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Medications

Goals:

  1. To understand which medications may be useful for chronic pain and which may be harmful.
  2. To understand the alternatives which are more effective in certain medications.
  3. To understand how to get necessary information about medication from your doctor or other sources.
  4. To understand the medication you are taking and how to take properly
  5. To understand the causes and treatment of chemical dependency.
  6. To understand the negative effects of sedative medications.

Medications are often prescribed for chronic pain and its associated symptoms. Often this is helpful. At other times, the medication itself may cause additional problems and complications. At times, patients did not take medications

You have a right to make your own decisions about whether or not to take medications. At a minimum, you need to know:

  1. What is the purpose of the medication?
  2. Possible side effects and complications.
  3. Other alternatives which are effective and may be more acceptable than a medication.

You have a right to this information and should be politely assertive with your physician if this is necessary.

All too frequently, medication is prescribed for symptoms rather than causes. Chronic pain is frequently accompanied by multiple symptoms.

Symptoms / Medications

  1. Pain / Narcotic or nonnarcotic analgesics
  2. Sleep disorder / Sleep medication
  3. Anxiety / Tranquilizers (alcohol is not a prescription tranquilizer)
  4. Muscle spasm / Muscle relaxants
  5. Depression  / Antidepressants

Unfortunately, many patients come to the Pain Center taking a number of medications and these categories for symptom control. Often the combination of medications has a negative effect. Usually, alternatives to medications are available but are sometimes not explored, either because the doctor is not knowledgeable about them, or they take more time and effort to teach. Fortunately, the Pain Center does have the resources and time to teach you these alternatives.

Medication use in chronic pain is very different from use with acute pain (pain, which will resolve within three months). It is appropriate to treat acute pain symptoms so that the patient can be more comfortable while healing occurs. With chronic pain, the symptoms will continue and since many of the above medications cause problems and complications long-term, medication use should be closely monitored.

Narcotics, most sleep medications, tranquilizers and most muscle relaxants should not be used long-term in treating most chronic pain. There are several reasons for this:

  1. These categories medications are sedatives, which have depressant effects on the central nervous system. With regular use, they alter brain chemistry (serotonin, norepinephrine, endorphins, etc.) In a way which leads to disturb sleep, fatigue, difficulties with concentration and memory, mental agitation, reduced pain tolerance, weight gain or loss, depressed mood and a variety of pain including headaches. These are. Symptoms often associated with depression. Patients with chronic pain are often already depressed and these medications frequently worsen the chemical depression.
  2. Each of these medications carries a risk of chemical dependency, both psychological and physical.
  3. Physical tolerance is developed to each of these medications so that more medication is necessary to achieve the same effect.
  4. Taking prescription medications makes the patient dependent on the medical system for pain control. It would be better to have all turn attends which are within the patient's own control.

Three non-narcotic classes of medications are frequently helpful in chronic pain. These include anti-inflammatory medications, antiseizure medications, and antidepressants. These medications tend to be less sedated and have a much lower risk of chemical dependency and tolerance. We will discuss each of these categories of medications individually emphasizing appropriate alternatives.

NARCOTICS

Purpose: narcotics are useful for treatment of acute pain for short periods of time.

Action: all narcotics are derived from the opium poppy. The molecular chemistry is changed slightly to form other opiates/narcotics. Some narcotics are stronger, shorter or longer acting, or can be taken orally or by injection. Narcotics work on the nervous system treating symptoms but not the cause of the pain.

Side effects:

  1. Tolerances develop some more medication is needed for the same effect.
  2. There is a risk of chemical dependency and addiction.
  3. Narcotics are sedative, which contributes to depression.
  4. Narcotics alter mood in ways that can be negative.
  5. Narcotics may result in hyperalgesia (a sense of increased pain).
  6. Narcotics disrupt our normal sleep architecture resulting in disrupted sleep.
  7. Narcotics lower your natural tolerance to pain. The nervous system produces its own" pain medication," substances called endorphins. Endorphins regulate the body's sense of pain. They are very similar chemically to morphine, but thousands of times stronger. Like many body processes, the level of endorphins is regulated by a feedback system. (For example, the thyroid gland makes thyroid hormone. If that level falls too low, the body text this and sends a message to the thyroid gland to make more. If the level is too high, a message is sent to stop production.) When narcotics are taken regularly, the feedback process stops the natural production of endorphins. The person no longer has their own natural pain regulation, but must rely on narcotic medications. Unfortunately, tolerance develops and with time it takes more narcotics for the same effect. If narcotics are stopped, it takes time for the brain to again produce adequate endorphin levels. Often the patient's pain increases, and they may become convinced that pain cannot be controlled without narcotics. This is untrue. Research has shown that when narcotics are discontinued long enough, endorphins return. This natural pain regulation is superior to taking narcotics for chronic pain.

