Pharmacological Management

Chronic pain is a serious health condition that often leads to complications beyond your physical symptoms, such as a weakened immune system, cognitive deficits, and new or worsened depression, anxiety. Chronic pain can make it more difficult to keep up at work, manage tasks at home and attend social gatherings, leading to problems in your relationships and financial instability. Some research suggests that the more severe your pain, the more serious these problems.

The process of finding relief of your chronic pain is complex and uniquely personal. What works for one person may not offer any relief for another.  Your diagnosis, biology and personal history all play a role, and finding pain therapies that bring you adequate relief can be a lengthy effort.  Working in partnership with Dr. Wills and the providers at Austin Pain Wellness, you will identify treatments that allow you to live an enjoyable, fulfilling life. The approach you choose should include more than just medication, but analgesic agents from a variety of categories are likely to play a role. 

Pharmacological management, or medication management, involves deciding what medications or combination of medications is right for you, helping you keep track of all prescribed and over-the-counter medications, and working to reduce the total amount of medication needed to control your pain. You should learn about the risks and benefits of common pain medications so that you can make safe choices as you seek your solution.

 

Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are most effective for mild to moderate pain that’s accompanied by swelling and inflammation. These drugs are commonly used for arthritis and pain resulting from muscle sprains, strains, back and neck injuries, or menstrual cramps. NSAIDs are divided into COX-1 and COX-2 selective agents.  Cox-2 enzymes help protect the lining of your stomach. COX-1 NSAIDs, can cause side effects such as stomach pain and bleeding. COX-2 inhibitors, on the other hand, help keep the stomach protected by acting only on COX-2 enzymes, allowing COX-1 to function normally.

  • Generic and brand names. Ibuprofen (Advil, Motrin IB, others); naproxen sodium (Aleve); celecoxib (Celebrex).
  • Mechanism of action. NSAIDs work by inhibiting cyclooxygenase, which is one of the most critical enzymes in your body released during any process of tissue damage. By blocking the different types of cyclooxygenase (COX) — including COX-1 and COX-2 — NSAIDs help reduce pain and inflammation.
  • Risks and Benefits. When taken as directed, NSAIDs are generally safe. But NSAIDs can cause nausea, stomach pain, stomach bleeding or ulcers, particularly if taken at greater than recommended dosages. Large doses of NSAIDs can also lead to kidney problems, fluid retention and high blood pressure. Risk of these conditions increases with age and in the presence of other health problems, including diabetes, a history of stomach ulcers or reflux, and kidney disease.
  • Conclusion. If you regularly take NSAIDs, talk to your doctor so that he or she can monitor you for possible side effects. Bear in mind that NSAIDs also have a ceiling effect — a limit as to how much pain they can control. This means that beyond a certain dosage, they don’t provide additional benefit. Exceeding the recommended dose may not relieve your pain and may increase your risk of serious side effects.

     

Acetaminophen

Acetaminophen is typically recommended as a first line treatment for mild to moderate pain, such as from a skin injury, headache or musculoskeletal condition. Acetaminophen is often prescribed to help manage osteoarthritis and back pain, and often is combined with opioids to decrease the total opioid dose.

Generic and brand names. Acetaminophen (Tylenol, others)

  • Mechanism of action. Acetaminophen works as a primary analgesic agent, but scientists have not pinpointed its exact mechanism of action. Some scientists believe there may be a third type of cyclooxygenase, COX-3, that acetaminophen blocks. Acetaminophen doesn’t affect the other two cyclooxygenase enzymes, and it doesn’t target inflammation — only pain. 
  • Risks and Benefits. Acetaminophen is generally considered safer than other non-opioid pain relievers because it doesn’t cause side effects such as stomach pain and bleeding. However, taking more than the recommended dose — or taking acetaminophen with alcohol — increases your risk of kidney damage and liver failure over time.
  • Conclusion. Acetaminophen is generally a safe option to try first for many types of pain, including chronic pain. Ask your doctor for guidance about other medications to avoid while taking acetaminophen. Acetaminophen is not as effective as NSAIDs for the treatment of knee and hip pain related to osteoarthritis.

