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Chronic Pain - Medications

Sunday, February 8th, 2009

Medications

Medicines can often help control chronic pain. Many different drugs, both prescription and nonprescription, are used to treat chronic pain. All these medicines can cause side effects and should be taken exactly as they are prescribed. In some cases, it may take several weeks before medicines work to reduce pain. It is important to let your health professional know all medicines you are taking (including herbal and other complementary medicines) to avoid dangerous drug interactions.

Medication Choices

You will likely be given medicines that cause the least significant side effects first (such as acetaminophen) to treat chronic pain. The dose will be increased or the medicines will be changed as needed. Older adults are more likely to experience adverse side effects, so medicines may be started at even lower doses and increased more slowly. Medicines used to treat chronic pain include the following:

  • Pain relievers (analgesics)—such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (for example, Motrin)—which may be prescribed for mild to moderate pain and to reduce inflammation. Always take these medicines exactly as prescribed or according to the label. Do not take a nonprescription NSAID for longer than 10 days without talking to your doctor.
  • Antidepressants, such as tricyclic antidepressants (for example amitriptyline), which may be used to treat chronic pain, although not all antidepressants are effective at reducing pain. Duloxetine (Cymbalta) is another type of antidepressant that is approved by the U.S. Food and Drug Administration to treat pain from peripheral neuropathy.
  • Corticosteroids, such as prednisone, which are used to reduce inflammation and pain.
  • Oral medicines, such as mexiletine (Mexitil), that act like a local anesthetic to dull pain.
  • Anticonvulsants, which may ease pain that starts in the nerves (neuropathic pain). Examples are:
    • Gabapentin (Neurontin) for postherpetic neuralgia (nerve pain from shingles).
    • Pregabalin (Lyrica) for postherpetic neuralgia and diabetic neuropathy (nerve pain from diabetes).
    • Carbamazepine (Tegretol) to help control the episodes of facial pain in trigeminal neuralgia. If you take carbamazepine daily, you should be checked periodically to be sure you don’t develop serious side effects (such as an allergic reaction or liver problems).
  • Pain relievers that are applied directly to the skin (topical analgesics), such as EMLA cream or a lidocaine patch (Lidoderm), which can numb the skin and decrease pain.
  • Capsaicin, a naturally occurring substance that is found in chili peppers and is used to make certain topical analgesic creams. Capsaicin changes the pain signals in the skin, blocking pain without blocking other sensations. Capsaicin may cause a burning sensation when it is first applied. Always wear gloves when applying capsaicin and do not touch or rub your eyes until you have washed your hands.
  • Opioid analgesics, which may relieve moderate to severe pain. Examples of opioids include morphine, oxycodone (such as OxyContin), hydrocodone with acetaminophen (such as Vicodin, Lortab, or Norco), or acetaminophen with codeine (such as Tylenol with codeine). Opioids are sometimes combined with other medicine, such as gabapentin, for nerve pain.

Other therapies that may be used to treat chronic pain include:

  • Nerve block injections. An anesthetic is injected into the affected nerve to relieve pain. The anesthetic may relieve pain for several days, but the pain often returns. Although nerve blocks do not normally cure chronic pain, they may allow you to begin physical therapy and improve your range of motion.
  • Epidural steroid injections (injecting steroids around the spine). Although these injections have been used for many years and may provide relief for low back or neck pain caused by disc disease or pinched nerves, they may not be effective for everyone.
  • Trigger point injections. These may relieve pain by injecting a local anesthetic into trigger points (or specific tender areas) associated with chronic facial pain or fibromyalgia. For many people, nerve blocks or other injections can relieve chronic pain for good. However, it is not completely clear how this type of treatment works. These injections do not relieve chronic pain in everyone.

What To Think About

Medicine may work best when it is used in combination with other types of treatment, such as physical therapy and counseling, to address the different causes of chronic pain. Each person tolerates and responds to medicines differently.

Medicines can reduce or provide temporary relief of chronic pain. At first, you may be given medicines that cause the fewest side effects. Then, if needed, the dose will slowly be increased or you will be switched to a different medicine.

In general, avoid drinking alcohol while taking pain medicines, and do not take higher doses of any medicine than your doctor prescribed.

Daily medicines can be an effective part of long-term treatment for chronic pain. However, sometimes a medicine loses some or all of its effectiveness when it is used daily over a long period of time, because your body develops a tolerance to it.

