Chronic pain relief medication

There is no "magic drug" that can 100% eliminate chronic pain without side effects. The core goal of treatment is to control the pain score below 3 points (without affecting sleep and daily activities). Priority is given to individualized multi-modal combination medication regimens to control the risk of adverse reactions within an acceptable range. The benefits of using a large dose of a single drug are far lower than the risks.

Last month, I met a 52-year-old aunt in the outpatient clinic. Her lower limbs had been radiating pain due to lumbar disc herniation for three years. She was so painful that she couldn't even walk to buy groceries. She saved half a drawer of ibuprofen at home. When the pain was severe, she would take 2 pills at a time. Last month, she suddenly had black stools and was sent to the emergency room. When she checked, she had multiple erosions on the gastric mucosa, which was caused by long-term overdose of non-steroidal anti-inflammatory drugs.

When it comes to medication regimens, there are actually two mainstream ideas in the industry. One is the WHO three-step analgesic principle that has been used for almost 40 years, from the most basic acetaminophen and non-steroidal anti-inflammatory drugs (often referred to as ibuprofen and celecoxib), to weak opiates such as tramadol, and then to morphine , oxycodone and other strong opiates, which are upgraded step by step according to the degree of pain. This plan is more universal and easy for primary doctors to master. It is especially suitable for home management of cancer pain. Of course, this does not mean that the three-step plan is outdated. In places with insufficient primary medical resources, the three-step plan is still the safest choice. However, in the past 10 years, more and more pain doctors are more inclined to the idea of multi-modal combination medication, that is, not stuck on the ladder. For example, for neuropathic chronic pain (such as post-herpetic pain, diabetic peripheral neuralgia), non-steroidal drugs can be directly combined with calcium channel modulators such as pregabalin and gabapentin, or even added Small doses of antidepressants are more effective than single liters of opioids and have fewer side effects. The new version of the American Pain Society guidelines two years ago even removed weak opioids from the recommended regimen for non-cancer chronic pain. This is because the addiction risk and gastrointestinal effects of weak opioids are no lower than those of strong opioids, and the analgesic effect is no advantage.

Regarding the use of opioids, there is now considerable controversy in the industry. Some physicians are extremely concerned about the withdrawal effects and addiction risks of opioids, and do not dare to prescribe sufficient doses even to patients with severe cancer pain, resulting in many people suffering from pain that is worse than death. ； But on the other hand, most doctors in the pain department believe that as long as they standardize their assessment and gradually titrate the dose, the benefits of using opioids for severe chronic pain far outweigh the risks. Last year, I managed an old man with advanced lung cancer. The pain was so painful that he could only lie down and cry. After standard use of oxycodone extended-release tablets and pregabalin, he was able to sit up and video chat with his granddaughter during the last period, and there was no obvious addiction reaction. Of course, I would like to remind you that you must be careful when using opioids for non-cancer chronic pain. I have seen many young people taking compound preparations containing opioids for a long time because of chronic headaches. In the end, the dosage of opioids increased, and they would get headaches and nausea without taking them. Instead, they developed drug-dependent headaches.

Many patients come to me and ask me if there are any special medicines with few side effects. To be honest, there are none. Take the most commonly used non-steroidal anti-inflammatory drugs, for example, there is a "ceiling effect" - after taking the maximum recommended dose, increasing the dose will not increase the analgesic effect, but will only increase the risk of gastric mucosal damage, liver and kidney damage several times. There used to be a 28-year-old programmer who suffered from chronic back pain and gout. He took celecoxib up to 4 pills a day. When he came for a review, his transaminase increased to 3 times the normal upper limit. He was so frightened that he stopped taking the medicine and adjusted it to half the dose of celecoxib plus physical therapy twice a week. Within two weeks, the pain was under control and the transaminase dropped back to normal levels. There are also many people who ask people to bring so-called "special painkillers" from abroad. I met a patient who brought it back. I took it apart and analyzed the ingredients. It was a compound preparation that added dexamethasone and indomethacin. After two months of taking it, his face swelled into a full moon face. The bone density test showed that he had osteoporosis. The gain was not worth the loss. Oh, by the way, there is another misunderstanding that many people make: take medicine only when the pain is unbearable. In fact, the medication for chronic pain needs to be regular, take according to time, and keep the blood concentration of medicine stable. It is much more effective and has fewer side effects than taking medicine unexpectedly when the pain starts.

After all, chronic pain is something that coexists with the body for a long time. Drugs are only one part of the entire treatment. Don't expect that taking drugs alone can cure it once and for all. In many cases, it is combined with physical therapy, exercise rehabilitation and even psychological counseling to maximize the pain relief effect. If your pain persists for more than 3 months and it still doesn’t go away, don’t just randomly save medicines at home. Go to the pain department of a regular hospital to have a look. It’s much more reliable than searching Baidu and buying medicines blindly.