Medication Management Services | South Bay Pain Doctors
medication management

At South Bay Pain Doctors, we are committed to getting you out of pain so you can live life to the fullest. Our doctors offer medication management to help guide your medication decisions and see what alternative therapies may be available. We don’t believe in a one size fits all approach and will tailor your medication program to you and your specific needs. We understand how medication decisions and managing your medication can be overwhelming and so our doctors will help to explain each medication clearly, when and how you should take it. Through our unique and integrated approach our patients trust us to get them back to feeling and functioning their best as quickly and safely as possible.

What is medication management?

Medication Management is an important part of our pain practice. Pain is a universal phenomenon and interferes with enjoyment, interrupts work, recreation, and relationships. Though it is universal, pain is so complex and subjective that it is difficult to comprehend and treat. Chronic pain may be “nociceptive”: the result of inflammation or injury to somatic or visceral tissue, or “neuropathic”: the result of injury or damage to the nerve itself. Nociceptive pain is most commonly treated with anti-inflammatory and analgesic medications (such as nonsteroidal anti-inflammatory drugs (NSAIDS) and opioids). Neuropathic pain, however, is treated differently using medications that act on neurotransmitters and excitable nerves (such as antidepressants and anticonvulsants). Deciding which medication management is right for you and your pain, helping you to keep track of your medications as well as helping to reduce the amount of medication you are taking is all part of the medication management service that South Bay Pain Doctors provides. Below is a general overview of the types of medications available to help in your pain relief:

Nociceptive Pain Medications

Nociceptive pain results from tissue damage. Injury to a specific area occurs, which causes intact nerves to report damage to the brain, and pain is experienced. Nociceptive pain can be sharp, dull, or aching and may radiate to other sites of the body. Nociceptive pain is generally responsive to, and first treated with, nonsteroidal anti-inflammatory drugs (NSAIDs). Opioids may be considered for more severe or refractory pain.

The following categories comprise the most commonly used medications for nociceptive pain:

Acetaminophen is an over-the-counter medication used to treat pain and fever. Acetaminophen works on the parts of the brain that receive the “pain messages,” but it does not have the anti-inflammatory effects of the NSAIDs listed below. Often, however, in cases of chronic pain there is no inflammation at the site of the pain, and thus Tylenol may be an appropriate treatment choice. Tylenol is a safe medication when used appropriately, but can be very dangerous when used inappropriately. The risk of liver or kidney damage is significant when more than the recommended dose of Tylenol is used. If you have known liver disease, acetaminophen should only be consumed under your doctor’s supervision. Acetaminophen is often combined with other pain medications to cause an additive effect.

These are the nonsteroidal anti-inflammatory drugs (NSAIDs) and many are available over-the-counter without a prescription. Included in this category are ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin (Excedrin). NSAIDs can be extremely effective at reducing inflammation and calming swelling and irritation.  In general these should not be used on a daily basis for the treatment of chronic pain. When used on a daily basis for a period of several years, there is a risk of damage to the kidneys that can be significant. Furthermore, there is a well-known risk of stomach ulcer formation with NSAIDs.

The COX2 inhibitor Celebrex has been shown to be equally effective as other NSAIDS while minimizing the risk of GI bleeding. The COX2 inhibitors are considerably more expensive than other over-the-counter NSAIDS. However, if an NSAID is truly needed and there is concern of GI bleeding, the total cost may be lowered by using this medication.

When treating chronic pain, narcotic opioids may be considered if pain cannot be otherwise controlled. Although these medications can be dangerous and addicting, they can also be effective when used appropriately. An opioid is a chemical substance that has a morphine-like action in the body. All of the opioids have similar clinical effects that vary from one another in potency, speed on onset, and duration of action. Both short-acting and long-acting formulations are available, as some opioids are used around-the-clock while others are used as needed for breakthrough pain. One common mistake when treating chronic pain with opioid medications is using the short acting types of medication (e.g. Percocet, Morphine, Vicodin, etc.). While these medications are useful for acute pain, they are also associated with sedating and euphoric side effects.

The short acting nature of these medications encourages overuse and the development of tolerance. Long-acting opioids may have fewer cognitive side effects and better control of chronic pain. Although no adequate long-term studies have shown their effectiveness in the treatment of chronic nonmalignant pain, and they are not approved for this use, they are often used for this type of pain management. Side effects may include GI upset, nausea, disturbed sleep, constipation, and addiction. Studies show about 5-15% of chronic pain patients using narcotic pain medications develop dependence.

Tramadol (Ultram) is an atypical opioid that is a centrally acting analgesic, used for treating moderate to severe pain. It is a synthetic agent and analogue of codeine, and appears to have actions on the GABAergic, noradrenergic and serotonergic systems. An extended-release formula is available to treat moderate to severe chronic pain when treatment is needed around the clock.

