EXCHANGING A PILL FOR AN ILL - What pain medications would I never take - and why.

pill-3264945_1280.jpg

I want to provide ample information to our wonderful readers who want to truly know their options in terms of pain management outside of Opioids.

I am educated in Trauma Surgery out of Cornell University. I have seen burns, people who have fallen from 3 floors up and landed head first or neck first onto the unforgiving concrete below. I am also board certified in Integrative and Holistic Medicine and believe in doing more than simply - EXCHANGING A PILL FOR AN ILL.
I want to treat the whole person. However, having said that let’s look at some traditional modalities of treatment then we will look at more holistic approaches.

What pain medications you would never take and why?

1) Firstly there are two types of pain...

  • A) Neuropathic pain, resulting from damage to or pathology within the nervous system, can be central or peripheral. Causes of neuropathic pain are multiple and include diabetes mellitus, postherpetic neuralgia, and stroke.

  • B) Nociceptive pain, in contrast, is caused by stimuli that threaten or provoke actual tissue damage. Nociceptive pain is often due to musculoskeletal conditions, inflammation, or mechanical/compressive problems.

I would hesitate to take even Acetaminophen — Para-acetylaminophenol, known as acetaminophen in the United States and paracetamol in Europe, is the most commonly administered over-the-counter oral analgesic. The analgesic mechanisms of acetaminophen remain uncertain. In contrast to NSAIDs, acetaminophen is not anti-inflammatory.

Acetaminophen (Tylenol) is commonly combined with opioid medications to reduce the amount of opioid needed. However, such combination products may be difficult to titrate as the opioid dose is limited by the toxicities of acetaminophen at higher doses. In the United States, because of concerns about unintentional acetaminophen overdose, as of January 2014, all prescription combination drug products with more than 325 mg acetaminophen per tablet have been withdrawn from the market and are no longer available.

There is controversy about the maximum safe daily dose of acetaminophen. The safety of long-term use of acetaminophen at a dose of 4 g per day has been questioned.

The FDA lists the maximum dose of acetaminophen to be 4 g per day [38]. Some but not all manufacturers of over-the-counter acetaminophen have decreased the maximum daily dose to 3 to 3.25 g. Significant liver disease or heavy alcohol use should be considered a relative contraindication to acetaminophen use and the maximum safe dose in these patients is conventionally thought to be 2 g per day.

Other side effects of Tylenol can include developing ulcers in your stomach and duodenum (The first portion of your small intestine), Chronic Kidney Disease and Hypertension.

A systematic review of NSAIDs for the treatment of low back pain found that NSAIDs were more effective than placebo for pain relief, although they had significantly more side effect(Roeloff PD, De York, Koef BW et al. Non -Steroidal Anti-inflammatory Drug for low back pain: A.M. updated Cochrane Review. Spine [Phila.PA 1976] 2008; 33:1766. This review did not find NSAIDs more effective than acetaminophen. Although several guidelines recommend oral NSAIDs as first-line therapy in selected patients, the American Geriatric Society (AGS) guidelines for the management of persistent pain in older patients and the National Institute for Health and Care Excellence (NICE) guidelines for OA suggest that systemic NSAIDs should be avoided when possible. For patients with localized pain in specific joints, topical NSAIDs may be a reasonable option for a trial of therapy.

I would also stay away from Opioids like Oxycodone as they can be very addicting and it can take as little as 3 weeks to become addictive.

2) Instead, I would use Lidocaine Pain Patches and Tiger Balm Ointment. Also for Nociceptive Pain Medicinal Cannabis is VERY Effective as there is less risk of respiratory depression as compared to using Opioids.

Also — Spinal cord stimulation (SCS), a spinal neuromodulation analgesic system, is an option for chronic neuropathic pain which can arise after nerve or nervous system injury. SCS is a minimally invasive and reversible treatment option which can be permanently implanted after an appropriately conducted temporary screening trial with an external pulse generator to assess therapeutic efficacy and adverse effects. In the United States, the most common indication for spinal cord stimulator placement is chronic pain from failed back surgery syndrome. SCS may also be used for complex regional pain syndrome, intractable angina, and painful peripheral vascular disease.

Interventional approaches — Interventional approaches may play a complementary role to other strategies and typically attempt to target the presumed "pain generators." The most common interventional procedures are percutaneous injections, whereby small-bore needles are inserted through the skin and directed (often with the assistance of imaging) to the presumed "problem" site. A pharmacologic agent is then deposited, usually glucocorticoid and/or local anesthetic. Neural "ablation" (with cryoanalgesia radiofrequency thermocoagulation, or neurolytic agents such as alcohol or phenol) is generally reserved for situations of severe cancer pain where the patient has a guarded prognosis.

Interventional procedures for non-cancer pain including intercostal nerve blockade, spinal injections (epidural steroid injections, selective nerve root injections, and medial branch nerve injections of the facet or zygapophyseal joint), occipital nerve injections, and multiple other peripheral nerve injections. Injections may provide short-term analgesia for a well-selected patient to facilitate physical therapy; however, evidence for significant improvements in long-term outcomes is limited.

Transcutaneous electrical stimulation — TENS involves the application of electrical currents to the skin primarily for the purposes of pain relief. It is a safe, noninvasive treatment that can be self-applied.

The clinical application of TENS involves the delivery of a low voltage electrical current from a small battery-operated device to the skin via surface electrodes. The majority of TENS devices offer variable frequency, pulse duration, intensity and type of output (burst or continuous). Combinations of different stimulation parameters are used to produce four main modes of TENS: conventional TENS (high frequency, short pulse duration, low intensity); acupuncture-like TENS (low frequency, long pulse duration, high intensity); burst TENS (high frequency trains of pulses delivered at a low frequency); and brief-intense TENS (high frequency and long pulse duration pulses delivered at a high intensity) . Conventional TENS produces paraesthesia in the area under the electrodes whereas the production of muscle twitches is desirable with acupuncture-like TENS.

Research on TENS for pain relief has suffered from a lack of rigorous randomized controlled trials (RCTs) and systematic reviews have found variable and inconclusive results of the efficacy of TENS in chronic pain management. Further evidence is required to determine the efficacy, parameter specific effects, and cost-effectiveness of TENS. Optimal stimulation parameters and treatment durations should be considered while interpreting the outcome of systematic reviews on TENS.

3) I can be referenced as Pain Management Physician and Addiction Medicine Physician with a specialization in Integrative and Holistic Medicine.