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Arthritis pain: Do’s and don’ts

Sunday, December 28th, 2008

Arthritis pain can be frustrating. And so is sorting through your pain relief options. To help you figure out the best means of relieving your arthritis pain, Gene Hunder, M.D., an emeritus rheumatology specialist at Mayo Clinic, Rochester, Minn., and a professor of medicine at Mayo Clinic College of Medicine, answers some commonly asked questions about arthritis pain. Dr. Hunder is an authority on rheumatology and is editor-in-chief of the book “Mayo Clinic Straight Talk On Arthritis.”

Will physical activity make your arthritis pain worse?

If you already have joint damage, you can make your arthritis pain worse with activities that are stressful to your joints or that require repetitive motion.

However, if you have only minimal joint damage and most of your symptoms are related to the ligaments, tendons and muscles surrounding your joints — not the joints themselves — a gentle exercise program could improve your arthritis pain. Be sure to include stretching and muscle strengthening in your exercise program.

Work with your doctor to determine the right solution and exercise program for your specific situation. Arthritis varies a great deal from one person to another. Ask your doctor to carefully define the type and extent of your arthritis. Use that information to decide the best approach to your hobbies and activities.

What sorts of activities should generally be avoided, and what types of activities are good for most people with arthritis pain?

Activities that put sudden pressure or stress on involved joints — such as running and playing tennis — are likely to make the symptoms of arthritis in the lower extremities worse and may cause increased swelling and inflammation. Activities that are likely to help include exercises that strengthen your muscles, protect your joints, and reduce stress and joint damage. For example, strengthening the muscles on the front and back of your thigh (quadriceps and hamstrings) helps protect your knee and hip joints. Your doctor might be able to teach you some exercises to increase your muscle strength without abusing your joints.

Do what you can to stay physically active while taking into consideration the condition of your joints. For example, you may be able to walk a mile or more at a comfortable pace with well-fitting, cushioned shoes. But you probably have to give up on high-impact activities — for instance sports such as soccer that involve running — which put a lot of stress on many different joints. If your joints are too painful or damaged to allow an activity such as walking, then swimming or other water exercise may be a better choice for keeping you active and getting toned.

How can you reduce the stiffness and pain that come from sitting for a long time?

Many people with arthritis experience stiffness after sitting or resting, especially if they’ve used their joints actively before periods of inactivity. Most people with rheumatoid arthritis have stiffness after rest, such as in the morning. These are common symptoms of arthritis. Movement will tend to diminish some of the symptoms.

If you must sit for a long time, adjust your position often to prevent or lessen stiffness. For example, turn your head at different angles, shift the position of your arms, and bend and stretch out your legs. Such slight movements may help prevent excessive stiffness. Many times the stiffness may be worse for a few days after you’ve used your joint strenuously.

When does arthritis pain indicate you should call your doctor?

If new pain develops or you have persistent symptoms — lasting more than several days — call your doctor. Treatment is often more effective when arthritis symptoms are caught early. If you have symptoms that you know are from overdoing it and they disappear in a few days, you probably don’t need to call your doctor.

What medications are best for arthritis pain relief?

The good news is that there are now many medications available for arthritis. Most are relatively safe and well tolerated, but no medication is completely free of possible side effects. If your symptoms are a regular problem, you need professional advice from your doctor about what medications to take and how much.

If your pain is present only occasionally and follows some unusual activity, you could try one or two acetaminophen tablets (Tylenol, others), which are sold over-the-counter. Many such preparations are available. Ordinarily, all work equally well. Some people prefer aspirin instead. If you have a history of peptic ulcer disease, bleeding, asthma or allergies, talk to your doctor before taking aspirin or a drug such as ibuprofen.

If your symptoms are prolonged and are related to activities that you don’t participate in all of the time, nonsteroidal anti-inflammatory drugs (NSAIDs) — such as ibuprofen (Advil, Motrin, others) and naproxen (Aleve, others) — may bring relief. These drugs can be purchased without a prescription. Weekend tennis players, gardeners and others with mild osteoarthritis can overcome some of the disagreeable stiffness by taking only one or two over-the-counter NSAID tablets for one or two days after the activity, or even before the activity.

If your symptoms are more prolonged and severe, it may mean that the joint involvement is more advanced, and you may need larger doses of drugs on a regular basis. Until recently we prescribed COX-2 inhibitors for people who had stomach pain or other side effects from other NSAIDs. However, recent data suggest that COX-2 drugs may cause heart problems in some people. Consult your doctor if you aren’t getting sufficient pain relief from your medications.

