DSI Newsletter: Pain Pills

DSI Newsletters, Issue 43:
Pain Pills

When you are in pain you want a pill to take away the pain as soon as possible, for as long as possible, with the fewest side effects. From listening to ads on TV, the public hears a mixed message of competitors stating that they are all stronger, longer lasting, and have fewer side effects than their competitors. But which pain pill is right for me?
There are three main classes of pain medications:

NSAIDs
Tylenol
Narcotics

Each class has its own strengths and weaknesses. It is advantageous to take a low dose of each of the three classes as apposed to taking a large dose of any one. In the higher doses the side effects tend to come out. In lower doses you get the most pain relief with the least side effects.

Class A, the NSAIDs:
Non Steroidal Anti-Inflammatory Drugs (NSAIDs) are medications which, as well as having pain-relieving (analgesic) effects, have the effect of reducing inflammation when used over a period of time (antiinflammatory). They include: Ibuprofen, Motrin, Advil, Aleve, Naprosyn, Voltaren, Arthrotec, Dolobid, Lodine, Ansaid, Indocin, Orudis, Toradol, Relafen, Daypro, Feldene, Clinoril, Tolectin, Mobic, Celebrex, Vioxx, and Bextra.

Class B, Tylenol:
Tylenol (acetaminophen) belongs to a class of drugs called analgesics (pain relievers) and antipyretics (fever reducers). The exact mechanism of action of acetaminophen is not known. Acetaminophen relieves pain by elevating the pain threshold, that is, by requiring a greater amount of pain to develop before it is felt by a person. It reduces fever through its action on the heat-regulating center of the brain. Specifically, it tells the center to lower the body's temperature when the temperature is elevated. Acetaminophen was approved by the FDA in 1951.

Class C, Narcotics:
"Opioid" is a generic term for natural or synthetic substances that bind to specific opioid receptors in the CNS (brain), producing an agonist (positive) action. Opioid analgesics are extremely useful in managing pain. They are often underused, resulting in needless pain and suffering, because the required dosage is often underestimated, their duration of action and risks of side effects are overestimated, and physicians and nurses often have unreasonable concerns about the development of addiction. Although physical dependence occurs in virtually all patients treated for chronic pain with opioids for a long time, addiction is extremely rare in patients without a history of substance abuse and should not be considered in the decision to begin or to increase doses in patients with severe pain. Morphine, an opium alkaloid, is the narcotic prototype. Other opioid narcotics which have the ability to turn into morphine like substances in the body include: Hydrocodone (Lortab, Vicodin); Propoxyphene (Darvocet); Levorphanol (Levodromoran); Hydromorphone (Dilaudid); Codeine (Tylenol # 3); Oxycodone (OxyIR, Oxycontin, Percocet); Merperidine (Demerol); Tramadol (Ultram) and Methadone. It is optimum to treat chronic pain with the combination of a long acting and a short acting narcotic.

FAQs

Don't all medications have side effects? So why take any? The answer is to know the side effects of each and be on the look out for them. For example, an NSAID may interfere with your BP medication. If you have insomnia and/or diarrhea, a narcotic at bedtime could potentially treat both of those diseases while allowing the BP medication to work properly.
Aren't Narcotics addicting? The answer is yes, but in my experience, this has not been a problem. I have never prescribed a narcotic to a patient and have them have trouble stopping them.
Don't you get used to the Narcotic? Yes, this is called habituation. That means, you may need larger doses as you go along. But you may not. Also, the main side effects of constipation and sleepiness tend to get less as you use the same dose chronically over a long time.
How can I drive on a Narcotic? This is a potential problem, but in my experience, I have not seen this in my patients. When you first start a higher dose, the sleepiness and constipation are worse. But I have patients taking large doses of narcotics everyday without side effects.
Is OxyContin Safe? Even though children have died on it and the news media has discussed Rush Limbaugh's events with the drug, it is actually very safe and effective. The children getting into trouble with it fooled with the tablet itself. They crushed it or hammered it. Then they took handfuls and mixed it with other drugs and alcohol. If it’s taken as prescribed and you are followed routinely by a physician, there should not be any problems.
What other side effects might be seen with Narcotics?

Constipation
Somulence (tiredness)
Urinary Retention (can't pee)
Blurry Night Time Vision (pinpoint pupils)
Facial Flushing
Excessive Abnormal Sweating
Abnormal Unexplained Mood Changes
Nausea and Vomiting
Improved Function

In conclusion, the proper treatment of chronic pain includes the use of a medication from column A like an NSAID, one from column B like Tylenol and one from column C like a narcotic. It is useful to combine a short and a long acting narcotic together. It’s important to be aware of the side effects listed above. If you are not having those and you’re feeling better and experiencing improved function (that is, you can do more) chances are you are doing well. When it comes time to considering an increase in dose, if you are not experiencing the side effects above and you think you might have improved function with a higher dose, it should be considered.

Sincerely:

Joseph Saponaro, MD, DABIM, FACP, CPI, CCI, CCRI, CCRC, CCRP
Board Certified Internist, JPMC
Principal Investigator, DSI
Diplomat American Board of Internal Medicine
Fellow American College of Physicians
Certified Physician Investigator by the AAPP
Certified Clinical Investigator by the DIA
Certified Clinical Research Investigator by the ACRP
Certified Clinical Research Coordinator by the ACRP
Certified Clinical Research Professional by SoCRA
Member: The American College of Preventive Medicine

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