Chronic pain relief medication options

The core logic of optimal drug treatment for chronic pain that is currently clinically recognized is never a single solution of "take painkillers when you feel pain", but a combination of "layered matching of pain types + low-dose combination medication + dynamic adjustment plan", and must be combined with lifestyle intervention. Long-term use of over-the-counter painkillers alone will 100% lead to side effects, and the analgesic effect will become worse and worse.

I just met a young man who has been working as a programmer for 8 years at the pain clinic last week. He has been suffering from chronic low back pain caused by lumbar protrusion for a year. I always keep ibuprofen at home and take 2 pills when the pain is severe. At the worst time, I ate almost 3 boxes in a month. Finally, I suffered from stomach pain and black stools. After a gastroscopy, I already had multiple ulcers in the gastric mucosa. I asked him why he didn’t come to the hospital. He said that painkillers were almost the same and he could just take them by himself. However, the pain did not stop and the stomach was damaged first. Don’t think this is an exception. At least half of the chronic pain patients in clinical practice have fallen into the trap of “taking random medicines and shouldering the pain”.

Many people don’t know that chronic pain is not the same thing as the acute pain you usually get from a cold or a fall: acute pain is the body’s alarm, reminding you to rest if you are injured; chronic pain becomes an independent disease in itself after more than 3 months, some are caused by nerve damage, some are long-term stimulation of inflammation, and some are because the central nervous system has become accustomed to "continuously sending pain signals." At this time, taking medicine without the treatment is useless.

When it comes to medication regulations, there are actually two schools of thought in the industry. Old-school doctors are accustomed to following the WHO three-step therapy that has been used for decades: non-steroidal anti-inflammatory drugs for mild pain, weak opioids such as tramadol for moderate pain, and strong opioids for severe pain. The advantage is that the boundaries are clear and drug abuse is less likely to occur. The disadvantage is also obvious: it is too rigid. I have seen many patients who have already developed symptoms of pinprick and discharge-like neuralgia, but are still stuck on the first step and insist on taking ibuprofen. After taking it for several months, the pain sensitization becomes more serious, and the skin hurts even if they touch it.

In recent years, new guidelines from the American Academy of Pain Medicine and other organizations have proposed that there is no need to strictly follow the ladder. As long as the tendency of neuropathic pain is assessed, even if it is mild pain, low-dose calcium channel modulators (such as gabapentin, pregabalin) or topical analgesic patches can be used early, which can prevent the pain from developing into chronic and persistent pain. This is still controversial in the industry. Conservative doctors are afraid that adding medication will cause additional side effects such as drowsiness and dizziness, while supportive doctors believe that the benefits of early intervention far outweigh the risks. My own clinical experience is that for patients who have had pain for more than 2 months, especially if the pain is obvious at night, adding half a pill of pregabalin early is indeed faster than waiting for the pain to get worse before adjusting the medicine.

When it comes to different types of pain, the logic of medication is very different. There is no universal "magic drug" at all. For example, if you suffer from chronic pain related to inflammation such as osteoarthritis and chronic tendinitis, and do not have basic diseases such as gastric ulcer or coronary heart disease, you do not need to take oral medication every day. You can take celecoxib 2-3 days a week as needed, 1 pill each time, and apply flurbiprofen gel patch every day. The intake of oral medication is reduced by more than half, the side effects are small, and the analgesic effect is better than taking it every day. I have a friend who has been playing badminton for 10 years and has had chronic pain from a rotator cuff injury for half a year. He used to take ibuprofen every day to get acid reflux. After a month of doing this, his normal playing ability is basically not affected now.

If you encounter neuropathic pain such as post-herpetic neuralgia and diabetic peripheral neuralgia, no matter how much ibuprofen or celecoxib you take, it will basically be useless. At this time, you have to use drugs specifically targeted at neuralgia. Pregabalin and gabapentin are the first choices. If it is accompanied by poor sleep and anxiety, add a small dose of duloxetine, and the effect can be doubled. There was a 72-year-old aunt who suffered from post-herpetic neuralgia. When she came to the doctor, she said that her chest felt like someone was pricking it with needles every day and that she couldn't sleep at night. She was given 1 pill of pregabalin at night and 1 pill of loxetine in the morning, combined with topical lidocaine patches. She came back for a follow-up visit a week later and said that she could sleep through the whole night and the pain was reduced by 80%.

The opioids that everyone is most afraid of are actually not as scary as the legends say. They are used regularly on patients with chronic cancer pain or severe non-cancer pain, and the addiction rate is less than 0.1%. On the contrary, problems are more likely to occur if you buy and eat them indiscriminately. Moreover, opioids are now used clinically in combination with auxiliary drugs. Try to reduce the dosage of opioids to a minimum, and the side effects will be much smaller. There is another controversial point in the industry: the use of tramadol. Some doctors think it is a weak opiate with low addictiveness and is suitable for patients with moderate pain. I don’t like to prescribe it myself, because I have encountered several patients who had particularly obvious reactions of dizziness, vomiting, and constipation after taking it. Instead, it is better to use low-dose oxycodone combined with non-steroidal drugs, which has better tolerance. Of course, this also depends on the individual’s constitution and cannot be generalized.

To be honest, I have seen too many patients who either endure the pain and refuse to take medicine, or take other people's prescriptions, which are two extremes. There is really no unified standard answer to the medication for chronic pain. You and Lao Wang next door both have low back pain. He suffers from muscle strain and you suffer from lumbar protrusion pressing on the nerves. The medication plans may be completely different. Copying homework will only hurt yourself. Of course, medications are only part of chronic pain management. If you suffer from lumbar pain and still sit for 12 hours a day, no medication will help. Only by combining exercise, rehabilitation, and adjusting your work and rest can you really stabilize the pain. If the pain persists for more than a month, don't think about taking medicine on your own. It's better to see the pain department of a regular hospital.