Considerable debate exists about the use of opioids for treatment of chronic pain of non-cancer origin. Many physicians feel that opioids can play an important role in the treatment of all types of chronic pain, including non-cancer pain. Others caution against the widespread use of opioids noting problems with tolerance, loss of benefit with time, and escalating usage with decreasing function in many individuals. The use of opioids (or for that matter any treatment) makes sense when the benefits outweigh the risks and negative side effects. Benefit is suggested when there is a significant increase in the person’s level of functioning, when there is a reduction or elimination of pain complaints, when there is a more positive hopeful attitude and when side effects are minimal or controllable. The dilemma with the long term use of opioids is that while there is a role for opioids in chronic, non-cancer pain, it is well known that prolonged use of opioids may result in problems including tolerance, hyperalgesia (abnormal pain sensitivity), hormonal effects (decreased testosterone levels, decreased libido and sex drive, irregular menses), depression, and suppression of the immune system.

While opioid treatment may be prescribed to reduce pain and improve function, the treatment may actually result at times in just the opposite. At South Bay Pain Docs we can discuss the pros and cons with you and help you decide if Opoids are right for you.

Neuropathic Medications

Neuropathic pain is associated with injury to the nerve. Often this type of pain is characterized by burning sensations, increased sensitivity or shooting sensations over the affected area. Patients often describe this type of pain as severe, sharp, lancinating, lightening-like, stabbing, burning, numbness, tingling, and/or weakness. It is important to understand neuropathic pain because it has very different treatment options from other types of pain. Remedies for nociceptive pain, such as NSAIDs and opioids, do not work as well for neuropathic pain, which is only marginally affected by opioids and anti-inflammatories. Neuropathic pain seems to respond best to the membrane-stabilizing medications: anticonvulsants and antidepressants. These medications act by blocking the brain’s neurotransmitters. The antidepressant medications also have beneficial effects of improved mood, decreased anxiety, and improved sleep cycle. These medications are not addictive, and when appropriately managed have few side effects.

Below is a list of the most common neuropathic medications

  • Carbamazepine (Tegretol) has been effective in the treatment of Trigeminal neuralgia. Evidence has also shown moderate efficacy in the treatment of postherpetic neuralgia and diabetic neuropathy. Carbamazepine’s main side effect is sedation. Patients treated with it should also have complete blood counts (CBCs) and liver function tests (LFTs) monitored, as blood dyscrasias and liver abnormalities can occur with the medication. These generally resolve with discontinuation of the drug.
  • Gabapentin (Neurontin) is the first line agent in the treatment of painful diabetic neuropathy and postherpetic neuralgia. Many physicians begin treatment with this agent, mostly because it has been well tolerated, even at high doses. In fact, some evidence shows it may be helpful for anxious patients. Unlike carbamazepine, it lacks significant interactions with other drugs. Patients may experience nausea, especially with rapidly increasing doses, or dizziness with higher doses.
  • Pregabalin (Lyrica) is a more potent successor to gabapentin. Lyrica is also been shown to be effective in the treatment of diabetic neuropathy and postherpetic neuralgia. This drug can be given less frequently than gabapentin (twice daily versus three times daily). The FDA also recently approved the use of Lyrica for the treatment of Fibromyalgia, and it is currently the only FDA-approved drug for the treatment of pain associated with Fibromyalgia.

Antidepressant medications have been shown to have success with the treatment of chronic pain. In addition, these medications have the added benefit of improved mood, improved sleep cycles and decreased anxiety. Antidepressants are drugs that can treat pain and/or emotional conditions by adjusting levels of neurotransmitters (natural chemicals) in the brain. They can increase the availability of the body’s signals for well-being and relaxation, enabling pain control for people with chronic pain conditions that do not completely respond to the usual treatments. Several categories of antidepressants exist:
  • Tricyclic antidepressants – Tricyclic antidepressants seem to work best for the burning or searing pain common after nerve damage. These drugs are also effective in some people for Fibromyalgia, or as a preventative for migraines. Tricyclic antidepressants don’t cause dependence or addiction, and they’re safe to take for long periods of time.  These drugs may cause dry mouth, drowsiness, constipation, weight gain, difficulty with urination, and blood pressure changes. To reduce or prevent side effects, your doctor will likely start you at a low dose and slowly increase the amount. Most people are able to take tricyclic antidepressants, particularly in low doses, with only mild side effects. The doses that are effective for pain are typically lower than the doses used for depression. Tricyclic antidepressants used for pain control include: Nortriptyline (Pamelor), Amitriptyline (Elavil), Imipramine (Tofranil), and Desipramine (Norpramin).
  • Selective serotonin reuptake inhibitors (SSRIs) SSRIs include such drugs as paroxetine (Paxil) and fluoxetine (Prozac). People who have chronic pain may feel better while taking SSRIs, but this effect is believed to result more from the easing of accompanying depressive symptoms rather than from actual pain relief.
  • Serotonin and norepinephrine reuptake inhibitors (SNRIs) SNRIs such as venlafaxine (Effexor) and duloxetine (Cymbalta) appear to be more effective than SSRIs at pain control, particularly neuropathic pain caused by damaged nerves. Cymbalta has an FDA indication for treating diabetic peripheral neuropathy.