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Medication Management

Pain is a universal but complex condition. Although many people suffer from pain, the types and causes of that pain can vary tremendously. Pain can be chronic or acute, and it can be caused by inflammation, tissue damage or nerve damage. Different pain medications work in different ways, and some will be more or less effective depending on the cause of a patient’s pain.

When it comes to pain management, the most crucial aspect of any treatment plan is to identify the ultimate source of pain and treat that source effectively. Some patients may need to try several medication types before finding the most effective treatment. In most cases, however, a pain management doctor is able to pinpoint the most likely cause of pain and prescribe a medication that will effectively treat it.

Pain Medications
Below are the medications most commonly prescribed for pain management.

Nociceptive Pain Medications

Most of the well-known over-the-counter pain medications are nociceptive medicines. These medications are designed to treat the pain caused by injury and inflammation to a body’s tissues. When one part of a patient’s body sustains damage, neurons report this damage to the brain, which in turn creates the feeling of pain.

Some nociceptive pain might radiate away from its origination point. This is especially common in visceral pain, such as that caused by gallbladder disease. This can make locating the cause of the pain difficult. Fortunately, nociceptive pain medication will relieve most types of nociceptive pain regardless of its origin.

Some of the conditions that are commonly treated with nociceptive pain medication include tissue damage, bone pain and inflammatory disorders like arthritis. NSAIDs, or non-steroidal ant-inflammatory drugs, are the most common type of medications used for this purpose. Other drugs used to treat nociceptive pain include COX2 inhibitors and acetaminophen. For severe pain, these medications may be combined with opioids or other drugs.

NSAIDs

NSAIDs work by reducing inflammation. This in turn helps to soothe the neural response to tissue damage and aid in healing. When tissue is damaged, the surrounding area will fill with fluid. Although this is the immune system’s natural response to an injury, it can invite infection and reduce blood supply to the damaged area. This is why reducing the swelling around an injury both relieves pain and encourages healing. The body’s swelling response is caused by the production of prostaglandins, a hormone-like substance. NSAIDs counteract swelling by inhibiting the production of these prostaglandins. Because NSAIDs are effective and available over the counter, they are some of the best-known medications.

Here are some of the most common NSAIDs:

  • Aspirin
  • Ibuprofen
  • Ketoprofen
  • Naproxen sodium

These drugs are best suited to treating acute pain. They are less effective against chronic pain conditions, and extensive NSAID use is linked to severe medical conditions including kidney damage and gastric ulcers. People with gastric bleeding or other stomach disorders should not take NSAIDs without consulting a doctor first.

Acetaminophen

Because acetaminophen works differently than NSAIDs, it is effective against different types of conditions. Pain that is not caused by inflammation or swelling can be safely relieved by acetaminophen. The drug is also effective at reducing fevers, which makes it a popular addition to cold medicines and other similar drugs.

Over-use of acetaminophen can result in severe and irreparable liver damage. People with liver disease or similar sensitivities should exercise caution when using this drug. Because of the risk of liver toxicity, long-term use of acetaminophen is not recommended.

Some patients couple acetaminophen with ibuprofen, aspirin or another NSAID. This can be very effective at relieving pain without taking a toxic high dose of any particular drug. The acetaminophen complements the NSAID for an additive effect, and combining the drugs reduces the likelihood of developing kidney, liver or GI tract complications from a high dose of a single drug.

Opioids

Opioids are drugs that are derived naturally from opium or created synthetically to resemble opium’s chemical structure. Opioids have been used in one form or another for centuries, but newer opioids are stronger and more effective than those used in the past. They are a common choice for treating severe acute and chronic pain, and they are often prescribed to patients who require a more long-term pain relieving solution than an NSAID can safely offer.

Pain Medication Bottles
Opioids work by interacting with the body’s opioid receptors, which are located in both the patient’s gastrointestinal tract and nervous system. These receptors create both the beneficial effects of opioids and the undesirable effects associated with addiction and substance abuse

There are several different kinds of opioids:

  • Natural opioids derived from the poppy plant, including morphine and codeine
  • Semi-synthetic opioids derived from natural opioids, including hydrocodone and oxycodone
  • Fully-synthetic opioids created through a chemical process, including fentanyl and methadone

There are also some drugs called Endogenous Opioid Peptides which interact with the body’s opioid receptors. These substances are created naturally in the body, but they can be administered as drugs for a variety of beneficial purposes. Some common examples include endorphins and endomorphines.

