What if Pharmacologic Pain Management is prescribed to me?

Given that most patients with acute or subacute low back pain improve over time regardless of treatment, individuals should select nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation, amongst proper diet and exercise.7 Pharmaceuticals are correlated with many adverse effects. Therefore, the dose of supplemental analgesic should provide the maximum therapeutic effect with minimum risk of side effects. Discuss with your medical provider any concerns that you may have and always ask what options you have. A patient centered approach should be at the forefront of intervention. If you ever feel like you are not being heard or feel uncomfortable with a prescribed treatment plan you can always get a second opinion by a different provider.  

If pharmacologic treatment is prescribed, nonsteroidal anti-inflammatory drugs or should be selected first. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as Advil, are associated with an improvement in pain intensity. Frontline use of nonsteroidal anti-inflammatories and acetaminophen decrease consumption of opioids by 25% to 30%. Although, chronic use of NSAID’s are the best idea long-term because of adverse effects, such as liver toxicity and stomach ulcerations. Evidence demonstrates that it is better to use COX2 NSAID’s because they are easier on the stomach mucosal lining. Likewise, skeletal muscle relaxants (SMRs) have proven to be effective for improvements in short-term pain relief. SMRs aim to decrease tone in muscles that may be injured allowing them to feel less tense and guarded which can reduce the pain response. Furthermore, topical creams pain relieving creams such as capsaicin or arnica have shown to be effective at mitigating acute musculoskeletal pain.

Additionally, systemic corticosteroids have become very popular in pain-management. Corticosteroids are commonly used in the practice of pain management for their anti-inflammatory properties. These agents, produced by the adrenal cortex, are widely used in epidural, joint, peripheral nerve and various types of soft tissue injections. Often a single intramuscular injection of methylprednisolone or a 5-day course of prednisolone is prescribed. These agents clearly reduce pain and result in a higher level of function when used judiciously in patients with chronic painful conditions such as rheumatoid arthritis, mixed connective tissue disease and skin diseases. However, when used for chronic pain syndromes with localized joint, nerve or disc disease the functional improvements are less common and alternative drugs are often the choice because of the deleterious effects that these drugs can have on the already damaged joint or structure. In example, atrophy of the subcutaneous and periarticular tissue occurs where repeated injections have been given in one particular site. This may lead to tendon rupture, tendon attrition, cartilage damage, crystal-induced arthritis and pericapsular calcification. Likewise, chronic corticosteroid intake often demineralizes bone causing osteoporosis with resulting fractures common to the spine, wrist and hip. Furthermore, caution is advised when administering these drugs to patients with heart disease due to the risk of congestive heart failure.  Additionally, other associated symptoms include insomnia, nervousness, increased appetite, hypercholesterolemia. Because corticosteroids are one of the most common reasons for admission to hospital for drug related adverse events; ranging from psychosocial to exacerbation of hypertension, diabetes, and osteoporosis, it is important that individuals discuss if the benefits outweigh the risks.

Persistent or chronic pain seems to be reciprocally associated with depression and anxiety disorders and long-lasting emotional disturbance whereas low mood states such as depression and anxiety increases the perception of acute and chronic pain. For this reason, antidepressants demonstrate moderate-quality evidence showing a reduction in pain. Serotonin is a monoamine neurotransmitter that plays a major role in both nociception and mood regulation, with higher-levels correlated with less pain. For this reason, selective serotonin reuptake inhibitors (SSRI’s) are commonly prescribed for pain, particularly neuropathic pain. SSRI’s can be gleaned as an alternative treatment for chronic pain due to the fact that they are better tolerated presenting less secondary effects than other antidepressants such as tricyclic antidepressants. 

