Pain Management

WebMD Live Events Transcript

Grin and bear it. Smile though the pain. No pain, no gain. We have had some strange ideas about dealing with pain in the past, but thankfully that's changing with the growth of pain management options. If pain is affecting your quality of life, read our Q and A with pain expert Charles E. Argoff, MD, for some insight into treatment options. He joined us on June 22, 2004

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MEMBER QUESTION:
My mother has neuropathy from diabetes -- her legs and feet are swollen and painful. It's bad enough that she's on Neurontin, Darvocet, and Vicodin. I know it's important to keep her moving. What about muscle activation therapy as a treatment?

ARGOFF:
The first thing that we need to do is back up, because I need to explain to you that your mother shouldn't be taking Vicodin and Darvocet at the same time. Each of these drugs has acetaminophen (Tylenol) in it and one can easily take too much acetaminophen. Also, in particular, the other active ingredient in Darvocet, propoxyphene, can make older people quite confused. So I think it's a good idea that you're asking me to think about nonmedical therapy that might be helpful for your mother as well.

I am not familiar with a specific technique known as muscle activation, per se, but looking at the simple proverb "Use it or Lose it," it is extremely important that your mother stays as active as possible so that her muscles remain as healthy as possible. Physical therapists can help directly with treatment to help your mother's muscles, and in addition she can be given a variety of exercises for her to do on her own. I hope this helps.

MEMBER QUESTION:
Doctor, do you consider the pain from fibromyalgia and arthritis/lupus to be chronic pain?

ARGOFF:
Of course. Both of the conditions that you have asked me about regrettably affect millions of Americans, and even more regrettably have no known cure. Since the definition of chronic pain is pain which last three months or greater, or pain that exists beyond the time of normal healing, each of the conditions you have asked me about would clearly be considered chronic.

Just to be clear as well, and equally regrettable, in the U.S. chronic pain disables more people annually, and costs more annually to our health care economy, than heart disease and cancer combined.

MEMBER QUESTION:
I have cervical ribs and I have constant pain in my shoulder, chest, neck, and arm. Chiropractic care is helping some, and I am on Doxepin. What else can I do? I don't do many things I used to because of the pain and I am missing out on my life. I am only 32 years old.

ARGOFF:
You bring up a situation that hopefully can improve. I hope that I can make some suggestions to you that will help you. The first thing to consider is whether or not the cervical rib that you have is treatable by surgery. Rarely, perhaps occasionally, surgical treatment can be very helpful. It's not always helpful, though, and you need to know that as well.

Doxepin is antidepressant medication that has been also used for chronic pain. You should know that many medications, including good old-fashioned aspirin, may be used for one purpose, but as scientific discoveries occur, new purposes may be discovered for the same medication. So for aspirin, even though it was originally used for pain and fever reduction, we now use it as a blood-thinning agent as well.

For you, a wide variety of pharmacological approaches might be helpful. Among these would include the use of topical analgesics. These would be applied directly to where you experience the pain. The advantage of a topical is they work locally and do not have systemic side affects. Of these the ones that I would guess most likely to help you would be the topical lidocaine patch, also known as Lidoderm, which has been shown to be helpful in musculoskeletal pain, although it was originally approved for shingles-related pain. Other topical agents could include capsaicin, which has a disadvantage of burning when placed on the skin.

Other antidepressants that might be helpful to you would include the medication venlafaxine or buprion. Sometimes anti-inflammatory drugs can be useful, as can injections into the painful area. Finally, traditional pain drug medications, such as opiates, can also be helpful. I hope you can find a pain specialist in your area to help you.

MEMBER QUESTION:
I work in front of a computer most of the day and try to get up and move often, but sometimes can't. I'm taking Flexeril but don't think it's working. What would be a good alternative? I'm also taking Norco two or three times a day for the aches. Is that too much to take daily?

