AUTHOR: Marc Mitnick DPM
REVIEWED BY: Podiatric Medical Review Board
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Pain Medication Management
In this day and age there is such an overuse and abuse of pain medication that I have decided to add a section to this site devoted to pain medication and its management. My guest editor for this section is Steven Poling DPM, RPh.
As a practicing podiatrist, like most doctors who treat musculo-skeletal pain Dr. Poling is very informed on pain medication in all their variations and the proper use of these medications. His expertise is further enhanced as he is also a registered pharmacist and as such maintains active licenses in both professions.
This section of the web site is a work in progress and pain medications will be continually added by Dr. Poling with his own comments regarding their proper use.
THE MANAGEMENT OF PAINUNDERSTANDING PAIN
Pain, an unpleasant sensory and emotional experience associated with actual or potential tissue damage whether acute or chronic, is a unique subjective universal condition experienced by everyone at various times throughout life. During a normal 2 week interval, approximately 12.5% of young adults and 25% of adults over age 60 will present to a health care provider for evaluation of pain requiring medication. (ANALGESICS-medication for relief of pain). Eighty percent of physician visits are due to pain complaints. Eighty-five percent of adults 65 and older will experience at least one pain inducing health problem in their lifetime.
Causes of pain (etiology) are many-low back, over-use, musculo-skeletal, arthritis, headache and injury are among the most common. Over HALF OF ALL individuals having attained the age of 15 will have experienced occasional NON-MIGRAINE like (i.e. tension or muscle contraction) headaches. The elderly suffer most from arthritis, knee, and back pain. The most common of sports injuries are related to trauma to the muscle-tendon complex.
Pain may be acute which is expected to alleviate completely with treatment in a relatively short time frame (days to weeks) or chronic which continues for a longer time with the possibility of never completely resolving even with treatment. Acute pain may present as a dental extraction or muscle strain/sprain. Chronic pain may respond partially to analgesics, more persistent pain may be a result of the extent of trauma to the nervous system. Transient pain is very common and may present as a stubbed toe or an injection. Pain is a complex response moderated by emotion, culture, and experience.
Its mechanism is complex, being perceived by activation of receptors which are nerve endings called nociceptors. These receptors are stimulated and signal to the spinal cord which is relayed to the brain and interpreted. The signal enters a complex nervous system which includes past experiences (cultural and emotional). Pain, untreated or under treated, has been linked to depression, decreased interpersonal relations, reduced ambulation and insomnia, and may have negative impact on quality or life function.
Pain may also be categorized as nociceptive, neuropathic, mixed, or psychogenic based on the pathophysiology. The etiology of noceceptive pain is stimulation of the “special receptors “by trauma, ischemia (lack of oxygen in the tissues), myalgias (skeletal muscle in nature) or visceral (soft muscle such as organs) and is managed by analgesics and non-drug treatments such a as ice. Neuropathic is due to peripheral(extremity) or central nervous system(spinal cord/brain) with examples such has diabetic neuropathy, trigeminal neuralgia, multiple sclerosis, and is treated by “atypical “ analgesics(i.e. medications with additional uses other than pain) such as antidepressants and anticonvulsants. The migraine and chronic recurrent headaches, have a “poly-pharmacy" approach (multiple medications sometimes each in lesser doses).Psychogenic pain such a somatization disorders are managed by psychiatric therapy and due to the fact of chronic persistent pain.
MPR, Pain Managment Pocket Reference, 2011 edition,
Prescribing Reference LLC, NY,NY, 10001, 2011
The RX CONSULTANT, "Pain Management" vol IX, #5, May,
see also treatment of pain
UPDATE November 2011- The United States Government reported that overdose deaths from prescription painkillers tripled over the last decade ending in 2008. Prescription painkillers led to the deaths of almost 15,000 people in 2008.
UPDATE May 2012-The goal of the pain medication section of his website is to inform and educate the reader about medications used for pain and update this section as changes occur.
Recently the FDA (Food & Drug Administration) has mandated all prescription strengths of acetaminophen (APAP) to limit the total amount per tablet to 300mg with the total daily dose not to exceed 4000mg daily, This has been based on studies associating hepatotoxicity, (liver failure) with doses greater than 4000mg .
The FDA mandated this to be effective as of January 2014; however some companies have begun to voluntarily changing their formulations.
Abbott Pharmaceuticals, the manufacture of Vicodin, Vicodin ES and Vicodin HP is one such company which has begun to change their formulations. Vicodin is a combination analgesic containing hydrocodone and acetaminophen, indicated for mild to moderate pain when perhaps an NSIAID (non –steroid anti-inflammatory) will not provide significant relief or when contraindicated.
Present formulations are:
Vicodin (hydrocodone 5mg/acetaminophen 500mg)
Vicodin ES (hydrocodone 7..5mg/acetaminophen 750mg)
Vicodin HP (hydrocodone 10mg/acetaminophen 660mg)
As of May 29, 2012 these are being reformulated to:
5mg hydrocodone/300mg acetaminophen, 7.5mg hydrocodone /300mg acetaminophen, and 10mg hydrocodone / 300mg respectively.
It must be remembered, the 4000mg is the TOTAL DAILY DOSE of acetaminophen, which includes the daily consumption of any prescription medication and any otc (over the counter ) medication that may contain acetaminophen, such as common cough/cold/allergies/sinus headache formations.
Other companies will be following this mandate and the information will be provided when available.
Abbott Pharmaceuticals direct to Physician Newsletter FDA mandate, May 29, 2012.
Due to the complexity of pain and its management, certain diseases require specific analgesics for treatment. This factor is due to the ever increasing knowledge both of pharmaceutical compounds and diseases through the advancements of both analytical chemistry technology and medical diagnostic instrumentation. Today, we are able to understand much more integral biochemistry and physiology of the human body through significant research capacity.
One such entity which has become a major medical pain management challenge has been neuropathy- the pain of the body’s nerve tissues due to many causes. Unfortunately, diabetes mellitus incidence has risen so enormously not only in the elderly, but also in the pediatric and adolescent population and has become a major etiology of neuropathy due to elevated glucose (sugar) damaging the nerves. Fibromyalgia, a very painful debilitating condition both physically and psychologically, due to persistent nerve pain of muscles and connective tissue, is another indication
For the neurolytic analgesics other sources of neuropathy include traumatic, arthritis to the spinal column and peripheral joints, alcohol induced, and vitamin deficiency and post-herpetic neuralgia (the pain of shingles –a painful rash caused by the activation of the dormant virus of chickenpox).
The neurolytic specific analgesics are one such class of medications used today. In my specialty of podiatric medicine, these patients present quite frequently daily hoping to achieve some relief of this extremely painful and debilitation of the quality of life.
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