By Dr. Vivek Sinha
Chronic pain can mean different things to different people. Whether you are a patient, a doctor, a parent or a politician, your view on pain medications can vary depending on your perspective.
Those who work the front lines of our healthcare infrastructure — police, fire, EMS and emergency departments — know all too well the impact that opioid abuse has on the population. Those who work in chronic care and pain management know the benefits that proper pain medication can have. One of the biggest debates in healthcare right now is how to help decrease the multiple side effects of prescription pain medicine use while at the same time ensuring adequate pain control and preventing under-treatment of chronic pain symptoms.
When should medications be given? How much should be given? To whom and in what quantity should they be given? These are all extremely difficult questions with complex answers that require discussion and an individualized treatment plan.The purpose of this article is to provide information on chronic pain and some of the factors that prescribers take into account when deciding what sort of treatment to offer patients. Understanding the science behind a treatment option is critical in understanding the potential drawbacks and side effects that treatment may have. As I often discuss with my patients, the best decision is an informed decision.
By definition, chronic pain is pain that has been present for more than three months. It is a condition that affects more than 100 million people in the United States and accounts for almost 20 percent of all doctor office visits and 12 percent of all prescriptions written. Prior to treating a patient with chronic pain, a comprehensive pain evaluation should take place. While there are multiple individual aspects to each person’s pain complaint that must be accounted for, there are some commonalities that help physicians classify the type of pain a patient is suffering from.
Chronic pain is often classified into one of four different categories:
- Inflammatory Pain – joint pain, pain caused by infection, etc.,
- Neuropathic Pain — pain caused by nerve damage such as seen in shingles, diabetic foot pain, fibromyalgia pain, etc.
- Mechanical/ Compressive Pain — pain from expanding tumors, kidney stone pain, etc.
- Musculoskeletal Pain — back pain, muscle pain, etc.
Often times, pain can be a combination of different types, so while it is important to categorize a patient’s pain symptoms, it is equally important to evaluate the mechanism of injury, how long the pain has been present, any associated symptoms and triggering factors.
A critical next step is to determine what sort of impact the chronic pain is having on the person’s life. Is the patient able to function as he/she normally would? Are they able to go to work and interact socially as they normally did? In other words, how is their quality of life? Asking about what they have used in the past for pain control is also very useful and can help guide the physician in deciding what the most effective option may be.
After obtaining all this subjective data, it is important to quantify a patient’s pain level. There are several pain intensity scales that healthcare workers are currently using. While one scale is not clearly better than another, the use of pain scales should be consistent, with the same scale being used at each visit and the patient being asked to rate his/her pain not only at that visit, but for the week prior as well.
After obtaining a thorough history, a focused physical exam, including a neurological exam should take place. While general lab work and imaging studies are not routinely indicated, directed studies should be performed in order to narrow the list of possible causes of pain.
Once the doctor has decided that some sort of pain medication is indicated, the question then arises, which one? There are many choices of pain medications, and often people assume that prescription pain medications are always more effective than over-the-counter medications; however, that is not always the case. The dose you take, how often you take it, and whether you are taking it as-needed or scheduled throughout the day are all important variables in determining how effective a treatment plan will be.
Over-the-counter pill medications are often categorized into two main categories: acetaminophen (Tylenol) and NSAIDS (ibuprofen, such as Motrin or Advil, or naproxen such as Aleve). While ad campaigns may pitch these medications against one another as competitors, acetaminophen and NSAIDS actually work differently. They both can lower fever and help with muscle type pain, but NSAIDS can help reduce joint swelling and are highly effective on inflammatory pain, while acetaminophen is an effective fever reducer and often used for pain associated with infection.
Since their duration of effect can vary, it is important to know how long these medications last in the body, so one can know how often to take them. Tylenol lasts for 4 to 6 hours, Motrin/Advil last for 6 to 8 hours and Aleve lasts for 12 hours. It is important to not take too many too often. Each bottle of medication has clear dosing instructions that should be followed carefully.
Just because these medications are over the counter, it does not mean that they are necessarily safer than prescription medications. Acetaminophen can stress the liver if taken too often. NSAIDS can increase the risk of cardiac events and can cause kidney problems and stomach ulcers. Guidance should be sought prior to taking these medications to ensure that medication interactions and side effects do not occur. Often physicians will advise patients to take these medications differently than what is written on the bottle, based on the severity of pain or underlying medical conditions.
When it comes to prescription pain medications, there are many different options. Determining the type of pain is important in deciding what medication to start. Neuropathic pain does not typically respond to NSAIDs and acetaminophen very well, therefore prescription medications like Neurontin and Cymbalta often have better efficacy on these conditions. For other types of severe pain, opioid medications may be prescribed.
Opioid medications are found under various brand names: OxyContin, Percocet and Vicodin are several examples. They work on the pain receptors throughout the body to decrease the transmission of pain input, thereby decreasing the perception of pain overall. These receptors are found scattered throughout the body but they have the most effect on receptors found in the central nervous system. While the overall effect is a reduction in pain, there are several significant other effects that occur, such as slowing of heart rate, a slowing of respirations, sedation and a feeling of euphoria. Physical dependence can occur very rapidly if care is not taken both by the physician and the patient.
Ultimately, the best treatment for pain control is a multi-pronged approach. Pain medications are just one tool in the toolbox. There are multiple other tools that have shown to be highly effective in pain management; physical therapy, acupuncture, chiropractic manipulation, acupuncture and cognitive behavioral therapy are just a few examples of modalities that can have fewer side effects than medications and often have excellent results.
It is important to weigh the risks of the medication versus the benefits and discuss possible alternatives and side effects with your physician, prior to taking any pain medication. As a primary care physician I find myself having this discussion with patients quite often. If you are advised to take any medication, whether it be over the counter or prescription, your doctor should not only discuss the risks versus benefits of the medication, but he/she should also talk about how to take it and when to stop it.
The best tool against any diagnosed condition is education. Talk to your physician because with knowledge comes power. Stay healthy.
The writer is the chief medical officer of Belleview Medical Partners.