• Dr. D

Are Your Meds Making You Sick? (Pain Meds - Part 2)

Absence of pain vs. lessening of pain.


With chronic pain there’s usually going to be some discomfort left after the worst is over.

And from the beginning, I let people know that. Getting somebody to a point where they don't have any pain just may not happen.


I can say this about many kinds of conditions, though. For instance, I don’t tell someone with a history of depression that their lives will always be happy now that medication helps their mood. There will always be times that are more difficult than others.


But being moody in hard times is not the same as depression and suicidal thoughts. Being adequately treated for depression doesn’t mean never having a down day.


Likewise, with the person with chronic pain, I can’t tell them they’ll never hurt again, or that they'll be totally pain free at any time.


Instead, I ask them what does pain keep them from doing? What they would do if the pain

was less? I ask what an acceptable level of discomfort is because they’ll probably hurt more on some days than others.


The idea is to come up with a realistic plan. How can we get to a level of relief that can make it possible to do the things you want and be able to enjoy life? Then we shoot for that.


Antidepressants, seizure medications, and pain relief


As I mentioned in my previous post (https://www.sjdpsych.com/post/are-your-meds-making-you-sick-pain-meds), I’ve had people come to see me who were furious when someone prescribed a depression medicine for their pain. They thought they were being told their pain wasn’t real, that it was “all in (their) heads.”


But it turns out, some antidepressants can help relieve specific types of pain. And, for example with migraine, it may actually prevent the pain from coming at all.


The antidepressants I see being used for pain relief most often are amitryptline, nortriptyline, and duloxetine (Cymbalta® and others). Other antidepressants can do it too though.


The first two meds are old-time tricyclic antidepressants (TCAs) that I talked about before. The latter is a member of the serotonin and norepinephrine reuptake inhibitors (SNRIs).


Like any substance that you take into your body, these medications can cause side effects.

However, they also have the upside of being quite helpful in relieving some of the pain that goes with direct damage to nerve endings.


In diabetes, people can get “diabetic neuropathy.” This kind of pain is burning and tingling or a kind of numbness, and occurs most often in the legs and feet.


It can wake people up at night because their lower extremities are so sensitive that even the touch of a sheet against their skin can cause a lot of pain.


By giving the person one of these antidepressant medications, we may be able to make the pain in their legs and feet less awful.


Likewise, there are some kinds of severe pain that respond well to seizure medications. For example, there is a condition where a nerve in the face, the trigeminal nerve, is inflamed or damaged.


This results in a shooting or stabbing kind of pain. It can be so severe that the person can’t do anything while it’s there. Sometimes it’s hard to breathe it’s so bad.


For this kind of pain one of the antidepressants can be helpful. More often, though, we use a medication that is typically for preventing seizures It’s almost as though the medication soothes the nerve ending to relieve some of the discomfort, just like it ‘soothes’ the brain to reduce seizures.


Over the Counter (OTC) Pain Relievers


The best known of the OTC pain meds are acetaminophen (Tylenol®) and Non-Steroidal Anti-Inflammatory Drugs (NSAID) such as ibuprofen, aspirin, naproxen and diclofenac.


Acetaminophen is in a family by itself and is used throughout the world. It can be quite effective for relieving some types of pain. Things like headache, acute back pain and some kinds of joint pain respond to it well.


And it does this without needing a prescription. You don’t have to rely on someone else to tell you how to treat yourself.


It isn’t habit forming. In other words, if you decide to not take it you don’t have any kind of withdrawal. And it doesn’t cause tolerance. This means that, unlike opioids, you don’t have to take more and more all the time to get the same benefit from it.


Sometimes acetaminophen is used alternating with an NSAID. The purpose behind this is to relieve pain, but not have to take as much of either drug. This way you can avoid side effects that either one can cause.


People often think of acetaminophen as being safer than the NSAIDs. But this really depends on what you consider “safer.” If you take too much of this medication it can cause liver failure and death.


Unfortunately, the fact that it isn’t safe at higher doses may be the reason that there are at least 150 deaths by Tylenol® every year and probably a lot more that aren’t discovered.

The maximum dose of acetaminophen in 24 hours is 3000 – 4000 mg. (There’s some debate about this). But the fact is, either one may be way too much for many people.


And it’s easy to get too much.


If you take the typical dose of three Tylenol Arthritis®, plus two Tylenol PM® and a couple of OTC cold pills that have acetaminophen as an ingredient, you’ve gone way over the recommended maximum daily dose.


Because acetaminophen can be so helpful at low and medium doses, I am absolutely not recommending that people quit using it. However, I do want people to be aware of how much they're actually getting. Because at higher doses it can be dangerous.



I’ve seen several Tylenol® overdoses over the years. None of them were intentional suicide

attempts or suicide. So please be careful.


NSAIDs: I think most people are aware of the fact that this family of medications, which includes aspirin, ibuprofen, naproxen, diclofenac and others can cause heartburn, stomach problems and even ulcers.


But they’re widely used because they work. And for many types of pain, they work well.


As a reminder, NSAIDs are Non-Steroidal Anti-Inflammatory Drugs. And inflammation causes a lot of the different kinds of pain that people experience.


The most common type of arthritis is osteoarthritis. This is the cause of most joint problems that we get as we age. It’s also the kind of pain that occurs after a joint is injured, like in football or running or from an accident.


NSAIDs can reduce the pain in a hip, for example. But it can also prevent it from worsening because it decreases the body’s response to the bad joint. That is, it decreases inflammation. This is something that acetaminophen can’t do.


Like with anything though, there are problems with using these medications daily or in excess. Taking these medications or acetaminophen can cause rebound headaches. In other words, using them all the time can actually result in headaches, while using them only when needed should relieve this problem.


So if you’re taking one of these drugs more days than not and you’re having headaches more days than not, it may be time to try doing without any pain relievers for a week or so, just to see if things get better.


Another problem with taking these medications is that they can increase the risk of damage to the kidney and at really high doses, liver and heart problems.


Once again, I have to warn people to look at the label of anything they take OTC. Just like with acetaminophen, it’s easy to get too much of an NSAID, because it can be in several OTC medications that a person takes.


You might take ibuprofen several times a day for general aches and pains, a baby aspirin a day for heart issues and Advil PM at night. If so, this might result in too much of the NSAID in 24 hours.


As noted above, alternating an NSAID with acetaminophen may help decrease the chances of having too much of either kind of medication.


So be sure to look at the label of OTCs to see exactly what's in them. This might prevent a person from taking excessive amounts of any one drug.


Plus, when in doubt DON’T – and ask the pharmacist.


Putting it all together.


Much typical pain can be relieved by using OTC medications. However, as with anything, it's possible to be harmed by them, especially if they're not used appropriately.


REMEMBER:


1. All pain is not the same.


2. Different kinds of pain respond best to different kinds of medications.


3. If a clinician prescribes something like a depression medicine or a seizure medicine for pain and you don't understand why, ask. It's possible that what is being offered is actually better for pain relief than typical pain meds.


4. Look at the label of everything you take. If several things contain acetaminophen or an NSAID, check to see that you're not taking more of that drug than is recommended as being safe.


5. The *BIG GUN medications often aren't the best choice for many kinds of pain. We'll get into that more at the next posting.


* BIG GUNS = opioids, especially oxycodone and hydrocodone.


Image of hands and pill by © Can Stock Photo/Zinkevych

Image of questioning by © Can Stock Photo/Orla

Image of diabetic neuropathy by © Can Stock Photo Inc/megija

Image of person and pill bottle by © Can Stock Photo/kounadeas