Alternatives:

  1. Tylenol or other non-narcotic pain medications (NSAIDs, antidepressants, antiseizure medications).
  2. Pain and mood techniques.
  3. Aerobic exercise, regular meals, sexual activity, and positive attitude all increase your natural endorphin production.
  4. If the patient has never been chemically dependent, narcotics can be used occasionally for severe flare-ups of pain for 1 to 3 days, and then discontinued.

TRANQUILIZERS

Purpose and Action: tranquilizers are used for the treatment of anxiety. There are several categories of tranquilizers. While alcohol is a strong tranquilizer, it has numerous adverse side effects and should not be considered a prescription medication.

Side Effects and Complications:

  1. Tolerance is developed tranquilizers so that more is required for the same effect.
  2. There is a high risk of chemical dependency and addiction.
  3. Tranquilizers are sedatives and contribute to depression and sleep disturbance.
  4. Tranquilizers affect mood, motivation, and the ability to learn and change. Use of tranquilizers can prevent developing more effective ways of coping with problems and stress.

Alternatives: it is important to realize that anxiety is not a disease, but one of the bodies warning signals. It warns of danger and often signals us to take some kind of action or solve the problem for our own benefit. It is important not to disregard or cover up these warning signals. Prolonged extreme anxiety can have severe physical effects; high blood pressure, ulcers, heart attack, increased pain sensation, depression and suppression of the immune system.

  1. Solving the problem or confronting the dangerous situation which led to the anxiety. Often anxiety signals that the patient does not have the skills or knowledge necessary to deal with the situation. Often, the person needs to seek help and assistance such as counseling, legal, financial or other help.
  2. Relaxation techniques. Relaxation is a skill which takes practice but can be learned by anyone.
  3. Physical exercise is often helpful for reducing stress and anxiety.
  4. Discontinue stimulants which increase anxiety, such as caffeine and nicotine.
  5. Learning to have reasonable expectations of oneself (pacing) often reduces anxiety.
  6. Often, the way people think or talk to themselves increase his anxiety. These thought patterns can be changed.
  7. Anxiety warns of danger. It is important to create a safe environment, whether it is at home, in the marriage, and work, etc.
  8. If the patient has never been chemically dependent, tranquilizers can be occasionally used for severe anxiety for several days and then discontinued.

SLEEP MEDICATIONS

Purpose and Action: the purpose of sleep medications is to help initiate and maintain sleep. Most sleep medications are sedatives which act on the brain.

Side Effects and Complications:

  1. Tolerance develops to most sleep medications.
  2. There is significant danger to chemical dependency and addiction.
  3. Sleep medications are sedatives which contribute to depression.
  4. Although hours of sleep may increase, the actual quality of sleep is lessened.

Alternatives:

  1. Learning relaxation techniques to quiet the mind and allows sleep to come.
  2. Antidepressants help restore normal brain chemistry and are helpful for improving sleep in chronic pain.
  3. Nighttime stretching to relieve painful stiffness will often improve sleep.
  4. Reestablish good sleep hygiene habits.

MUSCLE RELAXANTS

Purpose and Action: muscle relaxants are prescribed to decreased muscle tension and spasm. Most muscle relaxants did not work on the muscles themselves, but on the brain. They function as mild tranquilizers, decreasing anxiety and muscle tension. These medications treat the symptom of muscle tension rather than the cause.

Side Effects and Complications:

  1. Many muscle relaxants resulted in tolerance and have the danger of chemical dependency.
  2. Most muscle relaxants are sedatives which contribute to depression.

