Pain is among the primary reasons why many people seek medication across the globe. With the on-going prescription opioid epidemic in the United States, it is imperative for public health to educate and inform what the potential options of non-opiate pain killers and medications are, especially for those suffering from addiction.
Before getting into the options of non-opiate pain killers, we need to understand pain. Pain is a predisposing factor for disability and other problems and is classified into two categories; acute and chronic pain.
Acute pain is defined as having an onset that is readily associated with an underlying cause, and whose resolution tends to be associated with the resolution of the underlying condition, lasting no more than 3 months.
Chronic pain, however, is defined as pain that lasts at least 3 months, usually beyond the acute healing of the underlying condition, which often has underlying structural or physiologic abnormality that persists (i.e., arthritis, diabetic neuropathy or nerve pain). Unlike acute pain, chronic pain is not just a symptom – chronic pain is a disease unto itself that usually requires assessment and treatment if it is to improve.
More than 100 million Americans suffer from chronic pain, publishes the NIH. The condition is treated as a disease and it affects optimal body function, the nervous system, and it generally makes life less enjoyable. In fact, according to a report by the Washington Post, around 25 percent to 75 percent of individuals suffering from chronic pain also experience depression, which means effects like insomnia, loss of appetite, anxiety, and fatigue are inevitable.
Among the prescription drugs, people suffering from pain get include opioid medications. According to an independent report of self-reported data for Lakeview Health patients from September 2007 – March 2018, 45% of our patient population has suffered from back problems, many addicted to opioid pain medications. In 2017, Dr. Adrian Blotner developed our Pain Recovery Program, an integrative, multi-modal program designed specifically for patients in recovery from alcohol and substance use disorders who are also managing a chronic pain condition.
There is a little evidence to show that long-term treatment with opiate (narcotic) pain medication is any more effective than treatment with non-opiate medications, especially when combined with non-medication treatments. So when considering treatment options for chronic pain, it’s important to know about the limited benefits of long-term opiate therapy, as well as the potential for serious adverse effects and withdrawal symptoms of opiates.
In a study published by the Journal of the American Medical Association, it was found that all the groups depicted similar reduction levels of pain. This study sought to establish whether prescribed opioids are appropriate for the treatment of acute pain in four groups of participants with mild to severe pain. Three groups took opioids (either hydrocodone, codeine, or oxycodone) with 300 mg of acetaminophen, a non-opiate pain killer, and another group took 400 mg of the non-opioid pain killer, ibuprofen with 1000 mg of acetaminophen.
Although the opioids group showed positive levels of pain relief, they were no better than non-opioid pain killers combined. In 2017, the opioid epidemic was a hot topic in the media and according to Google, the query, “What are opioids” is searched over 40,000 times in America. Education on alternative, non-opiate pain medications is imperative for public health.
Although opioids are normally prescribed for acute and chronic pain, the following non-narcotic pain meds are also effective for several kinds of pains, even those that seem to be perpetual.
Non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve), are sold over the counter and are often the first choice for the treatment of acute pain. Prescribed NSAIDs include Meloxicam (Mobic), Celecoxib (Celebrex), and others.
Despite their effectiveness in relief of chronic pain conditions such as headaches, osteoporosis, and rheumatoid arthritis, long-term use of these drugs may have serious side effects such as stomach discomfort, stomach ulcers, clotting abnormalities, and other serious systemic side effects.
Acetaminophen (Tylenol) is a non-opiate that is sold over the counter and used by itself or in combination with other medications used for pain relief. Patients with arthritis, headaches, and cancer-related pains find this drug very useful. Acetaminophen (Tylenol) has not been associated with stomach problems or bleeding problems. It has, however, been associated with liver toxicity when used in high dosages for ongoing chronic pain, especially when the person has other contributing factors for liver problems, such as regular alcohol use or Hepatitis C.
There are several non-habit-forming muscle relaxants that reduce muscle tension and spasm, which are the great “amplifiers” for many chronic pain conditions. Commonly used agents (from less strong to more strong) include Methocarbamol (Robaxin). Metaxalone (Skelaxin), Cyclobenzaprine (Flexeril) and Tizanidine (Zanaflex). The stronger agents have more risk of causing daytime drowsiness, so some people take them only at bedtime. Carisoprodol (Soma) is an old agent that is metabolized to Meprobamate (Equanil, or Miltown), which can be very addictive, so many prescribers today avoid prescribing this.
