Treating Pain

Unrelieved pain can cause depression, which can result in:

• loss of appetite and sleep

• withdrawal from your usual enjoyable and productive activities

• feelings of hopelessness and

• in the extreme, thoughts of suicide.

Pain can be treated, often quite quickly, with a number of different approaches. The first step is finding a doctor with whom you can work to manage your pain. Because each person is unique, you will need an individualized pain program. Your pain doctor will explain treatment options to you:

• Medications such as over the counter remedies, NSAIDs, opioids, anti-depressants, anti-convulsants, steroids, local anesthetics, topical agents and many others.

• Mind-Body approaches which include guided imagery, relaxation exercises, biofeedback, learned optimism.

• Physical rehabilitation such as occupational therapy, physical therapy, ultrasound, electrical stimulation and other maneuvers.

• Interventional Pain management techniques which include various injections like nerve blocks and epidural steroid injections; spinal cord stimulation; and drug infusions.

• Behavioral therapies to help you take the emphasis off your pain and on to the positive aspects of your life.

Medications

Acetaminophen: A medication commonly used to relieve pain; acetaminophen is available without a prescription. It is often the first medication doctors recommend for osteoarthritis patients because of its safety relative to some other drugs and its effectiveness against pain. Ask your doctor if acetaminophen is a safe and effective choice for you.

NSAIDs (non-steroidal anti-inflammatory drugs): A large class of medications useful against both pain and inflammation, (NSAIDs). Aspirin is an example of an NSAID. They are often the first type of medication prescribed. All NSAIDs work similarly: by blocking substances called prostaglandins that contribute to inflammation and pain. However, each NSAID is a different chemical, and each has a slightly different effect on the body. Furthermore, each person responds to each medication differently; what works for one patient might not work for another.

Some NSAIDS are available over the counter, while more than a dozen others, including a subclass called COX-2 inhibitors, are available only with a prescription.

All NSAIDS can have significant side effects, and for unknown reasons, some people seem to have fewer side effects with one NSAID than another. Any person taking NSAIDS regularly should be monitored by a doctor.

NSAIDs can cause stomach irritation or, they can affect kidney function. The longer a person uses NSAIDs, the more likely he or she is to have side effects, ranging from mild to serious. Many other drugs cannot be taken when a patient is being treated with NSAIDs because NSAIDs alter the way the body uses or eliminates these other drugs. Check with your doctor before you take NSAIDs.

NSAIDs sometimes are associated with serious gastrointestinal problems, including ulcers, bleeding, and perforation of the stomach or intestine. People over age 65 and those with any history of ulcers or gastrointestinal bleeding are more susceptible.

There are measures you can take to help reduce the risk of side effects associated with NSAIDs. These include taking medications with food and avoiding stomach irritants such as alcohol, tobacco, and caffeine. In some cases, it may help to take another medication along with an NSAID to coat the stomach or block stomach acids. While these measures may help, they are not always effective. Consult with your doctor about how to take NSAIDs safely.

Topical pain-relieving creams, rubs, and sprays: These products, which are applied directly to the skin over painful areas, contain ingredients that work in different ways.

Two are on the market as prescription medications . A patch impregnated with lidocaine (Lidoderm) is approved for post-herpetic neuralgia and useful for various neuropathic pain syndromes. The second is a diclofenac patch (Flector). Diclofenac is a non-steroidal anti-inflammatory drug approved by the FDA for acute pain due to minor strains, sprains and contusions.

Capsaicin is an over-the-counter cream the works by depleting a substance responsible for pain signals. It has been studied with mixed results; some research shows it is effective for pain and other research does not. This medication is used to treat minor aches and pains of muscles and joints (arthritis, backache, sprains). It may also be used to treat nerve pain.

Tramadol: A prescription pain reliever that is sometimes prescribed when over-the-counter medications don't provide sufficient relief. It carries risks that don't exist with acetaminophen and NSAIDs, including the potential for addiction.

Mild narcotic painkillers: Medications containing narcotic analgesics can be effective against pain. But because of concerns about the potential for physical and psychological dependence on these drugs, doctors often reserve them for short-term use except in special cases. There are cases in which opioids are used on a chronic basis for patients with unremitting pain.

Adjuvant Analgesics: these medications are not primarily for treating pain, but can be useful in certain painful conditions:

Corticosteroids: Corticosteroids are powerful anti-inflammatory hormones made naturally in the body or man-made for use as medicine. Oral corticosteroids are not routinely used to treat pain although they are sometimes used to treat painful inflammatory conditions, some cancer pain syndromes, migraine headache and complex regional pain syndrome (reflex sympathetic dystrophy), low back pain sciatica and occasionally flare-ups from osteoarthritis. Steroids may also be injected into affected joints to temporarily relieve pain. They are occasionally used for inflammatory flare-ups in osteoarthritis. They have significant side-effects and are only used in the short term

Anti-depressants: The class of anti-depressants known as the tricyclic anti-depressants (TCAs), such as amitriptyline (Elavil®), and desipramine, have been studied extensively for their pain-relieving properties. These medications relieve pain independent of their ability to relieve depression. So, even a person who is not depressed may be treated successfully with a tricyclic anti-depressant.

Tricyclic anti-depressants are useful in (such as peripheral neuropathy, post-herpetic neuralgia.), tension and migraine headaches, back pain and arthritis and other painful conditions. These medications have the following possible side effects: sedation, constipation, dry mouth. Not everyone experiences all of these side effects and some people experience none of them. Also, sometimes side effects are experienced only initially.

The newer anti-depressants such as the SSRIs (serotonin re-uptake inhibitors) and some others have not been demonstrated in studies to be effective against pain. However, those of us who treat pain find that many of them can be helpful in treating pain. They generally have fewer side effects than the tricyclic anti-depressants.

When anti-depressants are used to treat pain, they are called adjuvant analgesics. That is, they have pain relieving properties even though their main purpose is not pain relief. Another class of medications also considered to be adjuvant analgesics are the anti-convulsants.

Anti-convulsants: These are medications primarily used to treat seizure but they can be effective in certain painful conditions, particularly migraine headaches, fibromyalgia and nerve pain.

Gabapentin and pregabalin (known by the brand names Neurontin and Lyrica), are the anti-convulsants used most frequently for neuropathic pain because of their efficacy and limited side-effects. They have been approved by the FDA for various neuropathic pain conditions. Side effects may include sedation and some patients complain of foggy thinking.

Alpha-2-Adrenergic Agonists: Tizanidine (known by the brand Zanaflex) is an adjuvant analgesic. Tizanidine is useful for tension headaches, back pain, neuropathic and myofascial pain. Clonidine is effective in neuropathic pain as well. It can cause blood pressure to drop, a serious side effect.

Local Anesthetics: local anesthetics are used both topically and orally to treat pain. Besides the local anesthetic patch mentioned above (SEE TOPICAL), mexiletine is an oral local anesthetic used to treat irregular heart rhythms. It too, has been shown to be effective in neuropathic pain.

Muscles relaxants:

• Lioresal (known by the brand name Baclofen) has been demonstrated in studies to treat nerve pain.

• Carisoprodol (known by the brand name Soma)

• Cyclobenzaprine (known by the brand name Flexeril)

• Metaxolone (Skelaxin)

These medications are not true muscle relaxants but they are marketed as such and can help relieve pain.

NMDA receptor blockers: This class of medications include dextromethorphan, the cough suppressant; ketamine, a drug used in anesthesia; and amantadine, a drug used in treating the abnormal movements in people with Parkinson’s disease. They can all be helpful in treating pain when used appropriately.