 

Alternatives:

  1. Muscles which are contracted for a prolonged time become painful and vulnerable to spasm. The most effective treatment is to gently stretch the affected muscles. Once a muscle can be stretched back to its original length, the related pain and spasm resolve. The most effective alternative to medication is to perform frequent and regular stretching exercise to help your muscles remain elongated.
  2. Relaxation techniques help decrease muscle tension.
  3. Dietary factors affect the muscles. It is important to have a healthy diet or take supplements containing adequate calcium, magnesium and potassium. Stimulants, including caffeine and nicotine, increase the likelihood of muscular spasm.
  4. Frequently, chronic pain patients sleep fitfully, tensing muscles, clenching and grinding their teeth at night. Antidepressants have been shown to be helpful toward obtaining a relaxed sleep. These may also increase pain tolerance so that the “pain-spasm-pain cycle” can be broken.
  5. Body awareness and pacing are important toward preventing muscle spasm. Pay close attention to your muscles before they are paying for and spasm. This allows you to take action early by stretching, changing your posture or body mechanics, pacing and decreasing your activity. Biofeedback is helpful for developing this body awareness.
  6. Myofascial techniques which you can perform on yourself are extremely helpful for relieving tight muscles. These techniques include stretching, ice, heat and acupressure.
  7. Muscle tension and spasm are often a sign of muscle fatigue. Involve muscles must be strengthened with appropriate exercise.

ANTIDEPRESSANTS

Purpose and Action: Antidepressants help to normalize your brain chemistry, which can be altered by the presence of chronic pain. Unfortunately, many patients react to the word “depression" and feel they are being told they have a psychiatric problem or a personal fault. This sometimes leads to an unwillingness to take and depressants, which may be quite helpful. It is important to realize that antidepressants are effective, not only for depression and sleep problems, but for managing chronic pain symptoms. Antidepressants treat the cause rather than the symptom by bringing the brain chemistry back to normal. It is this alteration in brain chemistry which is the cause of many symptoms including sleep disturbances, decreased pain tolerance, fatigue, difficulty with memory and concentration, mental agitation, decreased sexual interest, etc. Several antidepressants are now indicated for the treatment of pain related to fibromyalgia, osteoarthritis, chronic low back pain and diabetic neuropathy.

Side Effects and Complications:

  1. Side effects may include drowsiness, insomnia, nausea, dry mouth, weight gain, mental clouding or mood change. Fortunately, there are a number of antidepressants in several different categories. If the patient and doctor work together, an effective antidepressant can usually be found with minimal side effects. It is important to cooperate with your doctor on this.
  2. Antidepressants can contribute to other medical conditions such as heart disease, glaucoma, seizure disorders, prostate problems, etc. Patients with these problems may be unable to take antidepressants.
  3. Some patients do not tolerate antidepressants even when several are tried.

Alternatives: Frequently depression occurs with chronic medical conditions. Many of the medications used to treat chronic medical conditions, such as chronic pain, have sedative effects which contribute to chemical depression. Antidepressants are not the only treatment for depression and its associated symptoms. Many non-medication approaches are effective toward maintaining normal body chemistry. Regular nutritious meals, aerobic exercise, sexual activity, positive attitude and a supportive environment can all help. Psychological techniques, such as cognitive behavioral therapy, have been shown to be as effective as antidepressants. These approaches, along with antidepressants, are more effective than either individually.

  1. Aerobic exercise and proper nutrition.
  2. Discontinuing sedated medications and alcohol.
  3. Changing the way we think about things (cognitive behavioral approaches).
  4. Often, depressive symptoms are one of the ways the body and mind communicate needs. Depression can slow us down when our body is exhausted and needs to rest. It can give us time to pay attention and change things in our life which are not right for us. If you're depression is a symptom of things which need to be changed, antidepressants may not be effective by themselves.

How to take Antidepressants: antidepressants work only when they have reached a certain level in your blood stream. They therefore must be taken on a daily basis rather than on and off. The amount of medication one absorbs various from person to person. One person may obtain adequate blood levels with one dose while another may require a higher or lower dose. This should not worry you because there is no danger of addiction with antidepressants. The antidepressants should be increased until they either have a positive clinical effect or there are adverse side effects. Antidepressants should be continued for several weeks or months, even if you have improved. Stopping them to us or abruptly, may lead to a recurrence of depression. Over time, the body will regain more normal brain chemistry and antidepressants can be discontinued.

ANTI-CONVULSANTS

Purpose and Action: anti-convulsants or anti-seizure medications can be useful for the treatment of neuropathic pain or pain caused by nerve injury. Patients often describe their pain as electric or burning in character. Inhibition of neurons in the brain by anti-convulsant medications is a proposed mechanism of treating neuropathic pain.

