that many patients don’t initially expect.
Over-the-Counter and Prescription Anti-Inflammatories
NSAIDs (nonsteroidal anti-inflammatory drugs) are often the starting point, even in a specialist’s office. Ibuprofen and naproxen are the most commonly recommended for general pain because they’re short-to-moderate acting and well studied. For patients who need something stronger or more targeted, prescription-strength options include diclofenac (up to 150 mg per day), meloxicam, and indomethacin. Celecoxib is a selective version that’s easier on the stomach lining, which matters for people who need to take an anti-inflammatory regularly.
Acetaminophen plays a different role. It reduces pain and fever but doesn’t address inflammation, so pain management doctors often use it as an add-on rather than a standalone treatment. For moderate to severe pain, it’s sometimes combined with other medications to reduce the total dose of stronger drugs needed. The general principle with all anti-inflammatories is to use the lowest effective dose for the shortest time. For chronic inflammatory conditions like arthritis, a trial of at least two weeks is typical before deciding whether the medication is working.
Nerve Pain Medications
If your pain involves damaged or misfiring nerves, such as diabetic neuropathy, pain after shingles, or a spinal cord injury, your doctor will likely prescribe from two main drug classes: anticonvulsants and certain antidepressants. These weren’t originally designed for pain, but they work by calming overactive nerve signals.
Gabapentin is typically the first choice. If it doesn’t provide enough relief, pregabalin is the usual next step. Pregabalin also has a specific role in treating fibromyalgia. Both can cause drowsiness and dizziness, so doctors start at a low dose and increase gradually. For a condition called trigeminal neuralgia, which causes intense facial pain, carbamazepine or oxcarbazepine are the go-to options instead.
On the antidepressant side, duloxetine (an SNRI) and amitriptyline (a tricyclic antidepressant) have solid evidence for relieving neuropathic pain. These medications boost certain chemical messengers in the brain and spinal cord that help dampen pain signals. They’re not prescribed because the doctor thinks your pain is “in your head.” They work on the same pathways that process physical pain. When anticonvulsants alone aren’t enough, combining them with one of these antidepressants is a common strategy.
Topical Treatments
Topical medications are applied directly to the skin over the painful area, which limits side effects compared to pills. The strongest evidence supports topical diclofenac gel and ketoprofen gel for acute strains and sprains. In studies, about 78% of people using diclofenac gel for sprains got meaningful pain relief at seven days, compared to 20% with a placebo.
For chronic joint pain, particularly osteoarthritis of the hands or knees, topical diclofenac and ketoprofen remain the best-supported choices, though the benefit is more modest over longer periods of 6 to 12 weeks. High-concentration capsaicin patches have limited evidence for postherpetic neuralgia (nerve pain after shingles), helping roughly one in eleven people who try them. Topical lidocaine patches are widely prescribed for localized pain, though the supporting evidence is less robust than many patients assume.
Corticosteroid Injections and Oral Steroids
Pain management doctors frequently use corticosteroid injections to deliver powerful anti-inflammatory medication directly to the source of pain. These include epidural injections for spinal pain, joint injections for arthritis, and trigger point injections for muscle knots. Dexamethasone is the most commonly used steroid for these procedures because it’s potent, long-lasting, and doesn’t cause the fluid retention some other steroids do.
For short-term oral use, prednisone or prednisolone may be prescribed during pain flares. These aren’t intended for long-term use due to side effects like bone thinning and blood sugar changes, but a brief course can break a cycle of severe inflammation.
Opioid Medications
Opioids remain the most effective class of medication for severe pain, but they come with significant risks, and pain management doctors prescribe them with far more structure and monitoring than in years past.
Short-acting opioids include immediate-release forms of oxycodone, hydrocodone, morphine, hydromorphone, and codeine. These kick in quickly and wear off within a few hours, making them appropriate for acute pain, breakthrough pain episodes, or the early stages of treatment when the doctor is figuring out the right dose. For acute pain, an initial prescription of 4 to 7 days is typical, and often a few days is sufficient.
Long-acting opioids provide steady relief over 8 to 72 hours depending on the formulation. These include extended-release versions of morphine, oxycodone, oxymorphone, and fentanyl (usually as a skin patch), as well as methadone, which is naturally long-acting. Patients with constant, persistent pain are sometimes started on a short-acting opioid first, then transitioned to a long-acting version once the effective dose is established. The long-acting versions require less frequent dosing, which can simplify daily life and improve consistency.
Some patients do better staying on short-acting opioids even for chronic pain. They may experience fewer side effects or prefer the flexibility of dosing only when pain flares. The choice between short-acting and long-acting is individualized, not one-size-fits-all.
How Opioid Dosing Is Managed
Current CDC guidelines shape how pain management doctors approach opioid prescribing. For patients new to opioids, the typical starting dose is around 20 to 30 morphine milligram equivalents (MME) per day. This is a standardized unit that lets doctors compare the strength of different opioids on a common scale.
Before increasing a patient’s total daily dose to 50 MME or above, doctors are expected to carefully weigh whether the added benefit justifies the added risk. At 50 to 100 MME per day, the risk of overdose is roughly 2 to 5 times higher than at low doses. At 100 MME or above, the risk jumps to 2 to 9 times higher. When doses reach 50 MME, doctors typically offer a prescription for naloxone (an overdose-reversal medication) and increase the frequency of follow-up visits.
Before prescribing opioids at all, many pain management doctors use a screening tool called the Opioid Risk Tool. It assigns points based on factors like family history of substance abuse, personal history with alcohol or drugs, age (16 to 45 carries higher risk), and certain psychological conditions. A score of 3 or below signals low risk, 4 to 7 is moderate, and 8 or higher is high risk. This doesn’t necessarily disqualify someone from receiving opioids, but it guides how closely the doctor monitors the prescription.
Ongoing Monitoring Requirements
If you’re prescribed opioids or other controlled substances through a pain management practice, expect regular monitoring. Urine drug testing is standard. These tests check that you’re actually taking the prescribed medication (not diverting it) and that you’re not using other substances that could interact dangerously. The required frequency varies by state. Some states mandate testing at the start of treatment and at least annually, while others require it more often, particularly for higher doses or patients with a history of substance use.
Results are documented in your medical record, and many practices require you to sign a treatment agreement outlining expectations for refills, drug testing, and communication. This level of structure can feel intrusive, but it’s designed to keep long-term opioid therapy as safe as possible while allowing people who genuinely need these medications to access them.
Local Anesthetics
Lidocaine is the most widely used local anesthetic in pain management. Beyond topical patches, it’s injected during nerve blocks, trigger point injections, and other interventional procedures to numb specific areas. Some pain clinics also use lidocaine infusions, where the medication is delivered intravenously over a set period to calm widespread nerve pain, though this is more specialized and typically reserved for patients who haven’t responded to standard oral medications.