     

Antidepressants and anti-seizure medications

Some medications commonly prescribed to manage depression and prevent epileptic seizures have also been found to help relieve chronic pain, including back pain, fibromyalgia and diabetes-related nerve pain (diabetic neuropathy). Because chronic pain often worsens depression, antidepressants may doubly benefit pain and mood symptoms.

  • Generic and brand names. Tricyclic antidepressants used in the treatment of chronic pain include amitriptyline and nortriptyline (Pamelor).
    Serotonin and norepinephrine reuptake inhibitors (SNRIs) that may be prescribed to relieve chronic pain include duloxetine (Cymbalta), venlafaxine (Effexor XR, Pristiq) and milnacipran (Fetzima, Savella).
    Anti-seizure medications that are widely used for the treatment of chronic nerve pain, including postherpetic neuralgia and diabetic neuropathy, include gabapentin (Gralise, Neurontin, Horizant) and pregabalin (Lyrica).
  • Mechanism of action. These drugs may take several weeks before you notice the effects. Anti-seizure medications quiet pain signals from your nerve cells, and may be helpful primarily for stabbing or shooting pain resulting from nerve damage.
  • Risks and Benefits. Side effects of these medications are generally mild, but may include nausea, dizziness or drowsiness. As a group, antidepressants and anti-seizure medications may, rarely, worsen depression or cause suicidal thoughts. If you notice changes in your thinking patterns or mood while taking these medications, talk with your doctor right away.
  • Conclusion. To reduce the risk of side effects, your doctor may start you out on a small amount of these medications and gradually increase the dose. Tricyclic antidepressants can make you drowsy, so your doctor likely will recommend that you take these medications before bedtime.

     

Opioids

Opioid medications are either naturally-occurring or synthetic cousins of opium. These medications are often prescribed for acute pain that stems from traumatic injury, such as surgery or trauma. Misuse or abuse of Opioids is a national issue, and has led to a high rate of prescription drug-related overdose deaths in the United States in recent years. Because the risks are so great, opioids are used at the lowest dose possible, and for the shortest duration possible.

  • Generic and brand names. Hydrocodone (Hysingla ER, Zohydro ER); hydrocodone-acetaminophen (Norco, Vicodin, others); fentanyl (Actiq, Duragesic, others), oxycodone (OxyContin, Roxicodone, others); oxycodone-acetaminophen (Percocet, Roxicet, others); others
  • Mechanism of action. Opioids, just like real opium, mimic the natural pain-relieving chemicals produced by your brain called endorphins. These drugs attach to opioid receptors in your body, and inhibit or block pain signals being sent to your brain. They can also impact other nerve cell functions, such as breathing, heart rate and level of alertness.
  • Risks and benefits. Over time, your body adapts to opioid use, a process known as tolerance, and therefore can bring less and less pain relief. This could mean that you need more of the same medication to achieve the same degree of pain relief. Long-term use of opioids may lead to dependence on these medications and, eventually, addiction.  The difference between opioid dependence, and opioid addiction, is that opioid dependence is a purely physical occurrence, where your body becomes dependent on opioids for normal function and literally goes into “withdrawal” if opioids are withdrawn.  Addiction, on the other hand, refers to a behavioral illness characterized by compulsive craving for opioids, regardless of negative consequences, along with the physical dependence.
    The longer you use opioids, the greater your risk of becoming dependent or addicted. However, even using opioids to manage pain for more than a few days increases your risk.
  • Conclusion. Opioids are usually a last resort for long-term administration in chronic pain management.  Because of these risks, careful and frequent follow-ups with your doctor is necessary.

     

Opioid Management Guidelines

To see if you are a candidate for pharmacological management of your chronic pain, or to have a comprehensive review of your current medication regimen, call now to schedule your appointment.