There are several antiseizure or anticonvulsant medications that are effective for chronic pain, as well as chronic migraine headaches. Most people ask, “What do seizures, migraine headaches, and chronic pain all have in common?”
They all happen because, somewhere in the brain or spinal cord, bundles of nerve cells are firing a lot faster than they should be. If that bundle of nerve cells is in the motor cortex – the part of the brain that controls muscle movement – then it results in a seizure. If the bundle of nerve cells is in a place called the trigeminal nerve nucleus, then the result is a migraine headache. And if the bundle of nerves is in the spinal cord, or a damaged nerve outside the spinal cord (such as diabetic neuropathy, or shingles), then the rapid firing causes a burning sensation, often with muscle pain, tension, or spasm.
Gabapentin (Neurontin) and Pregabalin (Lyrica) are FDA approved for different types of chronic pain and fibromyalgia. Topiramate (Topamax) and Divalproex (Depakote) are FDA approved for a chronic migraine headache prevention.
Several antidepressants are safe and effective for chronic pain, for those who are able to tolerate these medications without having side effects. They act on the nerves that are transmitting the pain because some of the same neurotransmitters, or brain hormones, that are in the depression pathways are also in the pain pathways in the brain and spinal cord. They are known as serotonin and norepinephrine reuptake inhibitors (SNRI) and are prescribed by many primary care physicians, as well as psychiatrists.
The newest SNRI is Duloxetine (Cymbalta). It is approved by the FDA (U.S. Food & Drug Administration) for osteoarthritis and chronic back pain due to its pain relieving properties. It is also FDA approved for generalized anxiety disorder and clinical depression.
Tricyclic antidepressants (TCA) have been shown to be effective for chronic pain since the early 1980’s. For most individuals, they also have other benefits, such as improving sleep, reducing anxiety, and improving mood. The more common agents in this category include Amitriptyline (Elavil), Imipramine (Tofranil), and Doxepin (Sinequan). TCA’s commonly cause dry mouth and at least a mild degree of constipation (which can be treated), but can also lower blood pressure and have the potential to cause heart rhythm problems, particularly in those who already have heart disease. The elderly can be particularly sensitive to these adverse effects. TCA’s are potentially lethal if taken in overdose. desipramine (Norpramin), and nortriptyline (Pamelor) are a few examples of TCAs. Usage of these drugs should be kept in check since they may have serious side effects on the elderly or some individuals.
If started at a low dose and gradually increased antidepressants tend to have minor and transient side effects in most individuals. But some individuals experience serious emotional and behavioral side effects, including insomnia, restlessness, agitation, worsening of mood, and suicidal thoughts. As always: after starting a new medication notify your prescriber immediately if you feel worse in any way. Other types of antidepressants known to relieve pain include selective serotonin reuptake inhibitors (SSRI) However, there is not enough research to support this claim.
Non-medication treatments are usually effective for pain that is less severe, short term, and less chronic. They can also be effective when utilized along with non-habit forming medication. But the more severe the chronic pain, and the longer the duration of chronic pain, the more limited will be the benefit of non-medication treatments alone.
Physical exercise and behavioral therapy are both effective in treating chronic pain. These treatment methods are also known as complementary and alternative medicine (CAM). The journal Practical Pain Management says that these alternative methods significantly improve one’s quality of life.
Most often, these forms of treatment are used with other techniques in an effort to find what works best. They are not universal and may not work for everyone. If you want to get results that are better than what you’ve accomplished before, it is important to be willing to consider trying treatment methods and techniques that you have not tried before, with the guidance of your treatment providers. Speak with your primary care physician to discuss those treatment options that are most likely to be safe and effective for your particular conditions.
Due to the potential for physical, emotional, and behavioral side effects, including addiction, the risk of overdose, and adverse effects on physical and social functioning, including relationships with friends and loved ones. Long-term opioid treatment should be a treatment of last resort. Benefits tend to gradually decrease and side effects tend to gradually increase as the months and years go by. If a treatment trial with long-term opiates is to be undertaken, it should be very closely monitored by a qualified and experienced prescriber. In the long term, non-opiate treatments tend to be more effective as well as safer.
If you or a loved one is suffering from an opioid addiction or a physical dependence to pain meds, it’s important to seek addiction treatment. At Lakeview Health, we will address it properly with a medically monitored detox or other treatment options, depending on the level of substance use disorder treatment you need.
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