Uncommon Pain Medications Used to Treat Pain

October 30, 2013June 24, 2014 / Thomas Cohn, MD

Many 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.

5 Tips for Sleeping Through Pain

October 24, 2013June 24, 2014 / Thomas Cohn, MD

When 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:

Take your pain relief medications as directed, and right before bed if possible.
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.
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.
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.
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.

Signs of a Pain Medicine Overdose

October 9, 2013November 17, 2015 / Thomas Cohn, MD

All medications can cause problems when not taken correctly. Pain medications, even those sold over-the-counter, can have deadly consequences when overdosed. Having the right balance of medications for pain and not having significant side effects is the trick that a good pain physician will try to develop for a patient. It is always necessary to keep track of the patient’s medications, even nonprescription to monitor for adverse reactions. This article will discuss the signs of overdose for opioids, over-the-counter meds, and neuropathic medication.

Opioid Overdose

Narcotic/opioid medications have had the most publicity concerning overdose. These are the drugs like Percocet, Vicodin, Oxycodone, and Morphine. These drugs are powerful analgesics and are commonly given for severe pain. Side effects are common and include:

Upset stomach
Constipation
Nausea
A tired or “drugged” feeling

Signs of an overdose of opioid medications include:

Excessive tiredness & sleeping
Low pulse and blood pressure
Decreased breathing

Significant overdose may be treated with a medication called Narcan to reverse these effects. There is a push for all emergency responders to carry Narcan since overdose of these medications is becoming common due to drug abuse.

Neuropathic Medication Overdose

Neuropathic medications include many antidepressants (like amitriptyline, and Cymbalta), and seizure medications (such as gabapentin, Topamax, and Lyrica). These medications often have annoying side effects such as:

Dry mouth
Short term tiredness

If they cause significant changes like memory problems or worsening depression, talk to the physician about problems. Overdose with antidepressants such as amitriptyline can cause severe respiratory problems and needs to be treated with acute hospitalization.

Over the Counter Medication Overdose

Over-the-counter medications like acetaminophen and ibuprofen also have problems if overdosed. Anti-inflammatories like ibuprofen can cause ulcers and stomach bleeds in some people, even at normal doses, but these affects can be treated. Acetaminophen however is very dangerous if taken in to high of a dose. Taking 1.5 times the recommended amount can lead to liver failure and even death. If you have been taking too much acetaminophen the eyes and skin can turn yellow indicating liver damage, and must be treated promptly by a physician.

Pain medicines can be very helpful in managing symptoms. Like all drugs, they need to be taken only as directed. Make sure your physician knows all the medications that you are taking. Additionally, be sure to talk to your doctor about whether you can eat certain foods, or drink alcohol with your medication. If side effects of a medication are a problem, talk to the doctor before stopping the medication, sometimes these drugs need to be tapered off or just changed slightly to be helpful.

Pain Medication & Alcohol – A Dangerous Mixology

September 27, 2013June 24, 2014 / Thomas Cohn, MD

It is always wise to be careful about drinking alcohol when taking any medication. All medications can interact with other substances you ingest. For example, meds can interact with vitamin supplements, and even certain foods that you eat.

It is no surprise then that one should be careful with mixing alcohol and medications (including pain medications). In this article, I will discuss some of the most common medications and how they interact with alcohol in the body.

Opioids & Pain Meds

The most common concern about alcohol is with opioid/narcotic pain medications. These drugs include:

Percocet
Vicodin
Oxycodone
Oxycontin
Morphine
Codeine
Fentanyl

All narcotics can affect your cognitive ability and judgment, and alcohol can have the same effect. The combination of the two is not always additive, and the alcohol can greatly diminish both of the above. Thus your judgment could become very poor, and the toxicity increased such that either drug can essentially cause death. If one is on a stable dose of narcotic, people can usually function without impairment. An occasional alcoholic drink should be safe. You may feel more impaired then usual, but you should not be toxic.

Neuropathic Meds

Many pain patients also use neuropathic medications like gabapentin, or other seizure type drugs, and antidepressants. These drugs also can affect cognition, and mixing with alcohol can worsen this ability. Alcohol is metabolized and broken down in the body by the liver, and the same process is also used by many of these medications. Therefore, alcohol and these medications can also interact in unpredictable ways. Again, if you have been on these medications long-term, then an occasional drink is likely safe, but heavy drinking is not a good idea.

Ibuprofen, Tylenol, & other Over the Counter Meds

Over the counter pain medications such as ibuprofen and acetaminophen/Tylenol are generally very safe if taken as directed. Unfortunately, people often take a little more than directed in the hopes that they will work better. Mixing alcohol with these drugs can be very dangerous. Anti-inflammatories like ibuprofen can cause stomach irritation. Mixing them with alcohol can cause severe ulcers and stomach bleeding. Acetaminophen alone can easily be toxic to the liver. Mixing this with alcohol has led to fatal liver failure.

The answer to drinking alcohol with pain medications is not simple. If one takes their medications only as directed, and has been stable on them, then having an occasional alcoholic beverage, not daily and not more than one, should be safe. Your judgment, memory, and cognition could be affected even with one drink, and you may not be safe to drive, but it should not be toxic to the body.