Unlike years ago when physicians had only a handful of options for treating painful conditions with medications, modern pain management specialists have literally hundreds of pharmacological options to choose from to manage acute and chronic pain. In general, for almost every class of medication used to treat pain, the lowest effective dose should be used in order to minimize the risk of side effects, adverse reactions, and poor outcomes.
Controlled substances are often indicated for the treatment of acute pain and sometimes for the treatment of chronic pain. However, the physician and patient must remain vigilant at all times to watch for medication interactions and the signs and symptoms of prescription drug abuse and addiction.
While the use of controlled substances to manage pain always involves the risk of addiction, over sedation, respiratory depression, and death, these risks can be minimized by very close follow-up with the pain management specialist.
There are numerous pharmacological classes of medications used to treat pain by the physicians at Flamingo Pain Specialists. Some of these are listed below.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
Non-steroidal anti-inflammatory drugs are a mainstay of chronic pain treatment, however, this class of drugs has a number of side effects that must be considered. Such medications include aspirin, ibuprofen (Motrin, Advil), indomethicin (Indocin, Tivorbex), ketoprofen, naproxen (Naprosyn, Aleve, Anaprox, Vimovo), piroxicam (Feldene), sulindac (Clinoril), and tolmetin.
Acetaminophen
Acetaminophen (Tylenol) is an old drug that’s been used for decades. It is commonly used as both an analgesic (pain reliever) and antipyretic (fever reducer.) Its exact mechanism of action is poorly understood, despite decades of medical research. Acetaminophen can have a very harmful effect on the liver and it is important for chronic pain patients to closely monitor the total amount of Tylenol ingested per day.
Gabapentinoids
This class of medications is very useful in the treatment of neuropathic pain such as various types of neuropathy, as well as other types of chronic pain. Gabapentinoids (Neurontin, Gralise, Lyrica) are known to suppress neural cells in the spinal cord that transmit pain signals to the brain.
Gamma Aminobutyric Acid (GABA) Agonists
GABA agonists (Baclofen) are primarily used to treat pain due to muscle spasm.
Seratonin and Norepinephrine Reputake Inhibitors
These classes of medication play an important role in the management of chronic pain. They have a wide variety of interactions with the pain pathways from the peripheral nervous system to the brain. Medications in these classes include amitriptyline, nortriptyline, desipramine, duloxetine (Cymbalta), venlafaxine (Effexor), paroxetine (Paxil, Brisdelle, Pexeva), and fluoxetine (Prozac, Serafim).
Sodium Channel Blockers
These medications include the local anesthetics, lidocaine, bupivacaine, tetracaine, prilocaine, and mexiletine. They also include other medications that were initially developed to treat seizures, depression, and/or anxiety. This latter category includes lamotrigine, carbamazepine, phenytoin, and doxepin.
Alpha-2 Agonists
The alpha-2 agonists include clonidine and tizanidine (Zanaflex). These medications block the effect on the transmission of pain signals from the peripheral nervous system to the brain. Tizanidine also has a powerful antispasmodic effect on the muscles.
NMDA Antagonists
NMDA is a neurotransmitter in the brain and spinal cord. This class of drugs blocks transmission of the NMDA signals involved in pain. Commonly used NMDA blockers include dextromethoraphan and ketamine. Ketamine given intravenously or intramuscularly is used by anesthesiologists for surgery. However, it is sometimes used in chronic pain as an ingredient in a cream or lotion.
Glucocorticoids
Glucocorticoids such as hydrocortisone (Cortizone), dexamethasone (Decadron), and triamcinolone (Kenalog), are steroids and have powerful anti-inflammatory and associated pain relieving effects. While they have a place in the treatment of pain, they are almost always used to treat inflammatory conditions on a short-term basis. The long-term use of glucocorticoids is associated with numerous adverse side effects and potentially life-threatening complications.
Opioids
Opioids, sometimes referred to in the law enforcement and legal communities as “narcotics,” have been used to treat moderate to severe pain for centuries. While these medications can be extremely useful, particularly in the treatment of pain due to cancer, they have a number of serious side effects and must be used with extreme caution. Side effects of opioid medications include constipation, nausea, vomiting, itching, drowsiness, delirium, and sexual dysfunction. The most feared complication of opioid medications is respiratory depression which can lead to death. Very close follow-up and monitoring is required when patients are prescribed opioids.
Commonly prescribed opioid pain medications include tramadol (Ultram, Ultracet), morphine (MS Contin), hydrocodone (Vicodin, Norco, Lortab), oxycodone (Roxicodone, Oxycontin), oxymorphone (Opana), hydromorphone (Dilaudid, Exalgo), and fentanyl (Duragesic). Because of the risks of serious adverse outcomes, fentanyl “lollypops” and fentanyl nasal sprays are almost never prescribed by Flamingo Pain Specialists, other than for cancer patients. Similarly, because of its extremely long half-life, interaction with other medications, and tendency to accumulate over time, methadone is almost never prescribed for pain at Flamingo Pain Specialists.
Benzodizepines
Benzodiazepines such as diazepam (Valium), alprazolam (Xanax), and lorazepam (Ativan) are sometimes used to reduce anxiety and/ or insomnia associated with chronic pain. However, these medications must be used with extreme caution. They can increase the risk of respiratory depression associated with opioids. Benzodiazepines have no specific pain relieving properties themselves. Long-term use of benzodiazepines is associated with depression and cognitive impairment.