Medication Management

The use of medications is a common way to control painful symptoms. There are many of classes of medications that can help alleviate symptoms through different mechanisms and physiologic pathways (see below). Medication management is a core service we provide as part of your overall treatment plan. The ultimate goal, however, is to coordinate appropriate treatments as a means to actually improve your condition so you don’t have to rely on these medications long-term:

• NSAIDs: Non-narcotic analgesics are milder forms of the painkillers that include acetaminophen. Acetaminophen is used to treat mild-to-moderate pain and reduce fever. Acetaminophen provides relief from pain by elevating the amount of pain you can tolerate before you experience the feeling of pain. The best known brand of acetaminophen is Tylenol, but there are also many generic versions available.
• Tramadol: Tramadol was introduced as a non-scheduled drug in April 1995 based on the assumption that the risk of abuse was sufficiently low to warrant a non-scheduled status. It is a centrally acting analgesic indicated for the management of moderate to moderately severe pain. It has properties similar to both opioids and antidepressants. Tramadol reduces pain by interfering with pain signals to the brain (like an opioid) and by affecting neurotransmitters (like an antidepressant).
• Anti-depressants: The tricyclic anti-depressant amitriptyline (Elavil) has been used in “sub clinical” doses to improve overall pain control in combination with standard analgesics. Tricyclics are an older form of anti-depressant that have a range of side effects from dry mouth to disorientation. Usually, a 10mg dose of Elavil is provided to assist the relief of neuropathic pain. The action of Elavil in this use is not known. More commonly, the SSRI’s like sertraline (Zoloft), paroxetine (Paxil), and fluoxitine (Prozac) are prescribed to help reduce the depression and agitation (generalized anxiety) usually associated with chronic pain. The SSRI’s are generally well tolerated although sexual dysfunction, sleeplessness, and increased mania can result. The “normal” course of treatment with SSRI’s is about six months although some patients with longer term problems may be on this type of medication nearly indefinitely.
• Corticosteroids: Steroids are very powerful anti-inflammatories and immunosupressants. They are potentially dangerous drugs that should be used with great caution. Medicines like prednisolone, cortisone, and dexamethasone, are part of this class of drugs which mimic the body’s own natural steroids produced by the adrenal glands. Steroid drugs can be used topically, orally, by injection, rectally, nasally, in eye or ear applications, or by inhalation. There are many contraindications for these medicines including the presence of ulcer, high blood pressure, infection, and diabetes. These medicines also have a wide range of drug interactions that have to be carefully screened for. Side effects of steroids are multitudinous including weight gain, round face, blue tint to the abdomen, osteoporosis, and adrenal atrophy. While steroids are very useful in the treatment of asthma, allergies, and many other conditions, their primary use in pain control is to reduce inflammation surrounding a joint or spinal process or to treat flare-ups from rheumatoid arthritis or other autoimmune disorders. Even short-term regular use of steroids requires the dose be gradually raised then lowered to minimize steroid withdrawal syndromes.
• Anti-convulsants: Previously only used for neuropathic pain, many members of this drug class including gabapentin (Neurontin), phenytoin (Dilantin), and carbamazepine (Tegretol) are now being utilized for overall pain management. These drugs act on the brain reducing the overall level of electrical activity. The therapeutic window of this class of drugs can be difficult with serious problems of sedation and even liver damage being produced by too high a dose. Long-term use of this class of medication requires a gradual discontinuation or seizures may result.
• Muscle Relaxants: A muscle relaxant is a drug which affects skeletal muscle function and decreases the muscle tone. It may be used to alleviate symptoms such as muscle spasms, pain, and hyperreflexia. The term “muscle relaxant” is used to refer to two major therapeutic groups: neuromuscular blockers and spasmolytics. Neuromuscular blockers act by interfering with transmission at the neuromuscular end plate and have no central nervous system (CNS) activity. They are often used during surgical procedures and in intensive care and emergency medicine to cause temporary paralysis. Spasmolytics, also known as “centrally acting” muscle relaxants, are used to alleviate musculoskeletal pain and spasms and to reduce spasticity in a variety of neurological While both neuromuscular blockers and spasmolytics are often grouped together as muscle relaxants,^[1][2] the term is commonly used to refer to spasmolytics only
• Narcotics: Opioids (also called narcotics) are powerful medications often used to manage pain. These drugs include natural opiates (derived from the opium poppy plant) and synthetic narcotics. Narcotic pain medications are the most effective analgesics available today. Opioids act by attaching to specific proteins called opioid receptors, which are found in the brain, spinal cord, and gastrointestinal tract. When these compounds attach to certain opioid receptors in the brain and spinal cord, they can effectively change the way a person experiences pain.