ARGOFF:
First of all, let's talk about Flexeril. Flexeril, although sold as a muscle relaxant, is in fact an antidepressant medication with many side effects. You might consider asking your doctor to prescribe either Skelaxin or Robaxin, which are effective muscle relaxants with fewer side effects.

The use of two or three Norco tablets a day is not too much with respect to any harmful effects on your body. However, Norco contains acetaminophen in it, equivalent to one regular strength Tylenol tablet per pill. Therefore you have to be concerned not to take too much additional Tylenol if taking Norco. Second, Norco does not last very long as a pain reliever and is not designed to last very long as a pain reliever. If you find Norco to be helpful, ask your doctor to consider prescribing a longer-acting version of a similar medication. This would provide you with more consistent pain relief and be less of a roller coaster life experience.

Many people using Norco or other pain medications become concerned with using them because they are concerned that they will become a drug addict. This might be a good opportunity to review some terms that we in pain medicine use:

• Tolerance means that a higher dose of a drug, or a different drug altogether, has to be used to achieve the desired affect. That might be a higher dose of pain medicine to achieve relief or a different dose of a blood pressure medication to control a person's blood pressure. My example should indicate that getting used to a medicine doesn't only occur with a pain medicine and may occur with many other types of medicines.
• Physical dependence means that if you were to suddenly stop a medication you would have withdrawal affects. This also happens not only with pain medicines, but also with many of the commonly prescribed medicines for blood pressure management, for epilepsy management, for depression control, and for many other conditions. Therefore, many people, both doctors and nondoctors, confuse withdrawal symptoms with being addicted to a drug. This is a tragic confusion because it isn't true.
• Addiction refers to the psychological dependence upon a drug. For someone who is addicted to a drug, there is total preoccupation with the drug; perhaps even criminal acquisition of the drug, buying or selling the drug, and living totally for the drug only. The likelihood of becoming a drug addict because of use of a pain medication is less than 1%. In other words, very small.

I hope that these comments are helpful to you.

MEMBER QUESTION:
What are your thoughts on migraine/headache rebound withdrawal with ergotamine?

ARGOFF:
The occurrence of rebound headaches is a significant issue in general. It happens with the use of many different medications too often, too frequently, including ergotamine, any of the tripans such as Imitrex, Zomig, Axert, or others, as well as Fiorinal, Fioricet, Tylenol, anti-inflammatory drugs, or Midrin. If any of these agents are used more than three times each week there is a real risk of rebound headache. This is different from migraine and can be extraordinarily difficult to treat. It is absolutely wisest to not overuse any of the medications already listed.

If you are having headaches more than two or three times each week, please see your doctor, who perhaps can be a headache specialist, who hopefully can made recommendations concerning preventative strategies.

MEMBER QUESTION:
I am in chronic pain due to bone mets r/t prostate cancer. I am currently on 60 milligrams bid of morphine. However, I don't like the way it makes me feel and I have to keep increasing it to manage the pain. Would I be better off with something like oxycodone?

ARGOFF:
There are many different types of opiate medications for you to consider. First, I will assume that you are taking extended-relief morphine. All opiate medication, like any medication in general, can have side effects, but some people find that within that category they are able to tolerate one medication better than another. Therefore, it's important for you to be given the opportunity to utilize other opiate medications to determine if you can achieve equal or better pain relief but not the bad feelings you're having with morphine.

Here are some of your options you can consider:

• Oxycodone comes in an extended-release form called Oxycontin. This medication needs to be taken every eight to 12 hours to be affective.
• The Duragesic patch contains the pain medication fentanyl. This patch, unlike the lidocaine that we spoke of earlier, doesn't have to be applied wherever you hurt, because the patch works in such a way that it drives the medicine into your blood stream so that it will go throughout your body. This is a very potent pain medication and its chief advantages are that it last up to three days and is less likely to cause constipation, a very common side effect with pain medicines, compared with other pain medications.
• Sometimes, if morphine works for you, other preparations of morphine, including a once-a-day medication known as Avinza can be as helpful without the side effects.
• Another possibility, and please do not take this the wrong way, would be methadone . Methadone actually was not developed for drug addiction, as many people would think, but was developed originally more than 60 years ago by the German government to treat the pain of their injured soldiers during the World War. It is an effective medication that has helped many people worldwide.
• Finally, you might consider the use of levorthanol .

