Chronic pain, like the pain associated with arthritis, fibromyalgia, joint pain, carpal tunnel, etc. is one of the most common reasons patients seek medical attention, and can be reported by as many as 20-50% of patients in the primary care setting. Optimizing your outcome usually results from a multidisciplinary approach to care, including physical and behavioral medicine, pharmacological, neuromodulation, and interventional. Here is some advice to help you find the treatment you need.
- know that not all pain is created equal
- know the difference between neuropathic vs nociceptive pain
- know the available treatments for neuropathic pain
- understand the treatment of nociceptive pain
- know that over the counter medications can cause health problems
- forget to ask if your medication should be taken with or without food
- forget to read the ingredients in combination opioid prescriptions
- assume that exercise is bad for arthritis
- assume joint replacement is inevitable
- forget to try other non-medicinal therapies
The first step to managing your pain effectively depends on a thorough evaluation of the cause of pain and the identification of the type of pain. Specifically, is your pain from a neuropathic or nociceptive origin? You should get an evaluation of your pain from your doctor so that they can determine the right level of care for your specific needs.
Neuropathic pain results from a problem in either your central nervous system, for example your brain or spinal cord, or your peripheral nervous system, for example the pain associated with diabetic neuropathy, stroke, or fibromyalgia. Nociceptive pain results from actual damage to your tissue, such as in arthritis or inflammation.
Though your doctor should be the final decision on what type of pain you have, knowing the difference between the different kinds of pain is important so you know what to expect when going to your doctor and can research the different treatment options to get the right kind of pain management for you.
If your doctor diagnoses you with neuropathic pain, she may prescribe a medicine that is historically thought of as an antidepressant. Examples include tricyclic antidepressants or SNRIs (serotonin/norepinephrine dual reuptake inhibitors), like Cymbalta and Savella. It is very important to remember that your doctor is prescribing these medications because of their pain relieving qualities and not because you are depressed.
Other medicines that you may be prescribed can work directly on the nerves, for example gabapentin and pregabalin. Second line therapy may include medicines such as Tramadol or opioids, which are types of morphine derivatives. The right medicine regimen may include only one, or may be more than one treatment used in combination. You should be under the care of a practitioner who is familiar and comfortable with all of these types of medications.
Treatment of nociceptive pain that is associated with arthritis is generally divided into two broad groups: non-narcotic and narcotic. First line therapy, which is generally non-narcotic, that your doctor may recommend includes tylenol or acetaminophen, as well as non-steroidal anti-inflammatory drugs. Tylenol is the only available over the counter pain reliever that is not an anti-inflammatory. In addition to the well known over the counter anti-inflammatories, such as Advil, Motrin and ibuprofen, there are many other prescription anti-inflammatories your doctor may prescribe based on his or her preference and experience. Treatment with Tramadol or opioids is generally reserved for people who don’t respond to first line therapy.
Just because a therapy is available without a prescription it does not mean it should be used indefinitely without a physician’s guidance. For example, if you are older or have some other diseases like hypertension, chronic anti-inflammatory use can raise your blood pressure and even cause problems with your kidneys. It is therefore recommended that you see your doctor regularly for blood pressure monitoring and blood chemistry screening to minimize potentially life threatening side effects.
If your doctor prescribes an anti-inflammatory, or you are self treating with over the counter drugs, always remember to take your medicine with food to reduce the risk of having a stomach ulcer, which can be life threatening if it bleeds. Because of the risk of GI toxicity associated with anti-inflammatories, your doctor will likely also recommend therapy with a medicine called a “proton pump inhibitor”, like Nexium or Prilosec, to reduce the risk of having this complication. Adherence to this therapy is very important.
One of the most important things you need to do as soon as you fill a prescription for a narcotic like Percocet or Vicodin, is to figure out whether or not it contains acetaminophen. This is important if you are already taking OTC Tylenol for pain, because you may be getting too much acetaminophen. Our recommendation is that your daily acetaminophen intake should not exceed 3000 mgs. Also, your liver function needs to be assessed prior to starting these medicines because they can be dangerous in people with liver dysfunction.
On the contrary, maintaining an active lifestyle is recommended for you in spite of some pain limitations. It is helpful to understand that even if it hurts a little, you are not likely to be making your underlying arthritis worse by engaging in moderate, regular exercise. You should consult with your physician and/or physical therapist for specific recommendations, but generally speaking, strengthening your muscles and improving your balance and flexibility with help you in the long run.
Certainly, the field of joint replacement has come a long way in the last few decades, and for the right individual, it may be the best management option. For most of you, however, a combination of optimal pain management, exercise, and education will likely forestall joint replacement surgery. Only if all resources and avenues have been exhausted should you start looking into surgery.
If your approach to pain management is more holistically guided, there are a number of approaches that don’t require medicine that are recommended for managing chronic pain. Broadly, these are characterized as physical, like physical therapy, acupuncture, and/or massage, and psychosocial, like cognitive behavioral therapy, education, psychotherapy. It may be intuitive that the best outcome for you will likely be achieved when all of these interventions, or a combination of them, is employed by the caretaking team.
Identifying the cause or set of causes of your chronic pain is the first, crucial step in optimizing your outcome. You should seek out a physician familiar with the different types of chronic pain to lead a coordinated group of practitioners in your care. Always remember to enlist your physician’s guidance with both over the counter and prescription medications to limit side effects and adverse events. Non-medicinal approaches such as acupuncture and behavioral therapies can also be of great value to your total treatment plan. In fact, a multidisciplinary or collaborative approach is often the most successful when treating chronic pain.