Do you know your pain medications?

Painkillers (in my opinion) are a useful part of the recovery process. I work with individuals who may have sustained significant injuries, undergone painful operations or are coping with long term persistent pain.

Painkillers enables the individual in significant pain to participate in physiotherapy more effectively, therefore reduces the time spent towards recovery. Instances when it is very important are post-operatively, after significant trauma or injury. Therefore, to have a better understanding of what you are ingesting plays a pivital role towards your recovery (and safety)!

Although painkillers are useful, they usually have side effects. If pain medication has no side effects, they will be called magic pills! Who wouldn’t like pain relief without side effects? Every medication has a side effect profile, some more significant and some less. When I have a bad flu, my doctor prescribes me with the anti-histamine, Chlorpheniramine. It’s extremely effective for my flu but I get so drowsy that I cannot take it in the day if I have to work. Some side effects can be dangerous even, so care and knowledge about drugs are extremely important. The best drug is the one which treats the problem but has the least accompanying side effects. However, a drug that treats the problem but comes with many side effects doesn’t make it a lousy drug. For example, morphine is an excellent painkiller since long, long time ago and it is still used very often to deal with severe pain but there are risks involved because it can be addictive and it can cause your breathing to stop if overdosed.

Currently, there is also an interest to use a couple of medications at the same time at smaller dose to maximise effects and minimise side effects. For example, the doctor previously might say,

“Take paracetamol when you pain is mild, 3 times a day. However, when your pain is worse, stop paracetamol, take your Voltaren 3 times a day instead. If voltaren doesn’t help, take your Tramadol.”

Nowadays, the doctor might say,

“Take your panadol 1-2 times a day and use voltaren at the same time 1-2 times a day. If it still doesn’t give sufficient pain relief, add Tramadol. Stop Tramadol and reduce voltaren when you pain is getting better.”

Some clients I encounter think that they are taking too many different painkillers and reduce the amount of drugs that take on their own. Often, they get insufficient pain relief because they are taking less than the recommended effective dosage. I confess that taking painkillers is really something very technical and if I didn’t have any background knowledge, I will be as clueless as any other patient! I will try my very best to go through the various groups of common painkillers available for the treatment of musculoskeletal pain disorders:

Before I continue, I should state a disclaimer that I am a physiotherapist and my knowledge of medication is as much as what I was taught in school by a medical pain specialist and from reading of medical journals. Physiotherapists in Singapore are not certified to prescribe medication. However, this does not stop me from providing advice on medication. Also, never obtain pain medication from others for your own use as you never know whether it is the right drug for you. Do not be your own ‘doctor’. Always discuss medication use with your pharmacist or doctor. Information here is plainly for reference only.

Acetaminophen (Paracetamol) is the most common painkiller that is prescribed for mild to moderate pain, and we commonly use it to treat mild fever too. When taken within the prescribed dose, there is little side effects. However, there are still reports of overdose in the USA because people do not know that some combination medications also contain paracetamol. This drug is commonly prescribed for most musculoskeletal pain. Sometimes, this medication is combined with a muscle relaxant Orphenadrine citrate (for example Norgesic, Anarex) which results in drowsiness.

Non-steroidal anti-inflammatory drugs (NSAIDs) and COX-2 inhibitors (Coxibs) are medication prescribed for inflammatory pain, which can range from mild to severe pain and it usually is dependent on the severity of injury/disease. As most injuries result in inflammation thus causing pain, this group of medication works very well for most pain disorders. The difference between Coxibs and NSAIDs is that NSAIDs can cause gastric bleeds as it affects the stomach lining, while Coxibs are less likely to. Therefore, NSAIDs are usually prescribed with another medication to protect the stomach (commonly Omeprazole). The disadvantage is that taking this group of medication increases the risk of heart and kidney problems and stroke, especially in the high risk group of elderly people or those with existing heart conditions. This is the reason why we need a doctor’s prescription for this drug in Singapore. This drug is usually only used for a short period of time to manage the inflammatory pain, ranging from days to two weeks continuously at most, unless for the treatment of chronic inflammatory pain conditions like Ankylosing Spondylitis, Rheumatoid Arthritis, etc.

