Saturday, November 26, 2011

Pain Drugs

Subtitled "things to talk to your doctor about".

With the aging population, and the possibility of injury... well, I don't think enough attention is paid to pain control in the US. In fact, the state of pain control, and the approach to it, is a disgrace. Which is a rant for another day. So, we'll just get started with what I've learned in the last fifteen years.

First, a note. There is "acute" pain, which is pain from an obvious source, like an injury. Then there's "chronic" pain, which is long term and the source is either unidentifiable, unfixable, or both. For practical purposes, docs consider the first month after an injury acute pain, and anything after that chronic pain. I'm not sure it's accurate, in fact, I'm sure it's NOT, but that's how it's treated in the US.

So let's talk drugs! This is by drug family or group of similarly-acting meds.

NARCOTICS: Yeah, we'll just get that one out of the way first. They work great for acute pain, but suck for chronic pain. That's not to say they shouldn't or can't be used for chronic pain, but there are other, better meds that can be tried, first. Taking narcotics, regularly, over a long period of time, can screw up your brain chemistry and affect your pain perception, actually sensitizing you and making things hurt worse. When docs say long-term narcotics aren't a great idea? That's not the DEA talking. I've read the studies, because I thought the same thing. No. They're really not a good long-term choice. Yeah, they also cause physical dependence, but it's no different than getting headaches when you quit caffeine cold-turkey. Taking some, even taking a lot, isn't going to result in you turning tricks for more. On a personal level, I hate them. They've got oodles of weird side effects, of the minor but really annoying variety, and then having to wean off the damn things when I take too many is just more annoyance on top of it. But the next time I break a bone? I WANT SOME.

NSAIDs: An abbreviation for "non-steroidal anti-inflammatory drugs". Acetaminophen, ibuprofen, aspirin, and a host of others are all in this family of drugs. I think of them as the opposite of narcotics: Instead of being good for acute pain, these are better for long term. In fact, depending on the cause of your acute pain, the blood-thinning qualities of NSAIDs can fuck you up - you're not allowed to take them after surgery, for instance. Long term is kind of fraught, too. These have the potential to cause a LOT of damage, if you take enough. Liver and kidney damage, increased risk of stroke, respiratory (asthma) troubles, you name it. Drinking and taking NSAIDs is particularly bad, and a good way to blow out you liver and make it fall out and go squish on the floor. But... when they work? Best thing ever. My favorite drug of all time is Toradol, an NSAID. It's very strong, so it's potentially dangerous, but my gods, it's awesome to be able to take a pill and have the pain go away with no weirdass side effects or loopiness or anything. Just wonderful, pain-free glory. Seriously; my 'normal' behavior after Toradol is to sit around smiling. Blissfully. For about two days.

The rest of these are generally only used for chronic pain.

CNS MUFFLERS: I'm not sure if these have a technical group name... probably, but damn if I know it. Gabapentin/Neurontin and Lyrica are two drugs given for, well, originally nerve pain. But then someone had the realization that ALL pain has to do with nerves, and they've lately been giving them out more and more for other type of pain. They work by muffling the nervous system, reducing the signals sent. Obviously this is a good thing when you're in pain, but the drugs aren't selective about what signals they muffle; there were a couple months during our move, when I was on lots of Lyrica, that I couldn't feel my feet. Which is kinda scary when going down stairs, especially with a long-standing injury that'd probably be aggravated by falling. These have a lot of other strange side effects, due to their direct effect on the nervous system: 'brain fog', numb spots, tingles, strange tastes, visual disturbance that's not QUITE a hallucination.

SSRI and SNRI ANTIDEPRESSANTS: These, obviously, mess with the ol' brain chemistry. The part of the brain that controls mood is the same part of the body that controls pain. Someone got the bright idea of trying to boost pain tolerance with anti-depressants. They kind of work. You still feel the pain, but it's easier to shake off. It also can lead to weird moods (not all of them 'up'), euphoria, and everything else you'd expect from fucking around with your brain chemistry. These drugs are also known for causing weight gain, which is a bigger problem than it first sounds like; if you've got leg or back pain bad enough to take regular drugs for it, the last thing you need is weight to make it hurt worse.

TRANQUILIZERS: These make more sense than you'd first think. They've got lots of effects. They can work as a muscle relaxant. They can quiet damaged nerves. They can help with anxiety that's a pretty obvious result when you're in constant pain. Problem is, a lot of them cause wicked-bad physical dependency, so a lot of care has to be taken to match the proper med to the proper use.

MUSCLE RELAXANTS: For orthopedic problems in particular, these can be wonderful. As with tranquilizers, though, some can cause physical dependency. Flexeril, which is a really popular one these days, DOESN'T cause dependency, which is why doctors love it so.

On the topic of physical dependency; don't let it stop you trying a medication. Yeah, quitting them again is annoying, but it's just a matter of weaning off and maybe feeling like crap for a while. A week of mild nausea is worth it, for three months (or years, or whatever) of feeling better. Quitting caffeine or cigarettes is worse than any of these meds if you wean off them first.

Steroids are another option for some types of pain. I don't have much experience with them. I've got NO experience with them for pain - I took them for asthma once or twice. They DEFINITELY have side effects and need weaning to get off them, but they can be worth it. I liked how I could breathe when I took them. I like that.

I'm not covering other things, like nerve blocks and steroid shots and like that. They can be amazing, but they're a whole other level of pain control. And this was never meant as a diagnosing guide, just a list of things to try, if you haven't before, and are in pain. Good luck.


debsnm said...

Thank you. Pain is insidious, and sometimes it's hard to know where to go next. Oh, and Toradol? I completely agree. Giddy.

Rachel said...

thanks, this is really useful - I'm just starting the pain-clinic thing for teh Crohn's and currently doing narcotics. you're right; long-term, they sucks balls.

Emily said...

I don't have chronic pain, thanks be, just chronic infection. Pain itself has nasty side-effects, I've noticed, though.

In the hospital, I've found that "some discomfort" is a code for pain. The word "pain" means the passing-out variety. I do wish they'd come up with something more accurate.

Roxie said...

Thanks. It helps to have this explained in laywoman's terms. Doctor talk is sometimes so full of bullshit. ("This may cause some discomfort." can mean "You will want to scream out loud. Don't say I didn't warn you."

GrillTech said...

What category would marijuana fall under. My son in law is an advocate on it and considers it the miracle drug.

bobbins said...

Thank you - This is a fantastic summary of pain meds. Just sorry you have a personal and intimate knowledge of the medications and how they work.

Rheumatoid Arthritis was my teacher for pain. Yuk.

But I I did enjoy the blog Hyperbole and a Half and her updated pain scale: