Month: October 2013

Uncommon Pain Medications Used to Treat Pain

/ Thomas Cohn, MD

uncommon pain medicationMany medications are used in the treatment of pain. The most common pain medications include opioids, anti-inflammatories, simple analgesics, and others. Read our previous blog for more detailed information on these common pain medications.

For many patients, these common pain medications are not effective and specialized medications are often used. These uncommon medications include seizure medications, antidepressants, and a variety of others.  These drugs are often considered neuropathic medications and are used whenever abnormal nerve function is suspected in causing pain. Read on for more detailed information about these uncommon pain meds and how they’re used in the treatment of pain.

Antidepressant Medications

Antidepressant medications are used to control neuropathic pain. Two types of antidepressants are commonly used:

  • Tri-cyclic antidepressants (TCAs). Tricyclic antidepressants include amitriptyline, Nortriptyline, and desipramine, the later two are the best tolerated and used at very low dose.  The TCAs have many side affects including dry mouth, low blood pressure, sedation, and urinary problems.
  • Serotonin/noradrenaline reuptake inhibitors (SNRIs). The newer SNRIs include Cymbalta and Savella have very few side affects.  Cymbalta is very effective in a number of neuropathic pain situations including diabetes, radiculopathy and fibromyalgia, while Savella only is known to work in fibromyalgia.

Antidepressants such as Zoloft, Prozac, and Celexa along with Effexor have no affect on pain.  These medications decrease nerve transmission and nerve sensitivity.

Seizure Medications

Seizure medications were among the first neuropathic medications.  The originals were Dilantin and Depakote, but due to their significant side affects, these are now rarely used.  Tegretol is also used rarely for similar reasons, but has been found uniquely helpful with trigeminal neuralgia.

All seizure medications work by decreasing the ability of the nerves to be active and send signals.  They can be sedating and can cause mental clouding.  The newer ones include gabapentin (Neurontin) and Lyrica. For any pain nerve associated, these medications can be very effective, and if monitored and prescribed correctly have minimal side effects.

Lidocaine Skin Patches

Lidocaine skin patches use a local anesthetic to decrease nerve sensitivity at the skin.  These patches work on a variety of painful conditions including shingles (post-herpetic neuropathy), and diabetic neuropathy.  They may be helpful in headaches, neck and low back pain.  Myofascial pain and fibromyalgia sometimes respond to lidocaine skin patches as well.

Clonidine & Tizanidine (Zanaflex)

Clonidine and tizanidine (Zanaflex) are alpha-2 adrenergic agonists, blocking certain sensory interneurons important in pain transmission.  Clonidine is normally a potent blood pressure medication, but sometimes is very effective in neuropathic pain and is sometimes even used in intrathecal pumps.   Tizanidine has properties that help with analgesia in neuropathic pain and helps with muscle spasms, and was originally developed for controlling muscle spasm in quadriplegia.

Capsaicin & Baclofen

Capsaicin is a crème derived from chili peppers used in neuropathic diabetic pain and post-herpetic neuralgia. It activates certain pain fibers on the skin.

Baclofen is an unusual medication affecting nerve receptors in the spinal cord and brainstem.  Originally, it has been for spasticity, often in paraplegia, quadriplegia, cerebral palsy, and multiple sclerosis.  It is used orally as pills and sometimes by intrathecal pump.  It can help also with neuropathic pain.

NMDA Receptor Antagonists

A final group of adjuvant pain medications are NMDA receptor antagonists.  These medications also block a set of sensory fibers and pain transmission.  Ketamine is the main drug in this category.  It can only be given by IV or intrathecal pump, and has been used in CRPS, and cancer.  It is similar to the drug LSD, and can cause hallucinations.

Common Non-Opioid Pain Medications

/ Thomas Cohn, MD

pain medsThe most common medications prescribed by primary care physicians for pain are analgesics.  They can be divided into to two main categories: opioids/narcotics and non-opioid type medications. We have discussed opioids at length in previous blogs. This article will cover common non-opioid pain medications.

Acetaminophen/Tylenol

Acetaminophen/Tylenol works for mild to moderate pain, such as headaches. It works by enhancing the body’s inhibitory pain pathways.  The maximum safe dose was considered to be 4000 mg, but data now available is questioning that level.

Breakdown products of acetaminophen can be toxic to the liver, especially when the liver has other compounds to metabolize.  Alcohol can greatly interfere with acetaminophen breakdown, and when toxic it can kill the liver, and has been found to be the most lethal nonprescription medication sold. In short, be careful when taking this medication with alcohol.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) are some of the most prescribed pain medications.  Common examples include:

  • Ibuprofen
  • Naproxen
  • Aspirin
  • Diclofenac
  • Celebrex

These medications inhibit enzymes that are released from cells when they are injured and inhibit inflammation and secondarily peripheral pain receptors.  These drugs act on the “COX” enzymes.

  • COX 1 enzymes protect the gut, maintain kidney function, and cause platelets to form clots.
  • COX 2 enzymes are involved in inflammation.

Most NSAIDs are nonselective, impacting both COX 1 and2 enzymes, and therefore can cause stomach damage, bleeding and kidney problems.  NSAIDs are used for joint pain and pain after injury.

Corticosteroids

Corticosteroids are medications that include:

  • Prednisone
  • Hydrocortisone
  • Injectable steroids

These medications only work on inflammation.  They are very powerful, and can be used in a number of ways.  Topically they are used for rashes.  Orally and via injection they can bring down local or diffuse inflammation.  They have been injected in joints to bring down joint pain, and often are used by pain physicians as epidural injections to treat spinal pain causing radiculopathy.  Unfortunately, if not used with caution, they can have numerous side affects due to affecting hormone balance.

Muscle relaxers and anti-spasm medications

Muscle relaxers and anti-spasm medications are used to reduce muscle tightness.  Most of these drugs have no impact on pain, and may act by sedating a person.  These medications may help pain that is due to muscle tightness beyond what is necessary.  Some of them are very addictive, since they include Valium and similar anxiety medications. In chronic pain, most of these medications are ineffective.  Other muscle relaxers commonly used include Robaxin, Skelaxin, and Norflex.  These medications are sedating and some may be addicting, but generally have very little affect in overall pain.

5 Tips for Sleeping Through Pain

/ Thomas Cohn, MD

sleep through painWhen you’re in pain as the result of an injury or other condition, oftentimes the best remedy is to get plenty of rest and sleep. But sleeping through pain is easier said than done. Rolling over onto a painful back, leg, or arm can wake you up (and keep you up) in the middle of the night. More pain equals less sleep, and less sleep slows your recovery. It’s a vicious (dare I say painful) cycle.

But there are a steps you can take to help sleep soundly through the pain. Here are a few tips:

  1. Take your pain relief medications as directed, and right before bed if possible.
  2. Reduce your caffeine intake. Coffee, soda, and energy drinks are jam packed with caffeine. They are designed to keep you awake and alert. This is great if you need a pick me up at work, but not when you’re trying to sleep. If you can’t cut out the caffeine completely, try to only drink it in the morning.
  3. Cut down alcohol consumption. Many people find that a “nightcap” helps put them to sleep. While it’s true that alcohol can induce drowsiness, the sugars in alcohol are more likely to wake your body up later in the night.
  4. Get into a sleep cycle. Try to go to bed and wake up at the same times every day. This will help your body get into an internal rhythm or groove.
  5. Relax and avoid physical activity before bed. Exercising is a great way to reduce your pain, but exercising too late in the evening can keep you up and make it difficult to fall asleep.

Whether you’re dealing with chronic pain from an illness, or acute pain following an injury or surgery, getting a good night’s sleep is essential for your overall health. Follow these tips and you’ll be off to dreamland in no time.

