Selecting the Right Pain Medication

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Often times when seeing patients I hear similar concerns regarding initiation of “pain medication”.  Some of these concerns are appropriate, some legitimate, some are not legitimate, and some are simply a quest to box the prescriber into a prescribing what the patient thinks is best.

Here are the concerns, statements, or questions most often heard.

  1. I don’t want to take something that’s going to fry my liver.
  2. I don’t want to take something that’s going to fry my kidneys.
  3. All NSAIDs upset my stomach.
  4. You’re giving me ibuprofen?  I want a “real” pain medicine.
  5. My doctor said I can’t ever receive NDAIDs because I once had a bleeding ulcer.
  6. I only want hydrocodone because I heard terrible things about OxyContin® (or oxycodone or fentanyl patches, or whatever…) and that they bare addicting.

To quell some of these issues, here are the facts.

Almost no analgesics (pain medicines) will fry the liver in FDA approved doses.  The only analgesic that is likely to “fry the liver”, is acetaminophen (Tylenol®) and that is only if it is used chronically in doses exceeding 3-4 grams per day, and generally only if there is another underlying risk to the liver.  For example, if a patient has compromised hepatic (liver) function because of hepatitis-C, chronic alcoholism, binge drinking, or other disorder, or if the patient is receiving other medications that increase the risk of hepatic dysfunction, it is more plausible that acetaminophen could cause a problem.  If a patient uses acetaminophen 3-4 grams daily for 15 years or more, there is an increased likelihood of kidney dysfunction because of interstitial nephritis.  But generally, mild doses of chronic acetaminophen are fine.

Speaking of kidneys, the medication far more likely to “fry” the kidneys, are chronic use of non-steroidal anti-inflammatories (NSAIDs).  This is because of their effect on angiotensin and the resultant hemodynamics within the kidney, by inhibiting the counteracting effects of angiotensin II on efferent arterioles.  The risk of kidney toxicity is far greater in diabetics, elderly patients with decreased glomerular filtration, and/or concomitant use of “water pills” (diuretics), and/or angiotensin co-enzyme inhibitors (ACEIs).

NSAIDs do have a risk of bleeding, especially in patients with a previous history of bleeding ulcer, but, if the bleeding ulcer was determined to have been the result of H. Pylori which was successfully treated with antibiotics, an increased risk beyond the generalized bleeding risks from NSAIDs alone is questionable.  But remember this, if a patient is on once daily aspirin, antidepressants affecting serotonin, and/or blood thinners such as warfarin, the bleeding risks are enhanced.  Other factors increasing risk of bleed are cigarette smoking, age, and alcohol.

What if the patient takes a COX-2 (cyclooxygenase-2) specific drug such as celecoxib (Celebrex®), does that decrease risk of bleeding or kidney dysfunction?  Good questions.  The simple answer is that COX-2 specificity is the best and worst thing about COX-2 selective drugs. A table outlining relative COX-2 specificity is available on this website.  COX-2 specificity does decrease bleeding risk, but in a negative feedback loop, prostacyclin is involved that cuases just the opposite to maintain homeostasis.  That is, there is an increased risk of clotting with COX-2 specific anti-inflammatories.  COX-2 specific drugs as just as or even more likely to cause kidney dysfunction as the traditional NSAIDs in patients who are at risk.  The specifics of this and the history of the newly developed COX-2 class will be discussed in an upcoming [heated] blog.

Suffice it to say for now, that NSAIDs of any sort are not without risk, but they work far better for inflammatory pain than any other medications, except perhaps for steroids.  For the patient, know that opioids are not too useful alone for treating inflammatory arthritic pain.  Some have more or less gastrointestinal upset, which by the way is not predictive of gastrointestinal ulcer.  Some patients present to the Emergency Room with profuse GI bleed that had no warning signs such as pain.  Others have extensive GI upset, and upon scoping, no ulcers are present at all.

You think that opioids are the only “real” pain medicines?  Think again!  They are not a panacea, and are not without risks.  They also are far from the only option and they are not the only “pain medicines”.  Only select opioids are useful for neuropathic pain.  Opioids are a poor choice for chronic headaches because they can cause opioid rebound headaches. Opioids are not the best option for inflammatory arthritic pain, but can provide some benefit.

