Pain Medications And More
By: Manonmani Antony, MD.
Medications play an important role in the treatment of pain. Many different types of medicines can be used to relieve pain. A few, such as aspirin, ibuprofen, and acetaminophen can be purchased in a pharmacy (over-the-counter or “OTC”) without prescription, but most pain relievers are only available with a prescription from your physician.
Classes Of Analgesics For Pain Control
There are 3 major classes of medications:
Non-Opioids: non-steroidal anti-inflammatory drugs (NSIDS) and acetaminophen. Opioids: (may be also called narcotics) Morphine is an example. Adjuvant analgesics: a term referring to other medications originally used to treat conditions other than pain, but now also used to help relieve specific pain problems. (antidepressants and anticonvulsants).
Drugs with no direct pain relieving properties may also be prescribed as part of a pain management plan. These include medications to treat insomnia, anxiety, depression, and muscle spasms. They can help a great deal in the overall management of pain in some people.
Non-Opioid Analgesic Medications:
NSAIDs: They relieve mild to moderate pain by lessening the sensation of pain and reducing inflammation. Pain associated with inflammatory conditions (arthritis and gout) is especially susceptible to NSAID therapy. Ibuprofen (Motrin, Advil), Naproxen (Aleve), Ketorolac (Toradol), Diclofenac (Voltaren), Indomethacin (Indocin), Meloxicam (Mobic), and Aspirin are examples. NSAIDs are effective when taken by mouth. Ketorolac (Toradol) is available for injection into muscle or vein. Topical NSAIDs are available as a gel, solution (Pennsaid Lotion) rubbed on the skin; another is in the form of a patch (Flector patch). Key message for patients: Taking NSAIDs with alcohol increases the risk of GI bleeding and ulcers. Patients age 65 and older, patients taking high doses of NSAIDs, and patients also taking blood thinners (Coumadin, Plavix, Aggrenox) or steroids (Prednisone) are at high risk of GI bleeding.
A new NSAID: COX-2 Inhibitors (Celebrex): This was designed to be easier on the stomach and avoid GI problems. Celebrex remains on the market and appears to have same cardiac risk profile as other older NSAIDs.
ACETAMINOPHEN: This can be used to relieve mild to moderate pain and treat fever, but it is not an NSAID and does not reduce inflammation. It produces few side effects at the appropriate doses to relieve pain but can damage the liver when used in larger doses. Key message for patients: The recommended maximum daily adult dose is 4 grams in 24 hours. Taking more than the recommended dose can cause liver damage. Patients with liver disease or those who drink 3 or 4 alcoholic drinks per day should consult with their physician before taking acetaminophen. Many combination pain medicines contain an opioid with acetaminophen (Tylenol #3, Percocet, Vicodin). It is advisable to calculate how much acetaminophen they are taking “especially if both OTC and prescriptions drugs are being used at the same time.”
Opioid Analgesic Medications: (Narcotics):
Opioids are an important part of the multimodal management of chronic pain (cancer and non-cancer pain) when properly prescribed, dispensed and taken as directed. However, safety concerns about opioids include abuse, addiction, diversion, and serious injury or death from accidental or unintentional overdose.
Classes Of Opioid Analgesics:
Opioids are also divided into categories, called “schedules.” Hydrocodone compounds, such as Vicodin, and Butrans are Schedule III; many other narcotics are in Schedule II. Opioids can be classified as either immediate-release, with effects lasting several hours, or extended-release, with effects lasting anywhere from 8 hours to 1 week. Physicians use the extended-release forms primarily for chronic pain, where there is a continual need for pain relief. The intent is that by providing constant relief, the person suffering from chronic pain can focus on living their life rather than constantly worrying about taking the next pill. In this way, physicians hope to minimize the occurrence of addiction.
The following are commonly prescribed extended-release narcotic medications: morphine (MS Contin, Avinza, Kadian,), oxycodone (OxyContin), fentanyl (Duragesic, Fentanyl Patch), oxymorphone (Opana ER), methadone (Methadose), Nucynta (tapentadol) ER and Butrans. Methadone should be prescribed by pain physicians who are familiar with its use and risks, as it could cause adverse effects by way of overdose through accumulation and drug interactions. Key message for patients: NEVER crush, chew or take these extended-release medications differently than prescribed. These changes can destroy the time-release feature and cause an overdose.
Immediate-release medications are used in the chronic pain setting to treat breakthrough pain that can occur up to 3 to 4 times per day. There are many commonly prescribed immediate release medications, including preparations of morphine, oxycodone, percocet, hydromorphone (dilaudid), meperidine, oxymorphone (Opana), Nucynta (Tapentadol) IR and fentanyl in the form of, Actiq and Fentora, which allow it to be absorbed into the blood stream through the lining of the mouth. Actiq and Fentora have the advantage of a very fast onset and have been approved by the FDA for cancer breakthrough pain.
With all opioids, the major side effects are sedation, nausea, and constipation. Anyone taking opioids should treat possible constipation by maintaining a high fluid intake, a high fiber diet, and using stool softeners.
Opioid-Induced Hyperalgesia (OIH)
Recent research suggests that patients receiving opioids to control their pain somewhat paradoxically may become more sensitive to pain as a direct result of opioid therapy. OIH should be considered in any patient with increasing pain that is not responding to increasing opioids. Using non-opioid analgesics and rotation to different classes of opioids may yield improvements in pain.
Abuse-deterrent Technologies in Opioid Medications: A New Weapon in the Fight against Misuse and Abuse
The new formulation of Oxycontin and the Exalgo formulation of generic hydromorphone, combine some crush resistance with new chemical barriers designed to ensure the slow and steady flow of medication. Embeda contains a combination of morphine and naltrexone which is a special narcotic drug that blocks the effects of other narcotic medicines and alcohol.
Neurontin (Gabapentin) and Lyrica (Pregabalin) are used for treating pain caused by neurologic diseases such as postherpetic neuralgia, Pinched Nerve, Peripheral Neuropathy/ pDPN and Fibromyalgia. They are anti-convulsants that produce pain relief by reducing communication between nerves.
Cymbalta (duloxetine) and Savella (milnacipran) are antidepressants that give effective pain control in fibromyalgia.
Muscle Relaxants works by blocking nerve impulses (pain sensations) that are sent to your brain. Zanaflex (tizanidine), Flexeril (cyclobenzaprine), Skelaxin (metaxalone), Soma (carisoprodol) and Baclofen are some of the examples. Key message for patients: Taking Soma for longer periods of time could increase the risk of dependence and possibly abuse. More importantly, people with a tendency towards alcohol or drug abuse are at a high risk for abusing Soma.
Dr. Manonmani Antony is a pain fellowship trained, board certified anesthesiologist who focuses on comprehensive pain management including interventional pain medicine. Although opioid drugs can be addictive, Dr. Antony believes they have a role in pain management. “Opioids can be very useful in the treatment of chronic cancer pain and non-cancer pain,” she says. “However, their use requires careful patient selection, education, and follow-up by a physician. You can’t just throw pills at a patient and hope for the best.”