when I was 13 I fell while I was skiing and I tore ligaments in my knee I remember it hurt it hurt a lot it hurt when I fell it hurt when the ski patrols were taking me down in the toboggan it hurt while my parents drove me along the bumpy road from the ski hill to the hospital it hurt right up until they gave me an injection of opioid at the hospital and then I remember the intense feeling of relief and when I think back to that episode I remember that one of the most important things that a physician will ever get to do is to relieve painful suffering it's interesting to note that we really only have about four categories of medications to treat pain the first category is opioids now opioids act at the central nervous system when they bind to opioid receptors the fact that they're in the central nervous system and the fact that the central nervous system is usually the final common pathway for the receptors involved in pain is what makes opioids useful across a range of different pains so when it comes to moderate or severe levels of pain in the categories of nociceptive pain or inflammatory pain or sometimes even neuropathic pain opioids can play a role the second category of pain medication is nonsteroidal anti-inflammatory drugs or NSAIDs in this category you'll find lots of familiar names like aspirin and ibuprofen and naproxen they'll have one thing in common they block cyclooxygenase which is an enzyme that produces prostaglandins and prostaglandins are involved in the production of pain and inflammation so you can see how NSAIDs would be useful in the relief of pain that's nociceptive or inflammatory and you can also see how NSAIDs would be a lot less useful in neuropathic or dysfunctional pain the third category of pain medication is acetaminophen it's off on a category by itself for a couple of reasons one we don't really know exactly how it works and two because it doesn't have any anti-inflammatory effect so you can imagine how it's useful mostly for nociceptive pain the fourth and final category of pain medication are adjuvant in this category you'll find and de seizure medications and antidepressants these medications act mostly essentially by blocking neural transmission you can see why they'd be most useful in neuropathic pain now you may have noticed that none of the for pain medication categories that we just talked about related directly to dysfunctional pathological pain well there's the rub in fact with these pathological dysfunctional pain syndromes there is in fact not a lot of medication that will make any difference what will make a difference not only for a dysfunctional pathological pain but all the other categories of pain as well is to remember Woodruff's model of total suffering so if you can have an impact on someone's physical symptoms that are associated with the pain or on their hidden suffering associated with cultural or spiritual or social or psychological issues then you in fact can have an impact on their total experience of pain and their total suffering