Please don’t tell me you want hydrocodone because you heard that oxycodone is addicting.  Give me a break!  All of the opioids are potentially addicting.  Oxycodone by mouth or fentanyl patches transdermally is not any more or less addicting than oxycodone, unless of course you are crushing and snorting the oxycodone.  In that case, you shouldn’t have any opioid.  Hydrocodone products in this country all come with acetaminophen (see the first full paragraph above).  A subsequent blog will discuss the differences between addiction, physical dependence, and tolerance.  These three terms are all very different and for now let’s just say that using chronic opioid therapy does not make you an opioid [narcotic] addict.  To say that all opioid users are narcotic addicts is like saying all SSRI users are antidepressant addicts and all cardiac patients on adrenergic blockers are beta blocker addicts.  I promise to clarify this in an upcoming blog.

The take home messages for today are:

  1. Opioids are not the only “pain medications”.
  2. All medications have potential benefits and possible risks.
  3. Most analgesics will not “fry” your liver or kidney under normal circumstances if used in accordance with FDA approved doses within specified periods of time, depending on co-morbid conditions and alcohol usage.
  4. COX-2 specificity is the best and worst attributes of COX-2 selective NSAIDs (future blog, more to come).
  5. Chronic usage of opioids does not equal drug addict (future blog, more to come).
  6. Sometimes the best medicine is no medication at all.  We should not forget that a good night sleep, healthy and active lifestyle, balanced diet, exercise, physical therapy, hot/cold packs, message therapy, electrical stimulation, relaxation therapy, behavior health therapy, and a whole host of alternative therapies alone and combined with or without medication may all be helpful.

Healthy living to all, and as always, comments are welcome!

3 thoughts on “Selecting the Right Pain Medication

  1. This is a problem, especially when dealing with pain management through a Primary Care Physician who doesn’t specialize in Pain.

    In the past I was on 30mg of Morphine Sulfate 3x a day with 5mg Oxycodone for breakthrough pain, after losing insurance I was off all opiates for over two years.

    I got a referral to the pain clinic I used to go to, who gave my doctor their records stating they believe I need the medication due to my numerous pain issues, etc.

    I started on 15mg Morphine 3x a day, and it didn’t work at all. I’m on 30mg 3 times a day now and it doesn’t work at all. When I told my Doctor all he offered to change it to was Percocet which I’ve always had tolerance issues with, and wasn’t comfortable switching to.

    Any advice on how to approach the issue with him? I don’t just want to keep ramping up my dosage forever, but what I’m on now doesn’t work. If he refuses to move me to another medication or dosage I may just wean off the Morphine and not bother anymore.

    1. Nate,

      My advise is to seek out a physician that specializes in pain management that doesn’t concentrate only on interventional procedures. Often times these are physiatrists, anesthesiologists, or neurologists. The best of all worlds is a multidisciplinary group that includes several practitioners including behavior health and a clinical pharmacist. But, those practices are unique.

  2. The big disadvantage I see comes from the fact that patient has no idea of what the “best” medication to treat their pain is. they have not received the training and do not know what will have the best results with the least amount of side effects or consequences, they just present to the medical community with their issues and are at the mercy of the level of expertise available to deal with the problem at hand.

    I was born with a condition that doctors cannot readily identify and it is estimated that fully 95% of our population die before ever being diagnosed, when presenting for pain symptoms year after year I had one physician prescribe what he considered “monster ” doses of naproxen daily for 6 years and although it did not help in my relief of the pain hardly at all it kept my digestive tract torn up the entire time with a black watery stool and the only benefit I noticed was I did not have one single headache for that entire period.

    Eventually I gave up on his ability to assist in my treatment and stopped taking the NSAID’s and actually felt better for a while, I think I was suffering from dehydration on top of my EDS symptoms from the GI issues, But still having pain that was bad enough to be life threatening (since self termination seemed a viable alternative) I had no other choices because I did not know the cause nor the options available to the medical community to which I entrusted my life.

    The funny thing was that after being hospitalized for a bowel rupture like the one that killed Houdini and doctors not being able to determine what was wrong with me even after a week of testing and almost dying from the septosis they performed emergency exploratory surgery and corrected the problem, While recovering they told me if I needed anything for pain to let them know and I never asked for so much as an aspirin and they were beside themselves with my tolerance for pain.

