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Medication Management of Chronic Pain
Medications for chronic pain can be a Godsend or can be a curse- or both. Opioids have been the mainstay of chronic pain treatment for decades, but doctors naively believing chasing the tolerance that develops by ever escalating the dosages, have created an opioid epidemic of death and addiction throughout the country. As of 2016, 48,000 people in the US die each year due mainly to prescription and millions become addicted without knowing it, having the same identical symptoms as heroin addicts. High doses of opioids are almost never indicated for chronic pain, but controlled use of low doses may be beneficial. We now have 25 studies showing reduction from high doses to low doses or to no opioids causes chronic pain to either stay the same or improve. If opioids were really effective at high dosages, then the pain would significantly worsen.
Opioids
"If doctors told their patients they can be placed on marginally effective temporary treatments for pain (moderate to high dose opioids) that 5% of the time (addiction) would result in the destruction of their lives, their relationships with family, their finances, their jobs, and condemn them to poverty, how many patients would take their doctors up on it? If doctors told them that up to half those with this temporary treatment would engage in drug diversion (landing some in prison) or substance abuse, how many would agree to this treatment? If patients were told there are more deaths from patients receiving this treatment than in all automobile accidents in the US, it would be interesting to note their response. If doctors told them that long term, taking this treatment does not lessen the pain any more than not taking the treatment (25 studies prove this), how many would start on this path? If doctors were honest up front with their patients, what would happen?"
At Algos Medical, opioids are prescribed for pain, but with restrictions on dosage and DEA Schedule of drug depending on the medical conditions. For instance, for non-malignant pain or pain from what was previously an active malignancy (cancer) but is now in remission, only Schedule III, IV, and V opioids are prescribed. In other words, unless you have active cancer, you will not be prescribed Schedule II opioids that include hydrocodone (Vicodin, Norco), oxycodone (Percocet, Roxicodone, Oxycontin), hydromorphone (Dilaudid), oxymorphine (Opana), morphine (MS Contin, Kadian), meperidine (Demerol), fentanyl (Duragesic) or methadone. These drugs are drastically overused in the US, with a 600% increase in prescribing per capita over the past 2 decades but with no demonstrable increase in pain to justify such prescribing, nor is there any evidence such high dose opioids are effective for chronic non-malignant pain. Also, multiple studies show that 25-50% of the people receiving prescriptions for these risky drugs engage in substance abuse or diversion (giving away pills to family members or friends- a felony). Algos Medical will not be part of the societal disregard for the potential of these drugs to kill when misused as they frequently are. Addiction to the more potent drugs can occur in as little as one week's use, therefore getting off opioid narcotics as soon as possible after surgery or injury is critically important, and many studies show ibuprofen just as effective as opioids in relief of post surgical or dental pain.
For non-malignant pain we prescribe the much safer Schedule III-V opioids tramadol (Ultram), buprenorphine (Butrans, Suboxone), codeine (Tylenol #3), pentazocine (Talwin), or dihydrocodeine (Synalgos DC). In most cases, we are able to transition from the Schedule II to Schedule III-V drugs and still achieve pain control. Sublingual buprenorphine (under the tongue) is as strong as moderate to high dose Schedule II drugs while Butrans patches are as effective as 6- 10mg hydrocodone per day. Schedule III-V drugs are only rarely involved in overdose death or maintenance of addiction relative to these commonly occurring with Schedule II drugs. Opioids come with a medical price to pay: side effects, but Schedule III-V side effects are much less severe than Schedule II drugs. Opioid side effects are dose dependent, strength of drug dependent, and may be amplified by other medications. The most common side effects include constipation, difficulty urinating, weight gain, swelling, and itching. These do not occur in most patients and in those where they do occur, they may be mild. More severe side effects include respiratory depression, sedation (even during the day), difficulty thinking, unconsciousness. Combining any opioid with alcohol or benzodiazepines (e.g. Xanax, Klonopin, Valium, Restoril) taken within several hours of the opioid may lead to death or severe side effects.
BLOOD LEVELS AND RECEPTOR OCCUPANCY OF DIFFERENT COMMERCIALLY AVAILABLE FORMS OF BUPRENORPHINE
SINGLE DRUG Buprenorphine
Belbuca 75mcg film- 0.17 ng/ml- 8%
Belbuca 600mcg film- 0.76 ng/ml- 38%
Butrans 10mcg/hr patch- 0.19 ng/ml- falls to half of this on day 7- 8%
Butrans 20mcg/hr patch- 0.47 ng/ml- falls to half of this on day 7- 22%
Buprenorphine 2mg sublingual tabs- 1.25 ng/ml (Subutex- brand off market, generic available)
Buprenorphine 8 mg sublingual tabs- 2.88 ng/ml (Subutex- brand off market, generic available)
Buprenorphine 0.3mg IV injection (available clinically)- 2.1 ng/ml (calc)
COMBINATION Buprenophine/naloxone Generally Tmax ~ 3 hours
Suboxone generic tabs 2mg SL- 0.8ng/ml (est.)-40%
Suboxone generic tabs 4mg SL- 1.9ng/ml- 58%
Suboxone generic tabs 8mg SL- 2.65ng/ml- 78%
Suboxone film 2mg – 1.1 ng/ml (est)- 45%
Suboxone film 8mg - 3.0ng/ml (calc)-82%
Zubsolv 1.4mg tabs SL- 0.8 ng/ml-40%
Zubsolv 5.7mg tabs SL- 2.7ng/ml-78%
Bunavail 2.1mg buccal films- 0.88 ng/ml-41%
Bunavail 8.4mg buccal films- 3.0 ng/ml-82%
In patients with active cancer as diagnosed by other physicians and suffering severe pain directly related to the cancer or its treatment, Schedule II opioids are prescribed.
