As you can see I have placed medications and interventional treatments as steps six. It is not the first step. It is not the second step, nor the third, fourth, or fifth. It is the last step! All the other steps have to be in place in order for our medications and interventional treatments to be effective. Our first interest deals with the issue of pain. Most patients come to us already on significant levels of narcotics. Others have been on narcotics for a while but under treated. Our goal is to place the patient on the proper medication that is effective for the whole day with minimal side effects. The medications must be given in amounts that are effective in relieving pain. Patients in crisis must have their medications titrated up rather quickly. Hope must be given to a patient that there are certain medications that in combination with others will relieve the pain on a long-term basis.
Pain Medication: Opioids
The most common pain medications we use are: fentanyl, morphine, hydromorphone, oxycodone, methadone, and hydrocodone. Fentanyl, morphine, and hydromorphone come in forms that last an entire day. A fentanyl transcutaneous patch will last up to three days. It avoids the stomach and gastrointestinal tract entirely as the medication is absorbed through the skin. A relatively constant amount of medication is absorbed through the skin to provide consistent blood levels in the body. There are two morphine products that are taken once a day. These are Avinza and Kadian. Kadian can be taken both once a day or twice a day. There is a new hydromorphone product called Pallodone, but my experience is limited with this medication. Two sustained release products for oxycodone and morphine that last about five to six hours are called OxyContin and MSContin. Next, the immediate release products only last about two to three hours. These are hydrocodone, oxycodone, MSIR, hydromorphone and fentanyl. Hydrocodone and oxycodone usually come mixed with acetaminophen. Fentanyl has been formulated on a lollipop stick and is called Actiq. In my practice Actiq is reserved for oncology patients. Lastly methadone has been experiencing a resurgence as physicians recognized its unique qualities in pain management. I find it quite useful as a long acting agent in neuropathic pain states. It is able to modulate other neurotransmitters that are important in neuropathic pain in addition to blocking the opiate receptor. These additional capabilities make methadone the pain medication of choice for many of my pain patients.
OTHER ANALGESICS: Antidepressants
There are two types of antidepressants that are typically used in pain management. The first are the older tricyclic antidepressants such as amitriptyline or desipramine. These are typically used for neuropathic pain as a first-line agent. the second are the newer antidepressants such as Effexor or Cymbalta. Because they relieve pain, both of these become analgesic in character. That is, they decrease pain. These medications work both in the spinal cord and in the limbic system. In the spinal cord, they increase neurotransmitters which are important in inhibiting pain from being transmitted up into the brain. These include both serotonin and norepinephrine. These medications also improve one's mood, which improves one's ability to deal with stress and pain.
Other medications: sleep aids
Sleep is the first step in pain management. There are numerous medications from various classes that can induce sleep. My preferences include Trazodone, Ambien, and Lunesta. The goal is to pick a medication that preserves deep or slow wave sleep. The atypical antipsychotics such as Zyprexa are also good for sleep and pain. Anti-anxiety medication: mild levels of anxiety all the way up to panic disorder can be a significant component of pain and are well treated by both cognitive behavioral therapy and medication. These medications include Xanax and clonazepam. Many people use Soma as a muscle relaxant, but the mechanism of action is at the level of the limbic system in which it functions as an anti-anxiety medication. Another medication which calms the limbic system as well as muscle spasm is Valium. Other muscle relaxants include Flexeril, Zanaflex, and Skelaxin. Lidoderm patches are also useful for calming muscle spasm and pain. These patches contain lidocaine 5%, which is a local anesthetic, and can be placed for 12 to 24 hours at a time.
There are a number of interventional therapies that are quite effective and useful in pain management. These interventional techniques can be divided into diagnostic and therapeutic treatments. A solid foundation in human anatomy is mandatory in order to perform these injections. It is the combination of human anatomy knowledge combined with clinical skills that allows most pain generators to be identified. In any given region of the body, there are only a small list of things that can hurt. The nerve pathways that innervate these regions travel along predictable courses that are well known and well described. There can be some variation in the pathways but these are also well known and described. It is not as mysterious as it may seem. Some of the interventions that will be described are injection blocks of nerves and joints, somatic nerve blocks, transforaminal epidural steroid injections, and paravertebral facet and medial branch nerve injections and treatments with radiofrequency neurolysis. Other treatments of the sympathetic system are stellate ganglion blocks and lumbar sympathetic blocks. These can be treated with radiofrequency neurolysis as well. Some pain syndromes require spinal stimulator's or an intrathecal drug delivery system. myofascial pain syndromes can be treated with trigger point injections and acupuncture. Intra-abdominal pain syndromes may require diagnostic celiac plexus or hypogastric plexus blocks. Various types of catheters can be placed for significant periods of time to block the pain of malignancy.