List of Pain Medications - Margaret

[Guest guest]

Margaret wrote:

The funny thing about my pain med is the Doctor said that

Vicodin 7.5's was the strongest thing that he could " legally " give

me? I dont really get that? But just FYI they dont work...

Margaret,

As you can see by the article I've reposted below, unfortunately

what this doctor told you wasn't truthful. I'm posting it again

because I think it's really a through explanation of all the different

pain meds, and when I first posted it, it was in response to a

question about Whipple's, so the message title didn't suitably

identify the contents of the message within. I have to remember

to do this, and change the message title when I respond, since it

makes it so much easier when searching for something specific

in the archives, which I do all the time!!

This article was written by a doctor who is a pain management

specialist. What he says in this article pretty much parallels with

what was said by the fantastic pain management specialist that

Karyn had speak to us at the Symposium. That doctor was my

favorite speaker out of all the different specialist's that were

there, and I was enthralled with everything he had to say.

Since handling our pain is such an important part of dealing

successfully with this disease, I think we owe it to ourselves to

learn as much as we can about the different pain medications

that are available.

Many of our doctors are inexperienced with handling patients

who are in chronic pain, and are also unexperienced with the

different types of medications that are available. You can't really

fault them for that, since after all, pain isn't their specialty, healing

is, and many of them don't have the time to learn all the specifics

of each type of medication. They find one or two that work well

for the majority of their patients, get comfortable with those, and

then " expect " that those medications will work the same for

everyone. Yet we know that a chronic pancreatitis patient has a

different pattern of pain than someone with a headache, a sore

back or tendonitis.

Yet if we can learn about the different medications, we are better

prepared to know what might work better for us. If you have an

open minded doctor, sometimes you can explain to him/her why

you think something else would work better, and why. I've been

fortunate enough to find a GI now who seems like he's willing to

try some new pain medication for me, so I'm arming myself with

as many facts about all of them as I can. Some physician's are

more narrow minded about this, and I think for anyone that runs

into this, you need to find a pain management specialist. Those

are the physician's who DO know about all the different pain

medications that are available, and are usually the ones that can

find something suitable for their patient.

With my first GI, he was stuck on Percocet 5's and Dilaudid.

That's all he knew about, and all he would prescribe. At that

time, the Percocet 5's weren't strong enough for my pain, and the

Dilaudid was so strong, and had such a short fuse, that it was

totally unsuitable for every day use. I finally had to go to a pain

mangement specialist, and she wrote back to my GI with a list of

recommendations for other medications that were more

suitable. Once that was done, everything changed, I was put on

duragestic patches and a higher dose of Percocet with less

acetaminaphen for breakthrough, and this was immensely

successful for this last year.

So I hope you find this article as informative as I have.

**********************

Medication for Pain

Probably the most common type medication used for the

treatment of pain is an NSAID (non-steroidal anti-inflammatory

drug). There are many different ones. Some examples include :

advil, ibuprofen, aspirin, relafen, aleve, ketoprofen, celebrex,

vioxx, indomethacin, and many others. NSAID's work by inhibiting

the enzyme cyclo-oxygenase, and sometimes also lipoxygenase.

These enzymes synthesize many of the chemicals

(prostaglandins, thromboxanes, and leukotrienes) that are

locally released when tissue damage occurs. These chemicals

increase the sensitivity of nociceptors (nerve endings) to

respond to noxious(painful, potentially damaging) stimulations.

Therefore, inhibition of the synthesis of these chemicals can

prevent the local nociceptors from becoming sensitized,

subsequently reduce their activation, and thus result in lower

transmissions of noxious stimuli to the spinal cord. In other

words, pain relief. An individual's response to any particular

NSAID is highly variable, and therefore if a patient fails one

NSAID, either secondary to side effects or ineffectiveness,

another one should be tried. Some studies suggest a patient

should try 10-15 different NSAID's before abandoning them. I

generally try up to 5 different ones, trying the cheapest ones first

(motrin and aspirin).

Unfortunately, NSAID's have a lot of side effects, the most

significant I think is GI(gastro-intestinal) bleeding. Nationwide,

7000 people die and 70,000 people are hospitalized annually for

GI bleeds secondary to NSAID use. Risk factors include age

>60, history of stomach ulcers, steroid use, alcohol abuse, and

multiple NSAID use. For the prevention of NSAID induced GI

effects, antacids are not very effective. It's questionable if H-2

(histamine) blockers such as zantac and tagamet, or Hydrogen

pump blockers such as prilosec, are effective. Renal toxicity is

another possible complication. NSAID's decrease renal blood

flow and can lead to medullary ischemia, or kidney damage.