Effects Of Opioids

Because opioids work by interacting with the opioid receptors in the nervous system and GI tract, they provide a masking effect for pain rather than treating the source of the pain. In other words, they will not reduce swelling and inflammation the way an NSAID might. Instead, they soothe the body’s pain response to relieve symptoms while the patient undergoes healing.

In addition to pain-relieving effects, opioids offer other unique GI and neurological effects. Some common effects include feelings of euphoria or sedation. This is one reason why opioids are frequently abused for recreational purposes, and it’s why the availability of these drugs is limited. Gi difficulties like constipation are also a common side effect of frequent opioid use.

Some opioids are more fast-acting than others. Fast-acting drugs are the most likely to be abused for recreational use as they have the strongest neurological effects. Longer-acting drugs do not provide immediate relief to acute pain, but they are a good choice for chronic pain sufferers because their side effects are greatly diminished. These long-acting opioids do still have some side effects, however, and can still be addictive if used over a long term.

Controversies Surrounding Opioid Use

Opioids are a commonly accepted solution for short-term treatments of severe pain. For example, most doctors agree on offering morphine to surgical patients. For long-term treatment of chronic pain conditions, however, doctors are conflicted about the use of opioids. There are several reasons why some members of the medical community are reluctant to prescribe opioids for chronic pain management:

  • The side effects can increase in severity over time
  • The drugs lose effectiveness over time
  • Most patients develop dependency to opioids over time
  • Long-term use of opioids can affect the body’s normal pain response, which makes drug cessation even more difficult
  • Hormonal and psychological effects including reduced libido and risk of depression can occur from opioid use
  • Long-term opioid use can result in a suppressed immune system

Bear in mind also that many opioids are mixed with NSAIDs such as ibuprofen to increase their effectiveness. This means that the long-term use of such mixed drugs can invite may of the side effects of NSAID use in addition to opioid use.

Over the long term, opioid usage can create just as many problems as it solves. This is why many doctors are reluctant to manage chronic pain conditions with these drugs. Patients need to discuss the pros and cons of opioid treatments with their doctors and come up with an informed decision about their long-term safety and effectiveness. Dr. Geula follows a strict opioid protocol when prescribing opioids for pain management.

Muscle Relaxants

For patients suffering from muscle injuries and other pain, muscle relaxants can provide relief. Unlike NSAIDs, which reduce swelling in affected tissue, muscle relaxants work on the neural pathways that travel through muscle tissue. By interfering with neural transmissions from the brain, these drugs can cause muscles to relax or even induce temporary paralysis.

One common use for muscle relaxants is surgery and emergency medicine, where temporary localized paralysis can have extremely beneficial results. They are also used during patient recovery from certain bone and muscular conditions where relaxing an affected muscle will reduce the strain on surrounding tissues. Patients with spinal injuries and other back problems may be prescribed muscle relaxants to promote healing and remove stress from the spinal column.

There are two primary types of muscle relaxants: neuromuscular blockers and spasmolytics. Neuromuscular blockers interrupt neurotransmitters at several sites throughout the body to affect its muscles. Spasmylotics work specifically on motor neurons within muscles themselves to reduce the incidence of muscle spasming. These work by either exciting or inhibiting neural responses in the muscle.

Here are some of the most common muscle relaxants prescribed to patients:

  • Carisoprodol
  • Cyclobenzprine
  • Diazepam
  • Metaxalone
  • Methocarbamol

Although muscle relaxants can be extremely powerful and effective drugs, they have several potentially dangerous side effects. Because it’s difficult to target a specific muscle group, the drugs will often have unintended affects on other parts of the body. Serious side effects include heart failure and paralysis. More common effects are sedation, lethargy, loss of alertness, constipation and dizziness.

Users are cautioned not to use heavy machinery or drive while using muscle relaxants. It’s also important to be careful when mixing muscle relaxants with other drugs that could have negative effects, such as opioids. Such combinations should only be attempted under approval from a doctor.