Are alternative treatments helpful for arthritis pain?

This question raises complex issues, and there’s no short and easy answer that applies to all alternative arthritis treatments. Even the definition of alternative treatments varies from one source to another. For example, heat, massage and stretching — which help relieve arthritis symptoms for many people — have been listed as alternative treatment by some, but in reality these have been standard practice for many years.

The best treatments of this type are straightforward and have your doctor’s or physical therapist’s stamp of approval. Some activities may be more interesting and fun to do, such as tai chi. A good rule of thumb: If it keeps you active, then it’s helpful.

The problem with many alternative preparations is that they haven’t been adequately studied. In most people, arthritis symptoms vary from day to day. So if you take an herbal preparation, for example, on a day that you might have felt better anyway, you may become convinced that the herb made you better. In arthritis treatment studies, as many as 30 percent of people taking an inactive substance (placebo) improve, at least temporarily.

Finally, quality standards for over-the-counter alternative drugs don’t exist. Research shows that there’s a great variation in the amount of active substance in different brands and even different lots of the same brand. This alone may be reason to avoid them.

Finding an effective and safe medication for arthritis pain is a complex task that may take years. Trying to shortcut standard practices may lead to harmful effects and wasted money, time and effort.

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Epidural steroid injections for lumbar spinal stenosis

Thursday, December 18th, 2008

How It Works

An epidural steroid injection (ESI) is a combination of a corticosteroid with a local anesthetic pain relief medicine. Corticosteroids are strong anti-inflammatory medications used to relieve pain. The local anesthetic medicine helps give you immediate pain relief. Corticosteroid medicines take longer to have an effect.

Within the spinal canal, an ESI is injected into the epidural space. The injection does not go into the membrane (thecal sac) that contains the spinal cord and nerve roots.

ESIs sometimes are used to treat pain and inflammation that result from pressure on the spinal cord caused by lumbar spinal stenosis and that have not responded to other nonsurgical treatment.

Imaging tests, such as magnetic resonance imaging (MRI), computed tomography (CT) scan, or X-rays, may be done before or while you are being given the injection. These tests are used to identify the exact location where nerve roots are being squeezed.

Why It Is Used

An epidural steroid injection (ESI) may be tried when other nonsurgical treatments have failed to relieve severe leg pain from lumbar spinal stenosis.

The corticosteroids in an ESI can help provide relief from leg pain by reducing swelling and inflammation. Local anesthetics help relieve pain but do not reduce inflammation. Lidocaine can also help relieve pain quickly, before the corticosteroid has taken effect.

How Well It Works

Lumbar spinal stenosis may cause pain that radiates from the lower spine to the hips or down a leg. ESIs are used for leg pain rather than back pain from lumbar spinal stenosis.

Severe pain that has started recently is sometimes called “acute pain.” About 50% of people receiving corticosteroid injections for acute pain get relief that lasts from a few weeks to a few months. Some people get enough pain relief that they can delay or no longer need surgery.

These injections may relieve symptoms and reduce inflammation but do not cure spinal stenosis.

Side Effects

ESIs should be used with caution. This treatment only relieves symptoms for a short time, and the long-term effects are not well studied.

If side effects occur, they are usually minor and may include:

  • Back pain and tenderness where the injection was given for about 2 to 4 days.
  • Feeling sick to your stomach and sometimes vomiting.
  • Dizziness.
  • Headache.

More serious side effects are very rare, but can include bleeding, infection, nerve root injury, and meningitis.

People who have an increased risk for infections, such as those with diabetes or those with immune system problems, may be at a higher risk for problems from ESIs. People with mental health disorders may also have a higher risk for problems from this treatment.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About

Epidural steroid injections should not be given if there is any sign of infection.

Epidural steroid injections only relieve symptoms for a short time, and the long-term effects are not well studied. Talk with your doctor about the risks related to the number of ESIs you expect to get.

If lumbar spinal stenosis is caused by a congenitally (from birth) small spinal column, rather than by osteoarthritis or another degenerative bone or joint condition, corticosteroid injections may increase symptoms, such as pain and numbness.

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What Safe Pain Relief Options Are Left?

Monday, October 20th, 2008

It seems that every time we open a newspaper, we read about yet another danger from a popular pain reliever. Are there any safe options left to relieve our aches and pains?

