Conservative management of
chronic pain ... 2
Dr. Rami Rustum
Treating
chronic pain with medications is still
considered the cornerstone of the pain
management.
Various agents are used in different
regimens and combinations. However, the
most common agents are:
1- Non- Steroidal anti-inflammatory drugs
(NSAIDs):
Commonly used by practitioners as a first
line or step in managing the pain for its
availability over the counter and low
cost.
It is assumed that any pain condition is
associated with some inflammatory process
and swelling causing irritation of the
nerve endings in the surrounding tissues
resulting in secretion of chemical
materials, increasing the transmission of
the pain signals to the brain.
The effectiveness of such medications may
vary based on the severity of the
problem.
Examples: Ibuprofen, Naproxen,
Diclofenac..etc.
Most of these agents share the same side
effects like: stomach ache and irritation
progressing to ulceration and bleeding in
advanced cases, increase the chance of
inducing asthma attacks in prone people.
Newer agents as Celebrex usually dont
affect the stomach but recent report
cases showed some serious
gastrointestinal issues.
When these agents fail, some recommend a
course of oral steroids (cortisone) as a
Medrol Dose pack, to be taken for few
days. There is usually fast and very good
pain relief with this regimen but limited
for the duration of the treatment.
2- Muscle relaxants:
Many pain conditions especially in the
spine can be associated or result in a
limited or diffuse muscle spasm which may
aggravate the initial problem by limiting
the activity and the range of motion. It
may also apply more pressure on the
nerves increasing the spasm!!
Prescribing muscle relaxant in such cases
alone or with other medications could be
all is needed.
Muscle relaxants also share common side
effects profile like: drowsiness,
fatigue, decreased blood pressure,
feeling sleepy and day- time hangover
mostly with older agents like Skelaxin,
Valium and Flexeril. Newer agents rarely
cause any side effects as Baclofen, Soma
and Zanaflex.
Increased irritability and mood swings
were reported in few cases!
3- Antidepressants/ Anti-seizure
medications:
It may sound surprising to use such
medications in treating chronic pain.
The current medical research strongly
supports the use of theses medications as
part of a broader regimen in chronic pain
treatment.
It is believed that such medications help
control the nerves electrical functioning
by reducing and filtering the unwanted
signals. As a result of that, there is
less feeling of numbness, tingling or
burning sensation.
On the other hand, these medications help
improve the mood since some depression is
expected as a direct result of having
pain.
A key point here is to titrate the dose
to effect. The effective dose may vary
greatly from patient to another.
Common side effects may include:
drowsiness, fatigue, palpitation and
feeling anxious. A newer medication like
Lyrica was found to be especially
effective in treating Fibromyalgia and
post herpetic syndrome or shingles. It is
the only drug on the market approved by
FDA for treating shingles!
4- Narcotics:
Using a narcotic in treating chronic pain
could be tricky since it may lead to more
serious future issues including tolerance
and addiction.
The key here is to avoid short acting
agents as much as possible and use
instead long acting agents.
Supervised treatment by pain specialist
is recommended to optimize the best
regimen.
Current long acting medications such
Duragesic patch, MS Contin, Methadone and
Kedian in one or two doses a day offer an
excellent option for long acting agents.
It is very common to supplement those
medications with short acting agents for
breakthrough pain which is usually
unexpected. In this case, using one or
two Percocet, Vicodin, Darvocet,Tramadol,
Oxycodone or Dilaudid tablets is a very
acceptable approach.
Nausea/ vomiting, sweating, itching,
ankle swelling, constipation, fatigue,
headache and dizziness are common side
effects.
Keeping yourself well-hydrated in
addition to adding a stool softener is
highly recommended to avoid the above
listed side effects.
Finally, treating chronic pain with
medications could be a challenging task.
It requires a good understanding of the
condition in order to come up with the
best combination of medications, but more
important is finding a balance between
the prescribed medications and their side
effects.
Such goal could be in some cases too
difficult to achieve!
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