There are no shortages of options for you, and you should really keep in mind what Rocky Balboa said in all the Rocky movies, that he was not going down. There are so many options for you that you should not consider being stuck with one or face going down with pain. There are many options for you; please explore them.

It's important to talk to your doctor about your concerns. You might want to contact the American Chronic Pain Association, which can help you identify pain physicians in your area. A recent survey done by the American Chronic Pain Association, entitled The Americans Living With Pain Survey, found that almost 44% of people in our country with chronic pain do not immediately talk to their doctors about their pain control. Go right to your doctor and speak to him or her now.

MEMBER QUESTION:
I have pain every day from moderate during the day, to excruciating toward 6:00 p.m. The pain is shooting and intense in my heels, my ankles, my knees, hands, and wrists, but varies from spot to spot daily. I have SLE and am on prednisone and Plaquenil. These meds have reduced the swelling in my joints, but not the pain. My rheumy brushes me off when I ask for pain medication, maybe because he doesn't see the swelling anymore and my appointments with him are during the day when I am not in the excruciating pain that I am at night. What should I do?

ARGOFF:
Well, I truly wish that your rheumatologist would accept your complaint of pain and treat it accordingly. I think you bring up another tragic situation in which a doctor makes equivalent the activity of this disease, in this case lupus, with the absolute presence or absence of pain. Obviously, even when your lupus is not "active," your joint and connective tissues are not 100% normal. Therefore, there might be very clear reasons why you continue to have pain. I know that you know that, and if your rheumatologist is not able and/or not willing to accept that you have chronic pain that needs to be managed, you need to see someone in your community who is able and willing to help you.

You are not alone in this dilemma, as the survey I have just talked about would suggest. Again, the American Chronic Pain Association, the American Pain Society, the American Academy of Pain Medicine, or the American Academy of Pain Management might be able to provide you with a physician/pain specialist in your area that can help you, and maybe even teach your rheumatologist a thing or two.

MEMBER QUESTION:
I will look into finding a pain specialist in Canada. Maybe my family doctor could refer me to one.

ARGOFF:
What part of Canada are you in?

MEMBER QUESTION:
Near Toronto; 30 minutes north.

ARGOFF:
You should see Angela Mallis, who is a pain specialist at the University of Toronto, I believe. She's a very energetic, creative, brilliant pain specialist who hopefully can help you.

MODERATOR:
Wow; how's that for service?

MEMBER QUESTION:
My mom's neurologist has prescribed Nubain and Fioranol w/codeine for close to nine years now, and it seems to be making her tension migraine worse. Is there something else you would recommend?

ARGOFF:
You bring up one of the worst examples of how rebound headaches can be caused, and your mother more than likely must find another means of controlling her headaches other than the use of those medications. Again, it's important to find the right specialist in your region who might be able to help your mother make that transition.

It is not easy, no matter how much those medicines are causing her headaches, to suddenly discontinue them. Often a person like your mother might have to spend a few days in the hospital to change her treatment from the one that might be causing her headaches, as you've described, to a safer and more effective treatment strategy.

I can't provide any more details without actually seeing your mother, but it is extremely important to get your mother off those medicines. I hope this helps.

MODERATOR:
Dr. Argoff, we are almost out of time. Do you have any final words on pain management for us?

ARGOFF:
Remember that you don't have to suffer. Pain and medical care may be inevitable, but misery is optional. Get help for your pain.

MODERATOR:
Thanks to Charles Argoff, MD, for sharing his expertise with us.

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