Neuropathic Medications

Neuropathic pain is different from nociceptive pain. While nociceptive pain usually occurs as a result of tissue damage, neuropathic pain occurs when the nerves themselves become damaged. Patients frequently describe the pain as a shooting, stabbing, burning or lightning-like sensation. Other types of neuropathic pain are experienced as weakness and tingling in the affected area.

Although some types of neuropathic pain are caused by injuries that affect the nerves, pain can also occur for seemingly no reason. Sometimes overactive neurotransmitters will release pain signals even when there is no obvious cause for that pain. This type of chronic pain condition can be one of the most frustrating to treat as it is easily misdiagnosed. Individuals with chronic neuropathic pain might go through several ineffective medications before finding one that will work to soothe the overactive neurotransmitters. If opioids were used for the patient’s drug treatment, long-term side effects can also complicate the expression of symptoms.

Treatment For Neuropathic Pain

Because neuropathic pain is not triggered by the same causes as nociceptive pain, it requires a different sort of treatment. NSAIDs and opioids are both ineffective in treating neuropathic pain disorders, and they can have negative effects over the course of long-term treatments. Instead, effective drugs include antidepressants and anticonvulsants. These drugs act on the body’s neurological system by blocking neurotransmitters.

Anticonvulsants

Traditionally, anticonvulsants are given to patients who are prone to seizures. They have recently been discovered to be effective against some types of neuropathic pain. In general, anticonvulsants can be classified as either first or second-generation agents. Second-generation agents usually have fewer negative side effects for their users.

Not every anticonvulsant will be effective for every patient. Some trial and error may be required to find the proper neuro-chemical response that will relieve pain. For this reason, some drugs are commonly prescribed for certain neuropathic disorders but not others.

Common anticonvulsants used for pain:

  • Carbamazepine
  • Gabapentin
  • Pregabalin

Some neuropathic disorders that have been effectively treated with anticonvulsants include trigeminal neuralgia, fibromyalgia, diabetic neuropathy and postherpetic neuralgia.

Although anticonvulsant drugs are in many ways safer for long-term use than opioids, they are not without side effects. Because these medications affect the neurological system of the user, they can also have negative neurological effects. Common side effects of anticonvulsants include sedation, liver problems, nausea and dizziness.

Antidepressants

Most people associate antidepressants with their use in treating mood disorders like depression. Research has shown that some types of antidepressants also have a positive effect on the patient’s neural pathways, which can reduce the incidence of neuropathic pain disorders.

The most common type of antidepressant used in pain management is the tricyclic antidepressant. These affect the brain’s neurotransmitters and can help soothe the body’s pain response. This is also why antidepressants can be used to stabilize a patient’s mood, improve sleep cycles, decrease anxiety and enhance relaxation.

These are some of the most common antidepressants used in pain management:

  • Amitriptyline
  • Imipramine
  • Nortriptyline
  • Desipramine

In addition to tricyclic antidepressants, newer types of antidepressant drugs can be used for pain management. SSRIs and SNRIs inhibit the uptake of certain chemicals into the brain. This can be used to treat some pain disorders, but it’s still not clear whether any positive effects are directly related to pain relief or if they are secondary effects to the mood-enhancing effect of the drug. Nevertheless, these drugs can be taken with minimal side effects, which makes them an attractive option for individuals with chronic pain conditions.

Not every neuropathic pain condition can be treated with antidepressants. Tricyclic antidepressants are most useful in treating the searing or burning pain often associated with nerve damage. Some of the conditions that can be treated with antidepressants include shingles, fibromyalgia, diabetes, stroke and migraines. The dosage given for pain management is usually lower than what would be prescribed for mood stabilization,

Although antidepressants can have numerous positive effects, they do also have some drawbacks. Some side effects include dry mouth, weight gain, blood pressure changes, trouble urinating, drowsiness and constipation. Some patients also experience sexual side effects and unwanted mood changes. Individuals with certain mental disorders may have abnormal responses to antidepressants.

Conclusion

Pain management is a vital part of maintaining a patient’s good health. From acute pain to chronic pain conditions, a variety of underlying causes can be responsible for pain. Understanding the source of this pain is an important first step in finding the correct medication to treat the symptoms.

Understanding the primary purpose and side effects of different medications is also a key to correctly managing pain. Every pain medication will be most effective in certain situations and least effective in others, and taking the time to understand these effects will help to ensure the most effective pain treatment possible.