Optimizing medications

Patients with chronic pain
often say
• I have been taking strong medication for a long time now…and yet I still have pain By David Etlin MD FRCPC
• I am taking narcotics … it takes the edge off it…but I am still inactive and unhappy … no direction Principles
“Knowledge is the Best
1. Knowledge
Is the Best Medicine
You should know:
2. Take Control
You Make the Decisions
It's Your Life
3. Practice Alternative
Ways of Coping With Pain
Take control.
Be Aware of Alternative
You make the decisions
Pain-coping Methods
- it's your life
Alternatives that others have found useful: • Any medication can help as well as harm • Your reaction to medications can change over time. • Scheduling activities & medications, pacing, exercise, stretching, modifying activities 2. Meds used during the acute stage of injury may • Stress management, positive self-talk, , • Be assertive! Discuss your medication with your psychological counseling, support groups, doctor and your pharmacist. Let your doctor know what medications work (or do not work) for you.
Medicinal plants, used throughout the
history of mankind.
The fewest medicines possible
Often effective in relieving acute and
cancer pain, less so for controlling
In the lowest effective dosages
chronic pain.
Optimum solution:
For the shortest length of time
Maximize benefits Less pain, more
Minimize side effects
Optimizing Pain Medication (1)
Optimizing Pain Medication (2)
ƒ Do not take as needed:
ƒ Fixed Time schedule
to unlearn conditioned (‘pain-pill’) behaviour, Take pills at FIXED time during the day. The CLOCK becomes your cue, not the pain. ƒ Begin monitoring your
Optimize the Dosage/number of pills.
Reduce the number of pills you are taking very
slowly. Whenever, you reduce a pill, replace it count the pills you have taken, take the with “one thing” (a food, an activity, etc) which you like eating, doing, etc. that you only reserved to do at this time Categories of Drugs
1. Anti-inflammatory /
1. Anti-inflammatory / Analgesic
• Particularly useful if inflammation present 2. Acetaminophen Analgesic
3. Opioids (Narcotics)

NSAID’s Non-steroidal Anti-inflammatory
4. Antidepressants
Drugs Advil, Motrin (Ibuprofen) and Naprosyn
5. Anticonvulsants (for Neuropathic
(Naproxen), Dolobid, Feldene, Diflunisal, Voltaren, 6. Tranquilizers or Anti-anxiety Drugs
7. Muscle Relaxants.
Cox-2 Inhibitors Celebrex, Vioxx
8. Injections.
2. Acetaminophen (Tylenol)
Possible Side-Effects of NSAID’s:
• An over the counter (no prescription) • Generally, fewer side effects compared • Long-term use may cause kidney/liver • Many combination drugs contain
acetaminophen (such as narcotic
analgesics Tylenol #1/2/3/4 with codeine
or Percocet with oxycodone)

3. Opioids (Narcotics)
Opioid Preparations
• Work by reducing the signal in your brain Available
that is received from the peripheral nerve that enters the spinal cord • Long acting – 8-12 hour period,
• Stronger pain medications and are very effective for acute injuries, cancer and after • Patch - fentanyl, (Duragesic)
• The role of opioids in the management of non-malignant chronic pain remains controversial and is different for each • Short acting – lasts about 4 hours
Opioid Side Effects:
Opioid Withdrawal
• Nausea, vomiting, constipation, sedation, • If you abruptly stop taking this medication, ƒ Opioids cause chemical changes in spinal cord neurons that lead to tolerance. This can • You can gradually step down from these increase pain intensity. Over time, the dosage of the narcotics may need to be increased to offset these cellular changes • Overdose or mixing it with other meds/alcohol 4. Antidepressants
Tricyclic Antidepressant:
amitriptyline (Elavil), nortriptyline (Aventyl) Help boost energy level during the day.
desipramine (Novopramin), doxepin (Sinequan), imipramine (Tofranil), and trazodone (Desyrel) • Alter the level and release of chemical Selective Serotonin Reuptake Inhibitors
(SSRIs) fluoxetine (Prozac), paroxetine (Paxil),
• Alter the communication of pain signal to the fluvoxamine (Luvox), and sertraline (Zoloft) Newer Antidepressants
Side Effects of tricyclics:
bupropion (Wellbutrin), mirtazapine (Remeron), Dryness of mouth, drowsiness, constipation, nefazodone (Celexa) and velafaxine (Effexor) 5. Anticonvulsants (for
Anticonvulsant Side
Neuropathic Pain)
Carbamazepine (Tegretol) &
Gabapentin (Neurontin)
Most useful if nerve damage present
• Decreases the electrical activity in the • Nerve no longer transmits message normally & may fire spontaneously for unknown • Pain often described as “jabbing, stabbing, 6. Tranquilizers (Anti-
Tranquilizers (cont)
Diazepam (Valium), clonazepam (Rivotril),
Side effects:
alpraxolam (Xanax), lorazepam (Ativan), temazepam (Restoril), triazolam (Halcion Help reduce anxiety,fear and irritability associated with pain and as sleeping pill techniques such as biofeedback, stress management, coping skills training, and individual counseling to help reduce anxiety and panic or to increase a sense of control and empowerment 7. Muscle Relaxants’
8. Injections
relaxers” Misleading as this class of drug does not appear to act directly on the muscle to cause relaxation • Need to be used cautiously, little evidence for long-term benefit, invasive procedure • Side effects are similar to tranquilizers – with potential for serious complications 9. Drug Interactions & Alcohol
• Alcohol should not be taken with other Use of Alcohol to reduce pain, relax and to get
sleep at night may cause more problems such medication + alcohol can lead to stomach problems). impair your concentration, memory and reaction speed • Combining alcohol with narcotics, muscle cause irritability, anger and depression. relaxants and antidepressants can lead to interfere with normal sleep patterns.
Over time, your body becomes tolerant of the effects of alcohol and may lead to increased use and • Many herbal pain remedies contain mild • Effects on pain appear mild to moderate • May be more important in controlling nausea, seizures, poor appetite & weight • Before mixing herbal and pharmaceutical

Source: http://www.healthrecoverygroup.com/pmp/resources/optimizing_medications.pdf


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