The pill for persistent pain does not exist

I never talk about drugs. It is a choice that arises from the belief that it is not up to me to do so, in addition to the awareness that drugs are nothing more than a small piece of a great puzzle: those who only place hope in drugs are destined to remain disappointed.
Moreover, the temptation to DIY, especially if you are tired of wandering from one doctor to another, can be high.

But, lately, I am often asked about my medications (no, I will never give you the name). So I think I should spend a few words on it.

The goal, when prescribing pain-modifying drugs, is to enable you to achieve optimal conditions to improve physical function, mood, sleep and ability to manage pain. The name“painkiller”, when it comes to persistent pain, therefore, is a bit misleading.

It is very important to identify the type (or types) of persistent pain you are suffering from (nociceptive, neuropathic, nociplastic), in order for you to be prescribed an effective drug. Otherwise, it is impossible for the drugs to be effective. Indeed, they do you more harm than good. They do not help you with pain and harm your body unnecessarily.

To alleviate a painful manifestation, the use of painkillers is almost taken for granted. It shouldn't be though, if the pain is neuropathic or nociplastic (if you don't understand much about these two terms, I suggest you to read here ). In fact, potentially, the drugs that act on the central nervous system are the proper treatment option for "pain system dysfunctions". These drugs are antiepileptics and antidepressants. The name does not count. What counts is the fact that these drugs are able to interfere with the pain circuit: nobody is epileptic, nobody is depressed, simply, given at low doses, these medications can help to "lower the volume of pain". These drugs have side effects, at least at the beginning of treatment, of which a person must be aware, and they cannot be taken "once in a while". They are therapies, not headache pills. So you need to talk to a doctor who knows not only pain therapy, but the mechanisms of central sensitization.

I emphasize, in case there is a need, that these drugs are not opiates (it is easy to think pain therapy = opiates). Opiates are well known to be ineffective or even harmful for chronic pain. It may also seem us a cool thing to be prescribed with opiates, because maybe at last we feel recognized ("Oh, in the end a POWERFUL drug"). Eww. No. In addition to the development of addiction (so sorry for this pun), exists opiate-induced hyperalgesia, which is defined as a state of nociceptive sensitization, caused by exposure to these drugs. The condition is characterized by a paradoxical response, whereby a patient receiving opiates for pain treatment, may become more sensitive to certain painful stimuli.

And ... What about weed? Uh, weed. Mainstream. In February 2018, the "Canadian Family Physician" magazine published a systematic review of studies evaluating the use of medical cannabinoids. After identifying 1085 articles and keeping 31 relevant publications, the authors came to the following conclusions: there is reasonable evidence to support the use of cannabinoids for the treatment of nausea and vomiting associated with chemotherapy; these products could improve spasticity, particularly in multiple sclerosis. It is uncertain whether cannabinoids are capable of relieving pain, if they do they only relieve neuropathic pain (with modest benefits). However, negative effects (sedation, confusion, psychosis, tinnitus, distorted vision, ataxia, aphasia, dysphasia, memory disorders, psychiatric disorders, diarrhea, dry mouth ...) often occur, to the point that the authors have indicated that the benefits expected must be very high before considering the use of these products.

Pain is complex. Pain is difficult to explain. Medications can help. But don't lose the overview. The goal of a drug, when it comes to persistent pain, is to help you reach optimal conditions to improve physical function, mood, sleep and the ability to manage pain. Self-efficacy is always what you need to have in mind. Find people who can lend you a hand and help you be the real protagonist of your journey to healing. Persistent pain asks us to change our looks. And in these new looks we can find real solutions.

Sources:
Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018 Mar;319(9):872–882. PubMed #29509867
A Comprehensive Review of Opioid-Induced Hyperalgesia by Marion Lee, Sanford Silverman, Hans Hansen, Vikram Patel, and Laxmaiah Manchikanti, on Pain Physician 2011; 14:145-161 • ISSN 1533-3159
The cannabis paradox Roger Ladouceur, MD MSc CCMF(SP) FCMF, ASSOCIATE SCIENTIFIC EDITOR Can Fam Physician. 2018 Feb; 64(2): 86.
Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis Nanna B Finnerup, Nadine Attal, Simon Haroutounian, Ewan McNicol, Ralf Baron, Robert H Dworkin, Ian Gilron, Maija Haanpää, Per Hansson, Troels S Jensen, Peter R Kamerman, Karen Lund, Andrew Moore, Srinivasa N Raja, Andrew S C Rice, Michael Rowbotham, Emily Sena, Philip Siddall, Blair H Smith, Mark Wallace Lancet Neurol. 2015 Feb;14(2):162-73. doi: 10.1016/S1474-4422(14)70251-0. Epub 2015 Jan 7. PubMed# 25575710

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