NSAID's also can cause an allergic nephritis, an inflammatory

response in the kidney. NSAID's impair platelet function. Aspirin

irreversibly inhibits platelets for their life, 4-7 days. Most other

NSAID's reversibly inhibit platelet function, and platelets return to

normal after stopping that particular NSAID for several half-lives

of the drug, a day or so. Therefore, all NSAID's should be

stopped at least several days prior to an operation, and aspirin

should be stopped 2 weeks prior to an operation. Trilisate,

non-acetylated salicylates, celebrex, and salsalate do not inhibit

platelet function, and therefore are the NSAID's of choice in

patients who are coagulopathic, as often occurs with

chemotherapy. Finally, NSAID's can induce hepatitis. Patients on

long term NSAID use should have LFT's monitored. I would

follow the manufacturer's recommendations.

A patient never develops a tolerance to NSAID's, but

unfortunately, they have a ceiling effect which means that the use

of higher than recommended doses will not result in any greater

pain relief, but only increase the risk of side effects. Some are

expensive, others are not. Finally, they are highly protein bound

and will displace coumadin and digoxin into the plasma

resulting possibly in toxic effects of these drugs.

I often try advil (motrin, ibuprofen) since it is inexpensive. For

patients with sensitivity to NSAID's, I often try Trilisate since it is

easy on the stomach, and doesn't inhibit platelet function, which

is especially important if a patient has a history of peptic ulcer

disease or is receiving chemotherapy. Celebrex and Vioxx can

also be tried, but many HMO prescription plans will not pay for

these medications. Tylenol has no anti-platelet or GI side effects,

but it also does not have anti-inflammatory properties which can

make it ineffective in inflammatory pain states. In addition,

people can overdose with tylenol when taking percocets,

darvocets, or other medications containing tylenol if they are not

aware of the maximum doses. Indomethacin can be very

effective, but it has a high incidence of side effects. Torodol has

greater analgesic properties than any other NSAID, but is only

recommended for a 5 day use secondary to a high incidence of

side effects.

Opioids (narcotics) are medications that work like morphine.

There are many drugs in this class. Examples of some include

methadone, demerol, percocets, vicodin, oxycodone, and heroin.

Opioids bind to a variety of different receptors on nerve cells in

the CNS (central nervous system) and elsewhere in the body,

leading to pain relief as well as the various side effects. Different

opioids have different affinities for the various receptors and their

subclasses on different cells, and this gives each opioid a

unique blend of various responses (pain relief and side effects).

They cause pain relief by decreasing pain impulses and

sensations after binding to the nerve cells in the spinal cord and

brain. They also can cause many side effects including sedation,

respiratory depression, nausea, constipation, and sometimes

mental status changes by affecting other nerve cells in the body.

Unfortunately, over time, nerve cells become accustomed to the

effects of the opioids, and therefore, over time, opioids will have

less of an effect in decreasing pain impulses and sensations.

This is called Tolerance; the body becomes somewhat tolerant

to the effects of the opioids. This develops in everybody who

takes opioids chronically. A patient may find that the medication

will not seem to work as well as it did in the beginning. This is to

be expected. Even though they will develop tolerance, it will not

be complete, and the medications will always give them some

relief. There may be times when they may feel that the

medications are not helping them at all. I'm sure that if they were

to stop taking them for a day, their pain would worsen. The main

point of this is that with the use of opioids, the goal is only partial

relief, NOT complete relief, since the latter is unattainable due to

the development of tolerance.

There is no treatment to prevent the development of tolerance.

Increasing the dose of opioids to counteract tolerance will only

subsequently increase the level of tolerance. The body will

re-adjust to the new higher dose of opioid, and the degree of

pain relief will ultimately be no better than that previously

achieved with the lower dose of that opioid.

Opioids are the main medications used for the treatment of

acute, severe pain, such as experienced following surgery, bone

fractures, or any other severe injuries. If a patient already has a

high tolerance to opioids, they will not work well or not at all

using standard doses, if and when a patient needs them to treat

severe, acute pain. Therefore, it is important for a patient to

minimize the use of their opioids, to minimize their development

of tolerance, so as to preserve the ability of their body to respond

to opioids for pain relief should they experience severe, acute

pain.