Common NSAIDs are Aspirin, AleveVoltarenPonstanNeurofen. Common Coxibs are Arcoxia, Celebrex.

Opioids

Mild Opioids

Tramadol is used to treat moderate to moderate-severe pain. It is classified as a mild opioid (the class of drugs that morphine belongs to). As with all opioid medication, it typically comes with side effects of constipation, nausea, itch. Codeine is less often prescribed nowadays because it is often associated with abuse.

Stronger opioids

Meant for severe pain. Opioids commonly prescribed orally are Oxycodone, Morphine. Dangerous if abused, can be fatal. Not commonly prescribed for musculoskeletal pain unless short term post-operatively or slow-release formula for chronic, severe pain.

Antidepressants:

Antidepressants, used at specific lower dosage provide pain relief independent of their effect on the person’s mood. The mechanism of action does not work like other common painkillers like Paracetamol and anti-inflammatory where it gives quick pain relief, it usually has to be taken for a couple of weeks for best results. Therefore, this drugs are not commonly prescribed for common pain that requires immediate relief action. The side effect profile is that these drugs have anti-cholinergic effects, which causes symptoms like dry mouth, double vision, urinary retention, constipation. Sometimes, patients cannot tolerate the side effects and stop before they experience pain relief.

a) Tri-cyclic antidepressants (TCA) like Amitriptyline and Nortriptyline when used in low dose, are prescribed for chronic pain and nerve pain. The side effects for this drugs are usually intolerable for many people but research shows that it works best among the others for chronic, nerve pain. Not prescribed for those with irregular heartbeat, coronary artery disease.

b) Serotonin and Norepinephrine Reuptake Inhibitor (SNRI) like Duloxetine is usually prescribed for chronic pain conditions like fibromyalgia, chronic back pain and/or nerve pain. The side effect profile seems more favourable than TCAs, especially with respect to anticholinergic and cardiac side effects. Nausea is a common side effect. Most people experience resolving symptoms of nausea after a few weeks of usage.

Discontinuation syndrome and overdose is a major problem with these drugs and can result in death sometimes. Gradual reduction of medication with medical supervision is very important.

Anti-convulsants like Gabapentin (Neurontin) and Pregabalin (Lyrica) are usually prescribed for patients with nerve-related pain symptoms in smaller dose. In higher dose, it is used to treat seizures. The advantage of Pregabalin over Gabapentin is that Pregabalin requires 2 times a day dose compared to Gabapentin’s 3 times a day. However, Pregabalin is much more expensive although both shows similar effectiveness. Usually the doctor will gradually increase the dose along the way to get you used to the side effects. Most people complain about is the tiredness in the morning after the night dose. A recommendation is to take it slightly earlier at night. Prolonged use can also lead to peripheral swelling, weight gain. Those with chronic kidney disease should also take lower dose.

Discontinuation syndrome and overdose is a major problem with these drugs and can result in death sometimes. Gradual reduction of medication with medical supervision is very important.

Local anaesthetic like Lidocaine patch works for peripheral nerve pain and those with localised increased skin sensitivity (allodynia). Usually prescribed for neuropathic pain conditions like Complex Regional Pain Syndrome (CRPS). Typically used for 12 hours continuously.

You could have been prescribed with one of a combination of these medication. I hope that after reading this, you have understood your pain medication better. I would like to end off saying that painkillers are usually part of the recovery process and it is important that you have some amount of pain cover, especially after operation, trauma and significant injury. This is because the recent recognition by doctors specialised in pain medicine that insufficient pain relief in the early stage of severe pain is known to be a significant cause of future chronic pain, as complex mechanisms take place in the body that can result in sensitization of your nervous system, causing long term pain despite the recovery of damaged tissues.

“… recent recognition by doctors specialised in pain medicine that insufficient pain relief in the early stage of severe pain is known to be a significant cause of future chronic pain, as complex mechanisms take place in the body that can result in sensitization of your nervous system, causing long term pain despite the recovery of damaged tissues.”

Thank you for reading.

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