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Pain Management And Why It’s So Personal

Most of my patients think about pain medicines in terms of the symptoms they treat. “This is my headache medicine, and this is my arthritis medicine,” they often say. Healthcare providers are more likely to categorize pain medicines by the way they work: some are anti-inflammatory, some affect nerve endings, and others influence how the brain perceives pain. But the truth is that no matter how you classify pain medicines, there is no way to know if they’ll help until you try them for yourself.

Most people don’t realize that pain management is personal. Research is beginning to help us understand why people respond to medicines so differently, and one day we will probably be able to personalize treatment plans more successfully. For now, there are several known genetic reasons why pain medicines are more or less effective for one individual over another. Genes affect:

  1. The number of enzymes that break down medicines and remove them from the body. Some people have larger numbers of these enzymes and therefore require more drug to feel its pain-relieving effects. Others may be strongly affected by even small doses of drug.

  2. Pain medicine receptor variations can make one medicine effective and another (nearly identical medicine) ineffective in relieving pain.

  3. Differences in carrier molecules that transport pain medicine across the blood stream and into the cells that are triggering pain sensations. Some people have fewer carrier molecules to bring the medicine to the site of pain.

  4. The number of “middle man” neurotransmitter molecules that pass along the pain response. Too many of these molecules can reduce drug binding and mute the pain relief effects of some drugs.

When pain is severe, prescription medications may be necessary. However, mild to moderate pain may be effectively managed with over-the-counter (OTC) medicines. I believe in the start low, go slow approach to finding the smallest effective dose of pain medicines. I always recommend that my patients read and follow all the instructions on the Drug Facts labels to make sure that they don’t accidentally overdose on active ingredients.

When I choose a pain reliever with my patients, the first thing I think about is potential side effects. Some medicines (such as non-steroidal anti-inflammatory drugs like ibuprofen and naproxen sodium) can be hard on the stomach lining, or cause bleeding in people who are at risk for it. Other medicines (such as acetaminophen) can harm the liver if used in excess, while prescription pain medicines can cause constipation and drowsiness. The best pain medicine to start with is one that is least likely to cause harm to the specific person.

The next thing I ask is whether or not the medicine has worked for the patient in the past. Previous experience is one of the best indicators of future success. Since I know that my patient has a unique, genetically determined number of enzymes, transporters, and receptors, previous experience with pain medicines will give me a good idea of how well they will tolerate it again, and if it will be effective.

Finally, I consider the type of pain that they are experiencing. If the pain is caused by inflammation (from an injury, surgery, or arthritis) I’ll consider a medicine with primarily anti-inflammatory properties. If the pain is caused by tension (such has headache) or complicated by fever, I may consider acetaminophen first. If the pain is coming from a nerve (such as sciatica or neuropathy) then I’ll use pain medicines that work for nerve pain specifically. If the pain is complicated by depression, I may discuss additional medicines and approaches.

Sometimes, combinations of medicines are significantly more effective than one medicine alone at treating pain (this is why some prescription pain relievers are combinations of an opioid and acetaminophen). When using more than one pain relief medicine, it is important to compare active ingredients in both prescription medications and OTC products to make sure that accidental overdoses do not occur. I also recommend consulting with a healthcare professional if there are concerns about drug interactions or if the patient is already on a significant number of prescription medications that could interact with his or her OTC pain medicine choices.

The bottom line is that science is still catching up to pain management. Perhaps one day a simple blood test will help us to determine the very best pain medicine regimen for a specific patient at a given time. But until then, adopting a strategy of careful trial and error (avoiding unwanted side effects, using the lowest effective doses, and consulting a physician when pain is severe) is the only option. Don’t worry too much about whether a specific medicine is “best” for your pain. Pain management is very personal, so you will need to discover your own best solution.


Disclosure: Dr. Val Jones is a paid consultant for McNeil Consumer Healthcare Division.

Knee Arthritis Treatments Ranked By Relative Effectiveness

Wear and tear on the knee joints creates pain for up to 40% of Americans over age 45. There are plenty of over-the-counter (OTC) and prescription (Rx) osteoarthritis treatments available, but how effective are they relative to one another? A new meta-analysis published by the Annals of Internal Medicine may shed some light on this important question. After 3 months of the following treatments, here is how they compared to one another in terms of power to reduce pain, starting with strongest first:

#1. Knee injection with gel (Rx hyaluronic acid)

#2. Knee injection with steroid (Rx corticosteroid)

#3. Diclofenac (Voltaren – Rx oral NSAID)

#4. Ibuprofen (Motrin – OTC oral NSAID)

#5. Naproxen (Alleve – OTC oral NSAID)

#6. Celecoxib (Celebrex – Rx NSAID)

#7. Knee injection with saline solution (placebo injection)

#8. Acetaminophen (Tylenol – OTC Synthetic nonopiate derivative of p-aminophenol)

#9. Oral placebo (Sugar Pill)

I found this rank order list interesting for a few reasons. First of all, acetaminophen and celecoxib appear to be less effective than I had believed. Second, placebos may be demonstrably more effective the more invasive they are (injecting saline into the knee works better than acetaminophen, and significantly better than sugar pills). Third, injection of a cushion gel fluid is surprisingly effective, especially since its mechanism of action has little to do with direct reduction of inflammation (the cornerstone of most arthritis therapies). Perhaps mechanical treatments for pain have been underutilized? And finally, first line therapy with acetaminophen is not clinically superior to placebo.

