Medication Management

ANTIDEPRESSANTS FOR CHRONIC PAIN

Antidepressants are commonly prescribed to treat chronic pain issues. While many pain patients suffer from depression related to their pain, pain management specialists most often use antidepressants for their analgesic (pain relieving) effects, not their mood altering effects.

The pain relieving effects of antidepressants are thought to be related to their ability to enhance down-regulation of pain signals in the central nervous system. This means they enable the central nervous system to actually lessen the pain signal that is transmitted to the sensory areas of the brain, and thus, the patient will feel less pain.

Classically, the tricyclic antidepressants (amitriptyline, nortriptyline, and doxepin) are used for pain control. More recently, the SNRI antidepressants – particularly Cymbalta (duloxetine) – have been used more commonly due to a better side effect profile. However, in patients who suffer from insomnia as well as pain, tricyclic antidepressants are often used as first-line therapy.

ANTICONVULSANTS (ANTIEPILEPTICS) FOR CHRONIC PAIN

Anticonvulsants have been used to treat chronic nerve pain (neuropathy) since the 1940s and are among the most commonly prescribed chronic pain medications. The ability of anticonvulsants to help control chronic pain lies in their ability to stabilize the membrane of damaged or irritated nerves, thereby limiting the nerve from firing abnormal signals (which are often felt by the patient as electrical shocks or lightning bolts).

The most commonly used anticonvulsants are pregabalin (Lyrica) and gabapentin (Neurontin, Horizant, Gralise).

NSAIDS FOR CHRONIC PAIN

Non-steroidal anti-inflammatory drugs are remarkably effective in controlling chronic pain that is associated with inflammation – especially arthritic pain – as well as other non-inflammatory conditions such as fibromyalgia and headaches. NSAIDs are mostly available over-the-counter and are often the 1st line of therapy for patients.

WHAT ARE THE MAJOR SIDE EFFECTS OF NSAIDS?

The major side effect of NSAIDs is gastric irritation, and this can often limit their use in patients with a history of GERD or other GI disorders. NSAIDs can also have negative effects on the heart and kidneys, so it is always advisable to talk with your doctor before taking any NSAID, including OTC preparations.

MUSCLE RELAXERS

Muscle relaxers are a heterogenous group of medications that help to relax muscle and can often be as effective as an adjunctive medication in the treatment of chronic pain. They must be used with caution due to the multiple side effects that are common with this group of medications.

OPIOID PAIN MEDICATIONS

Opioid-based pain medications are medications that activate the opioid receptors in the central nervous system to help control pain. This class of medications have been used since ancient times to help control pain. Opioid-based pain medications are also referred to as opioids. They are sometimes called narcotic pain medications.

Common opioids include: Morphine, hydrocodone, hydromorphone, oxycodone, oxymorphone, dilaudid, and methadone.

ARE OPIOID PAIN MEDICATIONS RIGHT FOR ME?

HOW DO OPIOIDS WORK?

Opioids help to control pain by activating the mu-opioid receptor (MOR) in the central nervous system. When an opioid-based pain medication attaches to and activates the MOR, the nerve cell will release GABA which is the molecule in the central nervous system that causes analgesia (pain relief).

WHAT ARE THE SIDE EFFECTS OF OPIOID-BASED PAIN MEDICATIONS?

The most common side effects from opioids are nausea, vomiting, constipation, sedation, dizziness, and respiratory depression. The most concerning side effect is respiratory depression, which can cause you to stop breathing. Opioids can be particularly dangerous if taken with other medications that cause sedation and respiratory depression. These medications include benzodiazepines, sleeping medications, and certain muscle relaxants. Using alcohol with opioids can also be dangerous.

HOW WELL DO OPIOIDS WORK FOR CHRONIC PAIN?

This is actually a very difficult question to answer for a variety of reasons, and there is not a good research study that has been done that can confirm or refute the effectiveness of opioids for chronic pain. The lack of quality research does not mean that opioids don’t work for chronic pain – there is most definitely a subset of patient for whom opioids are very effective in helping to control chronic pain. However, it has become clear that opioids don’t work for everyone, and that they can have some serious side effects, especially at higher doses. Typically, patients receive about 30% pain reduction with opioids when taken at a reasonable dose.

WILL I GET ADDICTED TO OPIOIDS?

There is no way to know if a patient will become addicted to opioid-based pain medications. The fact is that the vast majority of patients who use opioids for pain relief do not become addicted to opioids. However, there are some risk-factors (such as a personal history of alcohol or drug addiction or a family history of addiction) that make it more likely that you may become addicted.

WHAT IS OPIOID DEPENDENCE VS. OPIOID ADDICTION?

It is very important to understand the distinction between physiological dependence and addiction. Opioid dependence is the physiological response of your body “getting used” to taking opioids. This is a normal response and will occur in every patient who takes opioid medications. Once your body is physiologically dependent on opioids, you may experience withdrawal symptoms if you stop taking opioids. This does not mean that you have become addicted to the opioids. On the other hand, addiction is primarily a psychological phenomenon that is characterized by compulsive use of opioids despite a lack of medical necessity or despite adverse consequences. Almost all patients who are addicted to opioids are also usually physiologically dependent on opioids, but only a small fraction of patients who are physiologically dependent on opioids will become psychologically addicted.