Because of the risks inherent in the use of these medications, urine drug screen monitoring is randomly used, and is mandatory in order to continue use at Algos. We also require in-person visits for prescriptions consistent with state and federal laws. We reserve the right to discontinue opioids at any time in cases of substance abuse, diversion, obtaining opioids from other physicians while getting them from us, use of dangerous combinations of drugs (e.g. Soma plus benzodiazepines plus opioids), use of alcohol, impairment from the drugs, admission to a hospital because of the drugs, admission to a rehab center due to drug use (opioids or illicit drugs).
Antidepressants
Depression associated with chronic pain occurs more than 50% of the time, and actually amplifies chronic pain significantly. Antidepressants such as the tricyclic antidepressants amitriptyline (Elavil), and the SNRI antidepressants venlafaxine (Effexor), duloxetine (Cymbalta), milnacipran (Savella), escitalopram (Lexapro), etc. are frequently used not only as a depression treatment but also to augment other methods of combatting chronic pain. By themselves, antidepressants have only a marginal effect on pain reduction but when combined with other methods of pain control, they may exert a powerful and sustained reduction in chronic pain. Even if you are not clinically depressed, you may be prescribed these medications. Antidepressants seem to be more effective on neuropathic pain compared to other types of pain.
NSAIDS
Non-steroidal anti-inflammatory drugs are useful in mechanical pain (that produced by movement), often due to inflammation of the joints, tendons, or ligaments. They are important to help prevent the development of hypersensitive pain states if used early after an injury or surgery. They are also partially effective in the treatment of chronic pain, but by themselves may not be sufficient to control chronic pain. These drugs include prescription meloxicam (Mobic), celexecob (Celebrex), etodolac (Lodine), diclofenac (Voltaren) and others, non-prescription ibuprofen (Advil), naproxen (Aleve), aspirin, and the "natural" substances ginger and turmeric. They may produce heart failure or high blood pressure in some patients and should be avoided after suffering a heart attack due to a much higher incidence of recurrent heart attacks after the first one when taking these drugs.
Anticonvulsants
These medications may be beneficial in neuropathic (nerve related) pain in some patients. These include diabetic neuropathy, lumbar or cervical radiculopathy, entrapment neuropathies, etc., but the effect is not consistently demonstrated in studies. These drugs include pregabalin (Lyrica), gabapentin (Neurontin), Keppra, topiramate (Topamax), etc. Some studies show high doses of gabapentin amplify the mortality rate of those who die from high dose opioids.
Muscle Relaxants
These really do not relax muscles, but instead act in the brain to cause a central effect. Some of these are overtly dangerous in combinations with opioids. The most dangerous is carisoprodol (Soma) that is metabolized into a major tranquilizer as used in the 1970s. Combining this with benzodiazepines (Xanax, Valium, Klonopin, Restoril) and an opioid is deadly and therefore the combination should never be received by any patient. Some patients inadvertently receive this combination when two or three doctors are prescribing medications at the same time and either do not notice the combination, lack the education to understand the danger of the combination, or simply do not care. At Algos we monitor patients on the state prescription database and if the combination is seen, opioids will be discontinued. Another muscle relaxant is cyclobenzaprine (Flexeril) which is structurally nearly identical to amitriptyline (Elavil). Therefore patients should never be taking the combination of these two drugs since excessive amounts may lead to cardiac dysrhythmias and death. Other muscle relaxants commonly prescribed include metaxalone (Skelaxin) or methocarbamol (Robaxin) that have less sedating effects compared to carisoprodol or cyclobenzaprine. Chlorzoxazone (Parafon Forte) is an older medication rarely used now and baclofen (Lioresal) is commonly used as a muscle relaxant. The latter may produce profoundly decreased muscle tone in high doses so the dosage should be titrated to effect.
Others
Clonidine, a medicine that is an alpha blocker, has some effectiveness on chronic pain. Ketamine is a medicine that may be received orally or intravenously for treatment of both chronic pain and depression. L-dopa, a drug used for Parkinsons disease, has been shown in animal studies to be effective in preventing chronic pain and in the treatment of chronic pain. Topical medications such as lidocaine (ointment or patch) may be useful in some patients with mechanical pain or neurological pain.
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