or exercise) and nonopioid medications (e.g., nonsteroidal inflammatorymedications) should always be used first. • Whenopioidmedicationsareused,thelowest effective dose forthe shortest duration of time should be prescribed. In these circumstances, immediate-release opioids are preferred to controlled-release products. • Patients should understand the risks and benefitsofopioidmedications.Whentherisks of opioids outweigh benefits, patients should be tapered off the opioid medication. Open Dialogue Between Patients and Physicians is Needed In order to solve the issues of chronic pain, there must be an open dialogue between physiciansandpatients.Datasuggestthatmany patients with chronic pain have unrealistic expectations that medications alonewill relieve all of their pain. Thrower noted that opioid products may not always be the answer to all pain issues. Otherpsychoactivemedications(specifically benzodiazepines such as Valium, Xanax, and Ativan) commonly prescribed for patients with MS can interact with opioid products. While not yet a public health emergency, fatal overdoses of benzodiazepine products are also on the rise. When benzodiazepines and opioids are combined, patients are at increased risk of experiencing respiratory depression. When seeing multiple providers, patients need to be honest about what other medications have been prescribed to them. 60 msfocusmagazine.org Medicine & Research MS Pain Syndromes Pain syndromes are common in patients with multiple sclerosis. Data suggest that approximately one-half of patients with multiple sclerosis experience chronic pain. It is important to understand that not all pain caused from multiple sclerosis can be treated with opioid medications. • The most commonly reported type of pain experienced by patients having multiple sclerosis is neuropathic pain. It is caused from the demyelination of nerves that is the hallmark of multiple sclerosis. Patients describe neuropathic pain as burning, aching, or electric pain. Neuropathic pain primarily affects the legs and feet, but can also affect the trunk and arms. Data suggest that anticonvulsant medications and antidepressant medications are the best treatment for neuropathic pain. Opioid medications are generally not recommended to treat neuropathic pain. • Spasticity, which is also common in patients with multiple sclerosis, results from muscle cramps and muscle spasms. Antispasticity medications and stretching exercises are the treatments of choice for pain secondary to spasticity. Opioid medications are generally not recommended to treat pain secondary to spasticity. • Musculoskeletal pain (or non-neuropathic pain) can occur in patients with or without multiple sclerosis. It is most often caused byan injuryto the bones, joints, muscles, tendons, or ligaments. Events such as jerking movements, car accidents, falls, fractures, sprains, and/or dislocations. Opioid medications are sometimes used to treat musculoskeletal pain.