The Doctor is
10/08/08

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 don’t 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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