Medication

Recently, a group of experts from the American Pain Society and the American Academy of Pain Medicine Opioids Guidelines Panel published recommendations on the use of opioids for treating chronic pain. The panel suggested that opioids can be useful medications for treating chronic pain when used appropriately and cautiously in carefully selected patients. Pain and Wellness Center uses these guidelines along with the World Health Organization's (WHO) Pain Relief Ladder protocol as tools to treat pain. The WHO Ladder recommended treating pain based upon mild, moderate, or severe levels. Each phase includes opioids and adjuvant medications to address pain.

The First Step
The First Step consists of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen for the treatment of mild pain. NSAIDs are fairly equivalent in analgesic effect with the exception of indomethacin, which is best when treating acute gout. NSAIDs vary in frequency of dosing and severity of side effects. NSAIDs are contraindicated in patients with aspirin or NSAID allergy and active bleeding disorders such as gastrointenstinal (GI) bleeding. Caution is advised in elderly patients and in patients with a history of nasal polyps, hypertension (high blood pressure), cardiovascular disease, and a history of GI bleeding and other bleeding disorders. Traditional NSAIDs include ibuprofen, naproxen sodium, diclofenac, meloxicam, and indomethacin. Another class of NSAIDs, called COX II inhibitors, includes celecoxib. COX II inhibitors, unlike traditional NSAIDs, have little to no effect on the stomach lining, resulting in less GI discomfort and bleeding. The Food and Drug Administration (FDA) requires that all NSAIDs products carry a "black box" warning alerting patients to the possible cardiovascular and GI risks.

Acetaminophen is another appropriate medication for mild to moderate pain. Unlike NSAIDs, acetaminophen lacks anti-inflammatory properties. Acetaminophen is generally well tolerated and has minimal to no side effects when used appropriately. Acetaminophen can be dangerous in overdose, so patients must be counseled on appropriate dosing.

The Second Step
The Second Step includes opioid medications for moderate pain. Acetaminophen is often added to opioid products to provide additional pain relief by targeting additional pain receptors. Common opioid and acetaminophen combinations include Vicodin (hydrocodone and acetominophen) and Percocet (oxycodone and acetominophen). At Pain and Wellness Center, the providers attempt to limit these combination products to reduce acetaminophen intake as many over-the-counter cold and sleep medications contain additional acetominophen. Adverse effects to opioids include constipation, lightheadedness, confusion, nausea, drowsiness, sexual dysfunction, respiratory depression (slowing or cessation of breathing), and addiction. Most people become tolerant to many of the adverse effects when opioids are used chronically.

Tramadol is a non-scheduled (non-controlled) opioid medication that provides pain relief by targeting the mu opiate receptor and inhibiting the reuptake of norepinephrine and serotonin. Common adverse effects include nausea, vomiting, and dizziness. Potential but rare serious side effects include addiction and increased risk of seizures (especially when taken in combination with certain antidepressant medications).

The Third Step
The Third Step includes various opioid medications for severe pain. Many of these opioids are available in extended release formulations, which reduce the frequency of administration and allow for higher dose escalation. Common long acting opioids include fentanyl patches, controlled release morphine and controlled release oxycodone.

While methadone is not a true extended release formulation, it has a long half-life and is typically included in the Third Step. Some studies indicate that methadone provides better relief for neuropathic (nerve) pain and causes less tolerance than other opioids. It must be used carefully, especially in patients taking medications with QT interval prolongation as a potential adverse effect. Methadone also carries this potential adverse effect, so routine electrocardiogram testing is required.

Additional Opioid Information
Pain and Wellness Center makes every effort to prescribe pain medications on a short-term basis. Opioid medications should rarely be the only modality to treat chronic non-cancer pain. Instead, they should be used in conjunction with a multidisciplinary approach. Sometimes, however, long-term medication management becomes one of the only treatments available for patients who suffer with pain. We try to limit patients' exposure to opioids if possible, but we also fully recognize that responsible opioid prescribing and management is an important service to provide for our patients, as many healthcare providers are unfamiliar or uncomfortable prescribing these medications. This point comes as no surprise given the fact that opioid abuse, particularly involving heroin and oxycodone, in Massachusetts is widespread according to 2004 data from the Drug Enforcement Administration http://www.usdoj.gov/dea/pubs/states/massachusetts.html.

Not all patients are appropriate candidates for opioid management. At the Center, we use a standardized approach (referred to as universal precautions for opioid prescribing) outlined below.

We make every attempt to establish a firm diagnosis prior to prescribing long-term opioids.
We counsel patients at length to become active participants in their care, and to use the medication as a tool to improve physical and social function allowing them to participate in more active treatment modalities, such as physical therapy, biofeedback training, psychotherapy, and chiropractic, for example. If patients are not committed to improving their physical, psychological, and social functioning, they are not usually considered for long-term opioid therapy.
Patients are screened by our psychologist Peter Mosbach, PhD, for any psychological contraindications to opioid therapy. They are asked about current or past substance abuse, their expectations about the goals of drug therapy, mental illness, social support, and coping skills.
Patients are drug tested to assess for compliance with their medications and to evaluate for any recreational substances that may interfere with a prescribed opioid.
We do not prescribe opioids the first time we meet a patient. We also contact their healthcare providers to assess their past behavior and adherence to medications.
Once a patient undergoes the above screening process, they are presented with a written opioid agreement and informed consent that outlines our expectations during therapy and provides information to patients about the potential risks of opioid therapy.
Our protocol for opioid management includes monthly office visits, no early refills, filling prescriptions at one pharmacy only, and agreeing to receive pain medication prescriptions only from the Center, among other points.
The Center's physicians and nurse practitioners can make the decision to discharge patients from our opioid program at any time if concerning behavior becomes apparent or if patients are noncompliant with the signed opioid agreement.

Adjuvant Medications
Adjuvant agents are used to supplement NSAIDs, acetaminophen, and opioids in the pharmacologic treatment of pain. Adjuvant agents include antidepressants, anticonvulsants (seizure medications), muscle relaxants, and topical medications such as lidocaine patches and compounded topical formulations. An older class of antidepressants, called tricyclic antidepressants (TCAs) can be helpful for both pain and insomnia. Common TCAs include amitriptyline, nortriptyline, and desipramine. A newer antidepressant, called duloxetine, can treat neuropathic pain and fibromyalgia pain.

Anticonvulsants may provide partial relief for various pain disorders, especially those involving neuropathic pain and fibromyalgia. Common anticonvulsants used in pain management include gabapentin, pregabalin, topiramate, and carbamazepine.

Muscle relaxants that are commonly prescribed in pain management include cyclobenaprine, tizanidine, baclofen, and metaxalone.