Medications for pain have come under much scrutiny in the past several years. Nevertheless, they can be helpful and safe when used in combination with safe prescribing and monitoring practices. At ASAP, a comprehensive interventional treatment program that uses physical therapy and procedural care is always combined with medication management, since this increases the likelihood our patients will improve. Our practice uses risk stratification protocols, urinalysis, and the best evidence for specific medications to prescribe medications for you only when appropriate and to maximize your relief.
Tylenol is the first drug of choice for mild to moderate pain. Tylenol is primarily used for arthritis, headaches, and musculoskeletal pain. In addition to its analgesic properties, it is also used to lower fevers. It does not have any blood-thinning or anti-inflammatory effects. A maximum of 2,500-3,000 mg total daily dose is now recommended to avoid adverse effects to the liver, kidneys, and gastrointestinal system.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are second-line medications for mild to moderate pain. Common conditions treated with NSAIDs are arthritis, headaches, and musculoskeletal pain. They have analgesic, anti-inflammatory, and fever lowering effects. Greater than 1600 mg/day of ibuprofen is needed for the medication to have an anti-inflammatory effect. Despite their general acceptance and abundance in the community, there are serious potential adverse effects including heart attacks, strokes, and impaired production of new blood cells. Examples include ibuprofen, naproxen, celecoxib, and meloxicam.
Aspirin is a blood-thinning medication with additional analgesic, anti-inflammatory, and fever lowering effects. The effects are dose dependent, as low doses are blood thinning, intermediate doses treat fever and mild to moderate pain, and high doses treat inflammation. Like NSAIDs, despite Aspirin’s general acceptance and abundance in the community, there are serious potential adverse effects such as gastric ulcers, gastric/colonic perforations, and kidney damage.
Corticosteroids have potent anti-inflammatory and analgesic effects. Orally and topically, they are used to control inflammatory processes not just limited to the musculoskeletal and nervous systems. These medications are catabolic steroids and, unlike anabolic steroids, are not responsible for raising testosterone and building up excessive muscle and aggression in weightlifters. Excessive corticosteroid consumption may be associated with the development of osteoporosis, a weakened immune system, weight gain, high blood pressure, high blood sugar, and difficulty sleeping among other adverse effects. Examples include methylprednisolone, prednisone, and triamcinolone.
Muscle relaxants decrease muscle spasms and secondarily reduce pain and discomfort. Most muscle relaxants act to produce their effects in the central nervous system (i.e. brain and spinal cord). Potential side effects most commonly include drowsiness, fatigue, dizziness, headache, nausea, and dry mouth. Patients with seizures should refrain from taking certain muscle relaxants. A number of muscle relaxants may have the potential to be abused. Examples of muscle relaxants include cyclobenzaprine, methocarbamol, orphenadrine, metaxalone, baclofen, tizanidine, diazepam, and dantrolene.
Tricyclic Antidepressants and Serotonin-Norepinephrine Reuptake Inhibitors
Tricyclic Antidepressants and Serotonin-NoreTricyclic Antidepressants and Serotonin-Norepinephrine Reuptake Inhibitors are medications do not solely function to help those patients suffering from depression. They may be used as first-line agents in neuropathic pain, which is pain that is described as “electrical”, “shooting”, “stabbing”, “dull”, “cramping”, “tingling” or “burning”. These medications work by increasing the availability of certain neurotransmitters like serotonin and norepinephrine. Potential adverse effects most commonly include dizziness, blurred vision, palpitations, increased heart rate, nausea, weight changes, dry mouth, sexual dysfunction, and constipation. Very serious potential reactions include heart attacks, arrhythmias, strokes, and seizures. These medications should not typically be used in patients with these serious conditions. If the medication is abruptly discontinued, withdrawal symptoms may occur. Examples of these medications include amitriptyline, desipramine, nortriptyline, doxepin, duloxetine, and venlafaxine.
Anticonvulsant medications do not solely function to help those patients suffering from seizures. They may be used as first-line agents in neuropathic pain, which is pain that is described as “electrical”, “shooting”, “stabbing”, “dull”, “cramping”, “tingling” or “burning”. Potential adverse effects most commonly include dizziness, fatigue, sleepiness, headaches, blurry vision, weight changes, fluid accumulation, and balance issues. If the medication is abruptly discontinued, withdrawal symptoms may occur, including seizures. Examples include gabapentin, pregabalin, topiramate, carbamazepine, and phenytoin.
Opioids are commonly used to treat pain and though they are often associated with “pain clinics”, they are only one type of treatment used in a comprehensive pain management practice. Naturally occurring opioid receptors are located mainly in the brain and spinal cord. They are able to modulate the pain response and are administered through various routes, including oral, IV, and transdermal. Although in some patients these medications are positively life-changing, they have a laundry list of potential drawbacks. Patients may experience tolerance to the dose of medication, thereby requiring a higher dose for the same pain relief effect. These medications are not suggested in pregnancy, as the fetus develops physical dependence. Physical dependence may develop if patients miss doses of the medication and experience unpleasant withdrawal symptoms. Additionally, pain may actually increase in a phenomenon known as “opioid-induced hyperalgesia,” as the number of opioid receptors decreases in response to higher than normal opioid levels in the body.
Addiction is the most dreaded complication, manifesting in physiological, behavioral, and cognitive effects. Patients who are addicted to these medications compulsively use and crave them, continue to use them despite harmful consequences and lose control over their use. Unsurprisingly, addiction may take over all aspects of patients’ lives and could even lead to overdose and death.
Common side effects are respiratory depression, constipation, nausea, vomiting, itching, hormonal imbalance, lowered immune system, muscle twitching, cardiac effects, urinary retention, dry mouth, fluid accumulation in the legs, excessive sweating, sedation, and cognitive dysfunction. Most of these side effects tend to decrease over time or could be treated with supportive medications; however, tolerance does not develop to constipation or respiratory depression. This could be life-threatening.
Lidocaine is a local anesthetic that is used primarily in a patch form. It is approved for use in post-herpetic neuralgia. A common off-label use is for arthritis. Common adverse reactions include local redness, swelling, itching, blistering, and discomfort, as well as lightheadedness and anxiety. Rarely arrhythmias, seizures, or cardiac arrest could occur. A lidocaine ointment is available as well for skin pain due to multiple causes.
Pain creams are commonly used and come either as a single medication or a mixture, usually a “compound”. Single product gels, creams, or ointments are available for commercial use, including capsaicin, lidocaine, DMSO, and diclofenac for musculoskeletal and/or neuropathic pain. Compounded creams are also a popular option to control pain. Multiple agents counteract pain with a variety of mechanisms. There are numerous available combinations and the physician has the ability to custom order them for patients. Skin site reactions are most common and other adverse effects depend on the individual products contained within the compound.