Side Effects and Complications: the most common side effects of anti-convulsants include somnolence, fatigue, headache, gastrointestinal upset, dizziness and skin rash. Anti-convulsant medications can potentiate the effects of other drugs used to treat pain and need to be taken only as directed. Most anti-convulsants should not be stopped abruptly, as a short weaning period is needed to discontinue them.

 

Alternatives: alternative treatments for neuropathic pain include antidepressants, as noted above, and topical agents (Lidoderm patches and capsaicin). Topical agents offer the advantage of local relief without systemic toxicity. Non-pharmacologic treatment for neuropathic pain includes TENS, acupuncture, physical therapy, occupational therapy, biofeedback, relaxation techniques, prayer, meditation and hypnosis.

NONSTEROIDAL ANTI-INFLAMATORY DRUGS

Purpose and Action: nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed for conditions where inflammation is present. Inflammation is your own body's reaction to injury. This reaction can cause pain, swelling, warmth and redness. Examples include swollen arthritic joints, sunburns and trauma. NSAIDs work on the cause rather than then symptom by blocking the chemical reactions which lead to inflammation at the site of injury. NSAIDs also have an analgesic effect and are prescribed for pain even when no inflammation is present. These medications include ibuprofen (Advil), Naprosyn (Aleve), and aspirin. Acetaminophen (Tylenol) has primarily analgesic effects and is not considered a true NSAID. Most of these medications are available over-the-counter, without a doctor's prescription. Not all patients have a positive response on these medications, and their effects should be monitored periodically if they're being used long-term for chronic pain.

Side Effects and Complications:

  1. The main side effect of these medications is stomach irritation, which can lead to heartburn, abdominal pain, stomach ulcers and bleeding. NSAID medication should be taken with food to minimize this.
  2. Rebound headaches.
  3. NSAIDs do not cause chemical dependency nor lead to tolerance like narcotics.
  4. High-dose NSAIDs for prolonged periods can lead to kidney complications.
  5. High-dose acetaminophen (Tylenol) can lead to liver complications.
  6. You should stay within the recommended dosage. Your doctor should monitor occasional blood work for any problems, if you remain on these medications for a long period of time.

Alternatives:

  1. Topical NSAIDs. These tend to act locally at the site of application and have lower systemic absorption, thus reducing potential side effects.
  2. Ice packs applied for 15 to 20 minutes.
  3. Glucosamine/chondroitin sulfate may be effective at reducing arthritic joint pain and inflammation.
  4. Diet modification. Studies have shown that nutrition has impact on inflammatory diseases. Several vitamin and mineral supplements and dietary fish and plant oils have been shown to display anti-inflammatory effects.

PAIN MEDICATION COMPLICATIONS

  • Studies have shown that less than 50% of patients take their medications as prescribed. Patients may not get the full benefit from their medication when taken improperly.
  • Physical and mental impairment from medication side effects. Adverse side effects can occur form overuse, abrupt cessation and even proper use.
  • Death from un-intentional prescription drug overdose (methadone & Oxycodone) is a major public health concern at this time.

Understanding Adverse Effects of Opioids

There are many potential side effects associated with opioid therapy which you should be aware of:

  • Acute Use
    • Allergic reaction, skin rash, nausea, shortness of breath, sedation, cognitive & motor impairment, dizziness, confusion, depression, constipation, difficulty initiating urination, sexual dysfunction, and overdose (respiratory depression, death).
  • Chronic Use
    • Disruption of sleep pattern, insomnia, endocrine deficiencies (diminished estrogen and testosterone), immunosuppression, hyperalgesia (increased sensation of pain), rebound headache.
    • Tolerance: a common physiologic result of chronic use resulting in diminished effectiveness and need for progressively higher doses to maintain the same level of analgesia.
    • Dependence: physiologic adaptation to the drug, with tolerance to its effects and experience withdrawal symptoms with prolonged absence or sudden cessation of the drug.
    • Addiction: physiologic dependence with compulsion and loss of voluntary control despite adverse consequences.

 

  • Withdrawal Symptoms
    • Sweating, nervousness, anxiety, abdominal cramps, diarrhea, nausea, vomiting, leg cramps, goose-bumps, runny nose, sneezing.
  • Accidental Overdose
    • Death from accidental overdose of opioids is a major health concern in the United States at this time.
    • Methadone and oxycodone have accounted for an increased proportion of these deaths, but all opiates are capable of resulting in death.
    • Careful prescribing, adherence to prescription directions, and avoidance of alcohol and non-prescribed medications usage will help reduce the chance of opioid use fatalities.