Addiction is the craving of opioids for reasons other than pain

relief, and is different from tolerance. With time, everybody

develops some degree of tolerance, but only a small fraction of

patients become addicted to or abuse opioid medications.

Withdrawal occurs when a patient, who is taking a large quantity

of opioids, suddenly stops taking them. With taking opioids

chronically, the body becomes accustomed to a high level of

them, and when this level suddenly drops, various different cells

in the body respond, and this results in withdrawal symptoms.

Examples of some symptoms include diarrhea, tachycardia, and

anxiety. Most patients are only using relatively low doses of

opioids, and if they would stop them suddenly, they probably

wouldn't have any withdrawal symptoms at all, or if they did, they

would be very mild. Increasing pain would be a greater problem.

Opioids can provide excellent, profound analgesia and have no

ceiling effect. However, they have many negative aspects as well.

They can cause sedation, confusion, constipation, N/V and

urinary retention. The elderly population is at higher risk to

develop side effects. Respiratory depression is a risk when

instituting opioids, but I feel is not a significant risk after a patient

has been taking opioids chronically. You should also place

patients simultaneously on bowel stimulants to counteract

constipation. All opioids are short acting except for methadone

and levorphanol. MSContin and OxyContin are extended release

preparations of morphine and oxycodone respectively. Crushing

or cutting these tablets will result in release of all of the opioid

immediately, possibly resulting in an overdose. In addition, the

extended release properties are abolished, and the drug will last

only as long as morphine or oxycodone does, 3-4 hours.

Morphine is inexpensive and is manufactured in various forms

(tablets, liquid, slow release tablets such as MSContin or

Oramorph, and parenteral). Morphine has metabolites,

morphine-6-glucoronide and others, that are excreted by the

kidneys, and build up in renal failure patients. They also can

build up in patients with normal renal function if they are taking

large amounts of morphine, about 1000 mg/day or more.

Unfortunately, these metabolites contribute to the side effects,

but not to the analgesic effects.

Oxycodone is manufactured as sustained released ( OxyContin )

and immediate release preparations. Oxycodone supposedly

does not have active metabolites, although I feel that it does to

some degree, although less than morphine. A negative aspect of

OxyContin is its cost, of which it is the most expensive oral

preparation, and a month's supply frequently is over $ 200. In

comparison, methadone, the least expensive of all opioid

preparations costs about $ 20 for a month's supply.

Heroin (Diacetylmorphine) has no analgesic or other activity

itself, but is converted in the liver to Morphine. All of the effects

from Heroin are actually attributed to Morphine and its

metabolites. Since there are no advantages of Heroin over

Morphine, there is no medical indication for its use, and

therefore, it has not been approved for medical use.

Hydromorphone (Dilaudid) is relatively inexpensive. Its

metabolites are not very active, and therefore it is one of the

drugs of choice to use in renal failure patients. Unfortunately,

there are no extended release preparations, which to me

eliminates it as being used for the management of chronic pain.

Methadone is a long acting opioid with no active metabolites,

and is available in liquid or tablet forms. It is also the most

inexpensive of all opioids. Unfortunately, not many physicians

prescribe it, and therefore do not gain experience with it. Also,

not many pharmacies stock it, and it can be difficult for patients

to get their prescriptions filled. Since Methadone has a very slow

onset and long half life, it is easy for the medication to

accumulate and result in oversedation and possibly respiratory

depression when just starting, especially in the elderly.

Therefore, with an elderly opioid naive patient, it is best to

prescribe it on a q day basis if they cannot be monitored closely,

before switching to bid or tid dosing.

Fentanyl, contained in Duragesic patches, is administered

transdermally, which has advantages and disadvantages.

Fentanyl is a very quick and short acting opioid used

intravenously for various indications where rapid, profound

analgesia is required, such as for surgery. It also is used when

only temporary analgesia is required as in outpatient

procedures, such that the patient soon recovers from the effects

of the opioid, as opposed to morphine in which its effects would

last much longer. By delivering the medication transdermally,

Fentanyl can be given continuously, and thus be used for chronic

pain management. Transdermal delivery, like IV, enables the

opioid to be given to a patient who cannot tolerate oral intake or

has poor GI absorption for any reason, such as continuous N/V.

One disadvantage is that if the patch is not applied correctly and

there are air pockets, less than the advertised dose will be

delivered. Also, fever can increase the rate of delivery. There is a

6-10 hour lag time from when the patch is applied before it starts

working, and a similar lag time after it is removed. The patch is

also somewhat expensive.

