Treatment of chronic pain

The medication treatment is established on the basis of the severity of the symptoms. (Photo: Pixabay.com)

A great variety of pain medication is available on the market; this article will focus only on a few examples. Generally speaking, it is important to remember that medication is only one constituent of the therapy, and that other therapeutic approaches are often essential for the therapy to be successful.

The treatment should first include non-opioid analgesics, such as acetylsalicylic acid (also known as Aspirin), ibuprofen, or paracetamol.  When used in the recommended dosage, Paracetamol is a simple pain medication that can be used regularly and over a long period of time for treating headaches and many other pains. However an overdose can lead to severe liver and kidney damage, for which reason the dosage and duration of treatment should be settled on by the treating doctor.

Anti-inflammatory medication such as acetylsalicylic acid and ibuprofen should not be used over a long period of time, as they can induce stomach complaints, including bleedings, kidney and heart problems. Non-opioid analgesics also include other substances such as Indometacin, Diclofenac, Naproxen and Metamizole.

Treatment with opioids

Opioids are medication that affect the body’s own opioid receptors. These receptors are to be found in the relevant “switching points” in the body’s pain-conducting and pain-receiving systems. Influencing these opioid receptors can have a direct impact on pain relief. However, because many opioid receptors are present in the human body, and not only in the pain-related system, the intake of opioids can induce various side effects, such as influencing the intestinal activity (for example constipation) or provoking nausea and vomiting. Further, other symptoms can appear during the initial phase, such as confusion, concentration disorders, etc. As regards side effects, it is important to remember these should recede within a short time or disappear completely when the indications are followed correctly. Only constipation must be treated over the whole period during which the medication is taken.

Developing a dependency to opioids occurs only rarely in chronic pain patients, and happens primarily when rapid-acting medications are being used. When this is the case, attention should be paid to follow the indication correctly in order to prevent a developing a dependency, similar to a drug addiction.

Codeine is a substance that belongs to the opioid family. Because combining codeine and paracetamol brings better results, these two substances are often offered in a preparation.

Tramadol and dihydrocodeine are other moderate analgesics. These must be used carefully, as they may lead to a medication-dependency. The most frequent side effects consist of dizziness, nausea and constipation.

When necessary, stronger analgesics such as opiates can be used over a longer period of time with patients suffering from chronic pain. Such medications rarely loose their effect, in which case it may be necessary to increase the dosage.

In the initial phase, side effects such as nausea or tiredness may occur temporarily. Constipation (see above) must be treated preventatively through optimal nutrition (for example plums, flax seeds, etc.) as well as with laxatives (lactulose or sodium picosulphate).

Against specific central pain caused by damage to the brain or to the spinal cord, opiates are usually not strong enough. This is where so-called co-analgesics may be needed.

Co-analgesics

Because chronic pain often induces or sustains muscular tension, pain therapy usually includes muscle relaxants. These medications may include centrally active drugs, such as tetrazepam, or peripheral active drugs, such as tolperisone. Flupirtine, for example, is an active substance that helps prevent pain chronification. In case of painful muscular tension, muscle relaxants can prove quite helpful, should however not replace relaxation or adequate gymnastic exercises.

In case of chronic pain, as opposed to the treatment of acute pain, the use of antidepressants can contribute to alleviate aches as well as emotional stress in a more effective way than any analgesics used on their own. These include substance such as amitriptyline, clomipramine, duloxetine. The treatment usually includes a lower dosage than when treating depression, but may be increased progressively. The pain-alleviating effect of antidepressants begins approximately 10 to 14 days after intake begin. It is important to inform the patient of this delay, so that he or she does not interrupt the treatment for thinking the treatment is ineffective.

Anticonvulsant drugs (used in case of epilepsy) such as carbamazepine, gabapentine or pregabalin are used primarily in the treatment of neuropathic pains. It is suspected that this drug induces a stabilisation of neurons and a reduction of nervous pains caused by an increased discharge of the neurons.

Capsaicin, the spicy substance contained in peppers, is used in some heat plasters or pain-relief ointments. It is usually well tolerated by most patients. Apart from its comfortable effects, it is also appreciated for de-sensitizing the pain receptors.

Finally, it should be emphasized that non-medication and medication therapies should be combined in order to increase their beneficial effects.

Text: Helga Grafe – 05/2016
Translation: MyH – 08/2016

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