Benzodiazepines (benzo’s), have also become a popularly prescribed drug even though it is parried with many adverse effects. Benzo’s are commonly prescribed to help patients deal with anxiety and calm them down. Benzo’s have been prescribed to alleviate insomnia, especially if driven by pain, to allow the individual to get a more restful night of sleep. This can be seen as a benefit because the patient will likely function better throughout the day. Conversely, benzo’s are associated with fatigue which can cause the individual to become less motivated and have a decrease in work/social performance. It must be noted that benzo’s can be addictive and have evidence has shown that it is commonly abused. Benzo’s are highly contraindicated for anyone that is currently prescribed opioids; the risk of respiratory arrest becomes exponentially greater and there is a high correlation with hospitalization and/or death.  Furthermore, long-term use of benzo’s have shown an upregulation of the pain response/severity later in life, and lower sense of self-efficacy with their response to pain.

Lastly, opioids work both effectively and rapidly to decrease pain, especially post-surgical/ intense pain or end of life care. There are different classes of opioids including Phenathrenes (morphine, codeine, oxycodone, buprenorphine etc.), Phenylpiperidines (fentanyl, merperidine), and Diphenylheptane (methadone). Fentanyl is a synthetic opioid that is 80-100 times stronger than morphine, regarded as the strongest pain killer available for use. Opioids are highly addictive and have proven to be correlated with cognitive impairment and a sense of feeling intoxicated or an acquired altered mental status, care should be taken when operating machinery. Opioids have been associated with nausea, dizziness, constipation, vomiting, dry mouth, dependence, addiction, respiratory depression, and death. Commonly opioids are given with an anti-nausea medication. Cannabis use for pain relief is also common among people living with chronic non-cancer pain. Cannabinoids alone tend to work best for neuropathic pain but aren’t as effective for other types of pain. For example, reduction of arm and leg pain at two hours was statistically similar with ibuprofen-acetaminophen (paracetamol) versus cannabinoids. In one study conducted by Roeher et al. concluded that all patients who were taking opioids reported reducing their overall drug use, specifically opioids, by using cannabis. This may allow for opioid treatment at lower doses with fewer side effects. There have been no serious adverse events with cannabinoid use, besides some mild headaches and sedation, although some mild neurocognitive effects such as trouble learning/ memorizing while dosing. Reports of improved appetite and reduction in muscle pain, nausea, anxiety, depression and paresthesia have been associated with cannabis use. Cannabis may also act to relieve inflammation and has been found to have a useful place in the treatment of rheumatic diseases.

Additionally, given that opioids are commonly the first choice for post-operative pain research has been exploring different avenues to accomplish similar goals. A research team developed a multimodal technique for the control of pain following knee and hip surgery, called local infiltration analgesia (LIA). It is based on systematic infiltration of a mixture of ropivacaine, ketorolac, and adrenaline into the tissues around the surgical field to achieve satisfactory pain control with little physiological disturbance. The technique allows virtually immediate mobilization and earlier discharge from hospital. Pain control was generally satisfactory, numerical rating scale pain score range 0-3. No morphine was required for postoperative pain control in two-thirds of the patients. Most patients were able to walk with assistance between 5 and 6 hours after surgery and independent mobility was achieved 13-22 hours after surgery. Orthostatic hypotension, nausea, and vomiting were occasionally associated with standing for the first time, but other side effects were unremarkable. Thus, local infiltration analgesia is simple, practical, safe, and effective for pain management after knee and hip surgery.

Yet, even with new treatments such as LIA and adjuncts like cannabinoids, opioid dependence has continued to rise exponentially. The US prescribes 50x more opioids than the rest of the world combined with the market now rising over a $446-billion-dollar enterprise. Furthermore, opioid emergency room poising visits are all too common, especially in the younger populations, and for many individuals it is too late. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options . An alarming amount of patients shift from short term use of opioids to chronic use and this has proven to increase as individuals are prescribed them for as little as 5 days. This is likely due to the phenomena of opioid induced hyperalgesia, or an increased pain response when the body is deprived of the opioid substance as well as a craving for the euphoria that is commonly associated with most opioid containing substances.

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