Propoxyphene (Darvocet) has only one advantage, it is

inexpensive. Otherwise, it is a weak opioid, a little more potent

than aspirin. It has a unique local anesthetic like property in that

it can interfere with cardiac conduction, and becomes a concern

in patients with liver failure or cardiac dysrhythmias. In addition,

patients can take large quantities and not realize they are

overdosing on the tylenol component of Darvocets. I rarely

prescribe these for chronic use in pain management; there are

better medications.

Demerol (meperidine) , like Darvocet, has only one advantage, it

is inexpensive. Its metabolite, normeperidine, which is excreted

by the kidneys, is responsible for lowering the seizure threshold.

At one institution where I trained, a patient died secondary to

seizure complications from the use of a Demerol PCA. Demerol

is contraindicated for use in combination with MAOI's. Finally,

Demerol also has a unique property among opioids in that it has

atropine like effects. I rarely use this drug for acute pain

management, and it is contraindicated for the chronic

management of pain, especially cancer pain, where patients

often require large opioid doses. Again, there are better drugs.

Ultram (Tramadol) has very mild opioid like properties. It is not

regulated by the DEA. Unfortunately, it is very expensive, and

other opioids give much greater degrees of analgesia for less

money. Ultram is of no benefit for a patient already taking an

opioid, or even a patient who has taken an opioid in the past.

Once a patient takes an opioid chronically, they develop some

degree of tolerance which they will never lose. I have found that if

a patient has a distant history of opioid use, Ultram is almost

never effective. Only opioid naive patients sometimes respond

well to Ultram.

Adjuvant medications include tricyclic antidepressants, SSRI's,

anticonvulsants, muscle relaxants, and benzodiazepines. The

name " adjuvant " is somewhat of a misnomer, in that although

these medications are not very effective for nociceptive pain

relief, they can be very effective for neuropathic pain relief, and

opioids may be the " adjuvant " medications.

Tricyclic antidepressants (TCA's) can be effective for various

neuropathic pain syndromes such as polyneuropathies and

post-herpetic neuralgia's. They have the beneficial side effect of

sedation, which is very helpful for treating disturbed sleep

patterns that are often present in neuropathic pain syndromes.

All tricyclic antidepressants are tertiary amines except for

Desipramine, which is a secondary amine. The importance of

this is that it is the tertiary amine properties that result in many of

the side effects including dry mouth and constipation. Elavil

(amitriptyline) has been the most studied, and also has the

highest incidence of side effects. I often use Doxepin (sinequan)

10-50 mg qhs @ 8 PM, as the side effects are less, and also

there is less cardiotoxicity. Other TCA's include desipramine and

nortriptyline.

SSRI's (selective serotonin re-uptake inhibitor's) can sometimes

be effective for neuropathic pain even though they are used

primarily for depression. Examples of these medications include

: prozac, paxil, and zoloft. Paxil has sedative effects as well,

where as zoloft doesn't. Wellbutrin is another antidepressant

that can help when the others have been ineffective.

Anticonvulsants (Neurontin, Tegretol, Dilantin, Valproic Acid) can

be effective for neuralgia's, dysesthesia's, and shock-like pain.

Occasionally they are effective for muscular pain, such as with

Fibromyalgia. Serum levels are only useful to monitor for toxic

serum levels, otherwise I dose to the desired effect.

Benzodiazepines (valium, ativan, klonopin) enhance GABA

inhibitory effects, which can greatly relieve anxiety, which

sometimes is needed for effective pain management. Often, a

patient will perceive their pain as improved with a

benzodiazepine, even though benzodiazepines have no or little

analgesic properties for nociceptive pain. For pain that is

secondary to muscle spasm or tension, central acting muscle

relaxants (Soma, Flexeril, Baclofen) can sometimes be

beneficial. Of all the muscle relaxants, I find that Skelaxin is the

least sedating, and many patients who need to get up early

prefer this medication as it rarely gives a hang over.

My theory for effective pain relief is to tailor the medical therapy to

the patient's pain and needs. I would first try non-opioids +/- an

adjuvant, and then add an opioid if needed.

I hope the information that I provided helps you with your

questions or pain syndrome.

**********************

I hope this helps you

With hope and prayers,

Heidi

Heidi H. Griffeth

South Carolina

SC & SE Regional Rep

PAI, Intl.

Note: All comments or advice are personal opinion only, and

should not be substituted for professional medical consultation.