Medication Management

Janet D. Pearl, MD, MSc

Suffering From Pain?

We Can Help

Suffering From Pain?

We Can Help

Suffering From Pain?

We Can Help

Suffering From Pain?

We Can Help

Medication Management

For more information about the actual medications used commonly in pain management click here.

Medication management can be a challenging consideration for both doctor and patient, but the decreased pain that results is worth the effort. Many myths and superstitions have arisen around using medications to treat pain, but many of them are false. In fact, pain is a biological process with a set of symptoms that can be adequately controlled by medication.

Some primary care doctors do not often know all of the medications and combinations that are so important in adequately controlling pain and may not have the time to delve into the full extent of your pain and how it impacts your life. For this reason, it is recommended that people who suffer from chronic pain seek out pain medicine specialists, who can help you find the best solution to reduce your pain and improve your quality of life.

Medication management is one type of treatment for pain and may be used in combination with physical therapy, interventional approaches, or psychological support to help you achieve the best possible quality of life.

pain medication management

Seeking Medical Treatment for Pain

Part of the problem with seeking medical treatment for pain revolves around knowing when pain should be treated. Patients sometimes feel that they must tolerate a high amount of pain to justify asking for medications, and some are nervous that if they take the medications, they will cease to be effective. While it is true that some pain medications, such as narcotics, can lead to a tolerance effect, many pain medication options and combinations exist that it is unlikely you will become completely tolerant to all of them. In many cases, adequate pain relief is possible without using a narcotic medication. Narcotics are only prescribed when all other medications have been completely exhausted, the patient passes screening for narcotic dependency, and all members of the healthcare team agree that narcotics are the best course of action.

You should seek medical treatment for pain if you are experiencing persistent pain that interferes with your quality of life. Chronic pain affects the way you think, eat, sleep, and move. It can affect your social life, hobbies, and enjoyment of life. For instance, if the constant pain in your neck keeps you from driving, your quality of life decreases.

The Pain Ladder

The pain ladder is an approach to managing pain medications that was developed by the World Health Organization for cancer pain.It seeks to maximize the non-narcotic medications, use strong narcotics sparingly, and address the pain from many fronts biologically. These principles can be applied similarly to non-cancer pain. When different classes of medicationsfor pain are used together, it is often enough to significantlyreduce the pain message from the body.

The goal of this process is to maximize the comfort and abilities of the patient while minimizing the side effects of the medications. One medication is tried at a time. This approach may take time, but it is the best way to know the effects and side effects of any particular medication.It will be helpful for you to bring in a list of all medications you have already tried when you come in for your visit/

WHO 3 step analgesic ladder

Medication Types used in Pain Management

Non-steroidal Anti-inflammatory Drugs

The first step on the pain ladder is non-narcotic analgesics. This can include over the counter NSAIDs, aspirin, and Tylenol, but it can also include prescription strength anti-inflammatory medications. These medications include Celebrex and Voltaren, in addition to corticosteroids to reduce inflammation. Some side effects of these medications include stomach ulcers and gastrointestinal bleeding, but close monitoring can alleviate these problems. The COX-2 inhibitors, of which Celebrex is the only remaining FDA approved type, can cause heart problems, but more research is necessary to determine the long term effects of these medications.

Muscle Relaxants and Compounded Creams

Another type of medication often used at this stage is the muscle relaxants, such as Baclofen or Tizanidine. This type of drug can help to reduce muscle spasm. With decreased spasm comes less pain, and side effects of these medications include sleepiness or fatigue. A compounded cream can be created by a special pharmacy to include a wide variety of medications and even a local anesthetic if your pain is in a localized area. This type of medication has very few side effects, but a rash is a potential side effect.

Antidepressants

It has long been known that certain antidepressants, most notably the tricyclic antidepressants like amitriptyline, help to control nerve related pain. They have been prescribed for chronic pain for many years, but recent research has shown that other antidepressants, such as the selective norepinephrine reuptake inhibitors, are also helpful to chronic pain patients. In fact, the SNRI Cymbalta is the first medication that has become FDA approved for the treatment of chronic pain. These medications may have side effects, such as sexual dysfunction and even possible suicidal ideation, but they are safe when closely monitored.

Anti-seizure Medications

In addition to antidepressants, your doctor may choose to prescribe you an anti-seizure medication. These medications, such as gabapentin, Lyrica, and Topamax, are well known for helping with the symptoms of nerve pain. In fact, gabapentin is particularly useful for peripheral neuropathy. The side effects of these medications are usually rare and some can even be life threatening, such as a dangerous allergic reaction.

Opioids

If you do not experience pain control with these medications, the next step may be a weak opioid, such as Tramadol. Again, it is used in conjunction with the other medications to form a regimen to control your pain. Side effects of these medications usually include constipation, but dependency with them is expected. Another concerning side effect is respiratory depression and even possible death from this complication. For this reason, keeping the dose as low as possible is important to prevent accidental overdose and fatalities.

However, if these combinations are still ineffective, more powerful opioids may be used and carefully titrated to control pain and improve activity. The weaker opioid is often replaced by the stronger one, but non-narcotic pain relievers are still used in combination as part of the treatment package. You will likely develop physical dependency, meaning that if you don’t take the medication, you may experience withdrawal symptoms such as anxiety, abdominal cramping, diarrhea, sweating and sleeplessness. You will also be monitored for psychological dependency, or addiction. In addition, we will monitor your ability to participate in life activities as treatment progresses.

Prescribing opioids is a task that doctors must take very seriously. In addition to rigorous government regulations, most patients need to be thoroughly screened to ensure that the incidence of psychological dependency or misuse is as low as possible. This includes scheduled and random urine drug testing and coordination of care with your primary care physician and other members of the care team. We scan each patient for possible misuse of the medications and for any signs of possible dependence. In addition, we will monitor you for pain relief, your ability to participate in normal activities, and any side effects that you may encounter. Sometimes, we request a friend or family member who knows you well to come to an appointment to provide an objective opinion as to how the medication is affecting you.

The risk of dependency on narcotics is extremely high, and the use of them is not undertaken lightly. First, the usage of other medications to treat pain is often far more effective than using a narcotic medication. Second, the risk for side effects from narcotics, from chronic constipation up to and including dependency, is high enough to cause many doctors pause for concern. If it is determined after exhaustive usage of the pain ladder and rigorous screening that you are a good candidate for narcotic pain medication therapy, the prescription process can cautiously begin. However, narcotics are not the best or the safest method of pain relief, and constant monitoring is vital to safe treatment.

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