The most widely used pain and anti-inflammatory medications are nonsteroidal anti-inflammatory drugs (NSAIDs), which include popular brands like Motrin and Aleve and the various brands of aspirin. There was much excitement when COX-2-selective NSAIDs were introduced about 7 years ago, because they were associated with less gastrointestinal bleeding, the most dangerous side effect of aspirin and some of the other NSAIDs.

By 2005, however, two of the most popular COX-2 drugs, Vioxx (rofecoxib) and Bextra (valdecoxib), were removed from the market because they significantly increased the risk of cardiovascular events.

A recent study has suggested that the cardiovascular risk of Vioxx may continue for at least a year after the drug has been discontinued, a finding that’s led some heart experts to recommend “vigilant follow-up” for people who previously took this drug.

The remaining available COX-2 drug, Celebrex (celecoxib), carries a warning from the Food and Drug Administration (FDA) that it may raise the risk of cardiovascular events. The FDA has required that all other NSAIDs, including over-the-counter and prescription drugs, carry a warning of their potential for increasing the risk for cardiovascular events, as well as life-threatening gastrointestinal bleeding.

Aspirin, the one NSAID that protects against cardiovascular disease, carries the risk of intestinal bleeding.

All of these problems with NSAIDs have led many doctors to prescribe acetaminophen (Tylenol) as the drug of choice for pain. However, acetaminophen does not counter the inflammation of joint pain caused by disorders like rheumatoid arthritis.

Recently, a headline in Baltimore’s Sun newspaper blared: “Tylenol linked to liver damage.” Tylenol is one of the trade names for acetaminophen, which is also a component of a number of over-the-counter drugs for pain relief.

The headline is based on a study of healthy young subjects who took the maximum dose of acetaminophen (4 grams a day) for two weeks. More than one-third of them developed significant, but temporary, elevations in blood levels of a liver enzyme indicating liver damage.

Does this finding mean we should also be wary of taking acetaminophen? I think not. “Acetaminophen clearly has a remarkable safety record when taken as directed,” say the authors of the study linking liver damage and high daily doses of the drug, “and chronic treatment with 4 g daily has been confirmed to be safe.”

Despite the results of this study and the accompanying frightening news stories, acetaminophen remains the safest, albeit least potent, drug for the treatment of pain.

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Questions About Natural Joint Pain Relief

Wednesday, October 8th, 2008

Earlier this year, doubts were raised about glucosamine and chondroitin, supplements that many people now take for joint pain. But news reports did not tell the whole story.

A study published in the February 23, 2006, issue of the New England Journal of Medicine concluded that, overall, glucosamine and chondroitin didn’t relieve knee pain among the osteoarthritis patients participating. However, the study also showed that the supplements did help patients with moderate to severe knee pain, and there were other positive findings. I’m afraid that news coverage of the study results failed to explain the results adequately.

A total of 1,583 participants were enrolled in the 24-week study, sponsored by the National Center for Complementary and Alternative Medicine and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. The patients were divided into five groups. One group got 1,500 mg of glucosamine, the second received 1,200 mg of chondroitin, a third got the combination of glucosamine and chondroitin, a fourth group took 200 mg of the drug Celebrex and the fifth group got a placebo.

Results showed that Celebrex helped but that glucosamine alone, chondroitin alone and the combination of the two supplements did not. However, patients with moderate to severe knee pain had more relief from the supplement combination than did comparable patients who took the placebo. The study showed that among these patients, 79 percent of those who took both supplements reported relief compared to 54 percent of comparable patients in the placebo group.

The combination of glucosamine and chondroitin for arthritis treatment was popularized by Jason Theodosakis, M.D., in his book “The Arthritis Cure,” first published in 1997 and revised in 2004. On his Web site, http://www.drtheo.com/, Dr. Theodosakis has expressed disappointment with news reporting on findings from the just-published study. For example, looking at subjects with moderate to severe pain, the results showed that glucosamine and chondroitin provided more relief than Celebrex in 12 out of 14 outcome measures (effects on pain, swelling and other arthritis symptoms). Overall, the glucosamine-chondroitin combination was 50 percent better compared to placebo than was Celebrex.

Over the years, glucosamine and chondroitin have helped millions of arthritis patients. Despite the inappropriate negative headlines this study’s findings received, I would recommend trying the supplement combination for joint pain. Chances are, you’ll find it helps.

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