Facial Pain and Trigeminal Neuralgia: Pain Management Options

/ Thomas Cohn, MD

face painTrigeminal neuralgia is a condition that causes facial pain.  The trigeminal nerves or nucleus (their origin) send signals of severe pain to the brain.  The symptoms are often severe stabbing pain or electrical shocks.  Pain is on the side of the face, usually always one side, and comes in episodes.  The frequency and length of attacks is variable.  It can occur at any age, but is more common in those older than 50, and has multiple causes and treatments.

Causes of Trigeminal Neuralgia

Causes of trigeminal neuralgia are numerous.  It can be related to a variety of neuropathies, including multiple sclerosis and diabetes.  Vascular changes can cause pressure on the trigeminal nucleus and pain, and tumors can also affect the nerves.  In most cases, the cause is often not found, and may be a spontaneous problem, possibly due to a previous infection.

The main characteristic of trigeminal neuralgia is facial pain.  If a cause can be found, such as vascular compression or tumor, neurosurgical correction sometimes can lead to a cure.  However, in many cases, nothing can be found on diagnostic tests.  Treatment then is focused on management of pain symptoms and diminishing activities that irritate the region.

Facial Pain Management

Medication management is often the first line of treatment of trigeminal neuralgia.  Neuropathic medications are very effective for this condition.  The most common of these medications are drugs used for seizures.  It is often a trial and error method used to find the right medication and limit side affects.  Neurologists are often the first physicians managing the problems since they are experts in the diagnosis of nerve issues, and have extensive experience with prescribing these medications.

If the pain is not readily controlled with medications, a segment of those with trigeminal neuralgia are referred to a pain specialist.  The trigeminal nerve can be blocked and settled down with local anesthetic and steroid injections in some patients.  When injections work, relief can be almost instantaneous and put a patient in remission for months at a time.  If the relief is not prolonged but good, then ablation/destruction of the trigeminal nerve may also be effective.  The nerve can be abated several ways, including by a radiofrequency needle technique, special radiation, or surgery.

Good sources of additional reliable information on trigeminal neuralgia can be found through Mayo Clinic and the National Institutes of Health.

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Spine Surgery Often Unnecessary in Treating Back Pain

/ Thomas Cohn, MD

spine surgeryA recent presentation at the North American Spine Society (NASS) meeting, points to the fact that a third of spine surgery patients are still using narcotic/opioid medications one year after surgery.

Further, the study indicates that of those patients using opioids before surgery, 51% continued a to use them a year later.  The article goes on to discuss the concern that too much opioid prescribing is occurring.  This is the wrong concern. The real concern should be whether spine surgery should have been done in the first place.

Reasons for Spine Surgery

The United States has one of the highest rates of spine surgery.  Compared to most other countries, the spine surgery being done is mostly unnecessary.  There are appropriate reasons for spine surgery, such as:

  • Trauma
  • Scoliosis
  • Changes in the spine causing nerve damage with loss of muscle or organ function

Pain alone is a poor reason for spine surgery.  Most spine pain is caused by degenerative discs and joints. Treating this surgically most often only changes the location of pain, and does not resolve pain.  Nonsurgical management of most spine conditions has been shown to be much more successful in numerous studies.  Ask a group of surgeons, the answer of course is that the surgery works.

Pain management experts will usually have a more conservative view with regards to surgery. Spinal fusion surgery has at most a 30% success rate for helping with pain.  Spinal surgery in general also has a 20% rate of significant surgical complication.  The above statistics highlight the real issues with spine surgery – that it often causes more problems than solutions.

Alternative Treatment Options

Treatment for spine pain involves many different options, including a variety of medications and possibly opioids.  Every person has different needs, and a Pain Medicine physician can evaluate you and help determine an appropriate treatment program.  Surgery should only be considered if neurologic compromise is occurring and without intervention, loss of motor control or organ function may result.

Opioid medication use in the United States may be out of control, but so is spine surgery.  Surgery and opioid use are truly independent problems.  Pain and opioid use after surgery is not a surprising issue.  The problem is too much surgery and not enough good pain management of spine problems by qualified experts.