There are several caveats to this information, of course. First of all, arthritis pain treatments must be customized to the individual and their unique tolerances and risk profiles. Mild pain need not be treated with medicines that carry higher risks (such as joint infection or gastrointestinal bleeding), and advanced arthritis sufferers may benefit from “jumping the line” and starting with stronger medicines. The study is limited in that treatments were only compared over a 3 month trial period, and we cannot be certain that the patient populations were substantially similar as the comparative effectiveness was calculated.

That being said, this study will influence my practice. I will likely lean towards recommending more effective therapies with my future patients, including careful consideration of injections and diclofenac for moderate to severe OA, and ibuprofen/naproxen for mild to moderate OA, while shying away from celecoxib and acetaminophen altogether. And as we already know, glucosamine and chondroitin have been convincingly shown to be no better than placebo, so save your money on those pills. The racket is expected to blossom into a $20 billion dollar industry by 2020 if we don’t curb our appetite for expensive placebos.

In conclusion, the elephant in the room is that weight loss and exercise are still the very best treatments for knee osteoarthritis. Check out the American Academy of Orthopedic Surgery’s recent list of evidence-based recommendations for the treatment of knee arthritis for more information about the full spectrum of treatment options.

FDA Restricts Acetaminophen In Popular Pain Medications

This is a guest post from Dr. Mary Lynn McPherson.


FDA Restricts Acetaminophen In Popular Pain Medications

The Food and Drug Administration (FDA) made an announcement yesterday that affects one of the most common pain medications on the market, and as a consequence may affect countless numbers of the 75 million Americans who experience chronic pain (for perspective, that’s more than the number of people suffering from cancer, heart disease and diabetes combined.) The FDA has asked manufacturers of popular prescription pain medications like Vicodin or Percocet to limit the amount of acetaminophen (also known as Tylenol, or APAP) used in these drugs to no more than 325 milligrams per tablet — the equivalent of one regular-strength Tylenol tablet.

The move came because research has shown that acetaminophen can cause liver damage when taken in higher than recommended doses. The problem is that many over-the-counter medications ALSO contain acetaminophen, and patients may take one or more of these common products (like Tylenol) to reduce their fever or get rid of a headache along with their prescription pain relievers.

Before you know it, you could be taking more than the maximum daily dose of acetaminophen which is 4,000 milligrams. I go out of my way to advise people I work with of this warning, but not everyone takes time to talk to the pharmacist and not all pharmacists make themselves readily available. That is why it is critically important that you talk to your pharmacist to make sure that you are not taking more than this amount. The pharmacist is the last stop between you and medication misuse — you could be taking a medication that contains acetaminophen and not even know it. Read more »

“What’s Wrong?” It’s A Generic-Drug Rip Off, That’s What

Cute packaging and product placement in the checkout lane at Duane Reade will get you generic Tylenol for a price equivalent to $50 for 100 tabs, as opposed to $6 per 100 count in the usual package.

*This blog post was originally published at tbtam*

Your Pharmacist’s Role In Safe, Effective Prescription Drug Treatment

This is a guest post from Dr. Mary Lynn McPherson.


Rescuing Patients On Darvon Or Darvocet With Zero Tolerance For Pain

On November 19, 2010 the Food and Drug Administration (FDA) called for a halt in the use of the popular opioid pain relievers Darvocet and Darvon. These products contain the opioid propoxyphene, and it has been used to treat mild to moderate pain for over 50 years. However, concerns have long been raised about the effectiveness of this drug, and the risk of death (accidental and suicide). Darvon and Darvocet were banned in Britain in 2005, followed by the European Union in 2009. Over the past 30 years, the FDA has received numerous petitions to take these drugs off the U.S. market.

Research has shown that Darvon and Darvocet are no more effective for treating moderate pain than over the counter drugs like acetaminophen, aspirin or ibuprofen. Unfortunately, Darvon and Darvocet cause a lot more side effects such as dizziness, drowsiness, nausea and vomiting, hallucinations and constipation (all pretty typical of opioids used to treat pain). But, the side effects don’t stop there. The data is in, and it’s not a pretty picture. A recent study requested by the FDA showed that when used at the recommended doses, Darvon and Darvocet cause significant changes in the electrical activity of the heart, which can lead to a fatal irregularity in your heartbeat, even after only short-term use.

Among those advocating for the removal of these drugs from the market were pharmacists. The American Society of Health-System Pharmacists approved a policy in 2007 advocating for the withdrawal of Darvon and Darvocet from the U.S. market, and recently testified at the FDA Advisory Committee to this effect. As an often overlooked member of the medical team, pharmacists have a vital role to play in providing safe and effective treatments. We serve as the last line of defense against improper or unwise prescribing of drugs — especially those for pain. We are drug experts, and we can help patients and doctors switch from Darvon or Darvocet to safer and more effective treatments. Read more »

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