Relieving Pain With Medications Other Than Opioids
Seventh in a series
It all started with an accident at work, or a car wreck, or age-related arthritis that got worse and worse. Or something else, even a surgical procedure or an infection.
Whatever caused your pain, it didn’t go away. Over-the-counter drugs like acetaminophen (Tylenol) or ibuprofen (Advil) didn’t do the job. So you asked your doctor for something stronger.
Whether you are taking opioid (narcotic) drugs now or thinking about trying them to combat chronic (long-lasting) pain, it’s important to know that you have options.
Opioid pain medications include oxycodone (Percocet), hydrocodone (Vicodin) and others. For some people with cancer pain, and some others, opioids may be needed, though lower doses may be effective, Einstein pain specialists say.
Yet there’s limited evidence that opioids are effective for long-term pain control. Most people can find pain relief – sometimes better relief – with other medications that have fewer side effects and risks.
“About 80% of the pain we treat is spine-related, and you can add joint pain, neuropathic (nerve) pain and headaches to that mix as well,” says Jasmeet Oberoi, MD, Medical Director of the Einstein Pain Institute. “All of that can be treated with a variety of options, and opiates are going to be a small part of it, have always been.”
Use of opioids for chronic pain started increasing more than 20 years ago when national organizations included pain relief among the criteria used for evaluating doctors and hospitals. Drug companies also heavily promoted newer, long-acting opioids such as OxyContin as a safe way to treat chronic pain.
As millions more patients took opioids, and in larger doses, some became dependent, leading to a surge in overdose deaths. But in recent years Einstein and other health care organizations have taken steps to reduce opioid use and focus on a variety of other treatments.
Non-Opioid Options for Pain
Dr. Oberoi and Leonard Kamen, DO, a physiatrist and pain specialist at MossRehab, say they prescribe a variety of medications in addition to physical therapy and lifestyle or behavior changes. These drugs, which target different pathways in the nervous system to relieve pain, include:
Gabapentin (Neurontin and others) and pregabalin (Lyrica), originally approved to prevent seizures, relieve pain from damaged nerves, including the type caused by the skin infection shingles. They do this by calming overstimulated nerves and blocking certain pain messages in the brain and spinal column.
Duloxetine (Cymbalta) and some other antidepressants are used to treat muscle and joint pain, fibromyalgia, and nerve pain caused by diabetes or shingles. They work by increasing the amount of specific chemical messengers in the nervous system that reduce pain signals.
Baclofen (Lioresal and others) is a muscle relaxer that relieves painful spasms, cramps and tight muscles caused by multiple sclerosis, spinal cord problems and other conditions. Baclofen produces these effects by acting on the central nervous system.
Nonsteroidal anti-inflammatory drugs (NSAIDS) include both over-the-counter and prescription versions of ibuprofen (Advil, Motrin) and naproxen (Naprosyn, Aleve). Celecoxib (Celebrex) is prescription-only, and diclofenac (Voltaren) is available as a gel you can apply directly to a painful area. These drugs block certain body chemicals that cause inflammation and pain.
CGRP inhibitors (several types) are used to treat migraines, prevent them or both. They work by blocking the effects of a protein involved in pain transmission.
Reducing and Stopping Opioids
Dr. Kamen also has patients who have done well on long-acting buprenorphine (Butrans, Belbuca). Buprenorphine is an opioid, but deemed safer by the Food and Drug Administration, with less risk of causing breathing problems. It’s also effective in relieving pain in small doses. In larger doses, buprenorphine is used in the treatment of opioid use disorder.
“It’s tremendously gratifying to see people go from hundreds of milligrams of opiate medications to taking microdoses of buprenorphine, often at less than 3 milligrams a day,” Dr. Kamen says. “And they don’t see the same euphoria. They don’t have the cognitive clouding, and they’re able to talk with their children and their families in a more coherent way.”
Patients using opioids often resist the idea of stopping them, Dr. Oberoi says, even when he explains the side effects, such as constipation and drowsiness, and the risk of dependence and overdose.
“So I’ll give them the same prescription and tell them to try to reduce it on their own,” he says. “They’ll go home, come back after a month and say, ‘Well, you know what, I tried taking two times a day and I’m fine doing that.'”
Many patients have been able to stop in this way, on their own or with a gradual reduction in their prescription, he says. “It takes a lot of time and energy, but they manage it. People who have stopped using opioids, their functionality hasn’t changed at all. They still do what they were doing before.”
Dr. Oberoi and Dr. Kamen agree that there’s more involved with pain management than just taking medications.
Pain has its roots in the brain and the nervous system, and things can go wrong that cause pain to persist or even get worse after an injury is healed. (See “Why We Feel Pain and Why It Can Last So Long.”)
Lifestyle, Emotions and Pain Management
It’s also intimately tied up with emotions, mood, and a person’s physical and mental well-being. Therefore, long-term solutions must address a person’s total life and health needs.
Exercise has many documented benefits that include reducing pain and improving mood, so these pain specialists encourage patients to get more active as medications help them feel better.
“How do you motivate patients to do something?” Dr. Oberoi says. “You give them ideas. You first have to understand what the patient’s lifestyle is.” For example, he recommends putting an exercise bike near the TV so you can watch and pedal at once.
“I try to get people involved in community support systems wherever possible,” Dr. Kamen says.
“Perhaps the most effective thing is getting them to join the YMCA or a group that is doing yoga for seniors or tai chi. I want people to show self-reliance and a lifelong commitment to their own healthcare needs.”
Psychological issues may affect pain, Dr. Oberoi says. “People with untreated anxiety and depression tend to overuse their opiates, so we have partnered with the behavioral health services to focus on those issues.”
It’s also important to help patients deal with the trauma they have been through with pain, including the accident, injury, illness, or other event that caused it, Dr. Kamen says.
Research shows that thoughts and attitudes can make the experience of pain better or worse. Dr. Kamen uses techniques that encourage change and help people to stop “catastrophizing” – having negative thoughts that treat each setback as a sign of something worse to come rather than a bump in the road.
“Your pain is a fixed thing; it’s not just in your head,” Dr. Kamen says. “But everybody suffers differently. So, let’s see if we can find ways to mitigate your suffering.”