    It was this situation that finally allowed me to connect the dots that allowed me to discover EDS and present it to the doctors for confirmation, the problem was that I had been living with such extreme pain everyday of my life that even the trauma of surgery that would have had most people crying out for morphine afterwards was a drop in the bucket as compared to the pains I had been seeking relief from unsuccessfully all of those years.

    The sad thing is that possibly 1 in 3000 could very well have the same condition as me and be invisible to the medical community, thinking that the pains they deal with day after day are the same as everyone else’s when in fact nothing in the medical toolbox appears to be able to completely block out our pain signals but they can dull them down in sufficient quantities of some opiates from my personal experience.

    Luckily I have learned how to still function and be a productive member of society with the daily use of hydrocodone over the last 4 years, and although still enduring quite a bit of pain at times it allows me to provide for my family even though my disease normally will have everyone my age on permanent disability, we have tried things like fentanyl but even to the point of not being able to function from the amount of medication the pain was still present so the end did not justify the means, it has been better to function normally with a reduced amount of pain than to be medicated to the point of stupor and still hurt.

    But what if all of the deaths each year for drug overdoses could be explained by something like this?, it is not a far reach for me to consider after dealing with all of these circumstances personally. Consider someone like Michael Jackson who might have well had the same disease, it would have accounted for the plastic surgery failures because of the collagen deficiency in his skin, felt pain that was greater than the medical professionals could readily detect because of hyper mobile joints, the anxiety causing him to be considered “wacko” but is common due to the psychological component caused by EDS and yet even with all of the money that he had could not be properly diagnosed.

    Then lets say that he stumbles onto street drugs and finds that with opiates he finds relief, but the pain does not go away. So he eventually tries more and more trying to cross the threshold but eventually has a drug overdose before ever getting the pain to completely go away. Now after having an overdose he is considered a drug seeker and does not get access to the one item that appears to best be able to control our pain and goes so far as to have a doctor try giving him propathol to try to mask the felt pain.

    My mother was an recovered alcoholic probably for the same genetic condition but she was never diagnosed before she died, when widowed with children to take care of and was forced into the workplace with a body that fatigues easy and hurts she learned to use whiskey to dull the pain in the evenings to be able to escape the pain enough to get the strength to go back and endure the same thing day after day, eventually no matter how much she drank could she keep the pain at bay and ended up in rehab where she learned to stay away from alcohol, but lived the last 20 something years of her life sober and in pain.

    Eventually she died from complications of surgery for having multiple herniations on her back fixed but was willing to try to have the surgery done to get some relief from the pain, the same type of herniations that an orthopedist told me a couple of weeks ago that I have on every disk on my back but I can still work daily without restrictions because the hydrocodone my doctor prescribes allows me to hold the pain at bay enough to be a functional member of society.

    I will agree with you that there is no one perfect drug, but also I must state that for certain conditions like ours opiates do seem to have the best effect with the least risks and if there was anything my doctor could prescribe for me that would do a better job of masking the pain without any risk of euphoria or decrease in motor functions I would be all for it, but the knowledge to even diagnose us is not even there and to ask for them to be able to find alternatives for something they do not have a way to understand I guess is a bit much.

    But I also cannot condone the measures pursued by the FDA and those who would remove opiates from the society that has “non-cancer” pain because our existence is barely tolerable as it is, we are forced to live with crushing pain that makes us question our sanity or purpose for living, our own fears of being dependent or addicted to the the only thing that quiets the pains enough to allow us to function, and to have to deal with it as a life sentence.

    That is the worst part of it, because if we had cancer it would either remiss or terminate us and not force us to endure decade after decade of this torture, and personally if they wish to consider removal of opiates from all but the cancer patients I hope they include an euthanasia provision as well because it would be much more humane to offer us a dignified alternative to the suffering that death gives the cancer patients, I know that would seem hard to understand but until you have been chased everyday by such a cruel and vicious monster you will not understand the hope that death will finally release you from this torture.

    Thank You for dedicating so much of your life to the enhancement of living through pharmacology and I hope your knowledge continues to enrich the medical community, it needs all of the help it can get!

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