chronic pain relief medications

Currently, there is no specific clinical drug that can cure all types of chronic pain. Commonly used relief drugs mainly include four categories: nonsteroidal anti-inflammatory drugs, opioid analgesics, neuromodulatory auxiliary drugs, and topical analgesics. The core principle of drug selection is "matching the type of pain + the minimum effective dose + the lowest risk of side effects." There is no "optimal drug" suitable for everyone.

The most depressing case I encountered in the first six months of my rotation in the pain department was a 47-year-old aunt with lumbar disc herniation and sciatica. She had been suffering from pain for more than a year and was reluctant to go to the hospital. She stocked up on three boxes of ibuprofen in the drugstore. When the pain was severe, she would take two pills. At most, she would take four pills a day. In the end, the pain did not stop, and she went to the emergency room for gastrointestinal bleeding. It's a coincidence that her gastroenterologist turned around and sent a consultation application to our department. He complained about the problem of indiscriminate prescribing of non-steroidal drugs at the grassroots level. This is also the biggest controversy in the industry about this type of commonly used drugs. Most orthopedics and general practitioners believe that as long as the short-term use is strictly controlled within 7 days, drugs such as ibuprofen and celecoxib for moderate to mild musculoskeletal pain are extremely cost-effective, have quick effects and do not require a prescription. ； However, doctors in gastroenterology and cardiovascular departments have always maintained a conservative attitude. Some data show that taking non-steroidal drugs continuously for more than 3 months will increase the risk of gastrointestinal ulcers and bleeding by 3-5 times. Patients with a history of coronary heart disease may even induce acute cardiovascular events. Even selective COX-2 inhibitors that are said to be "stomach-friendly" are not completely safe.

Compared to the minor disagreements over nonsteroidal drugs, the opioid discussion is a world of ice and fire. In the past few years, there has been a lot of news about the opioid crisis in Europe and the United States. In China, both patients and many grassroots doctors are now talking about the negative effects of opioids, and they always feel that they will become addicted as long as they take them. Last time, I had a patient with chronic pain after a fracture. I mentioned that low-dose telenine could be used for a short period of time, and he jumped up on the spot and said that I wanted to make him addicted to drugs. But on the other hand, in the treatment guidelines for cancer pain and severe refractory neuralgia, opioids are still the first-line medication. The man I once treated for advanced lung cancer was banging against the wall all night in pain. His family refused to use him for fear of addiction. Later, he prescribed oxycodone sustained-release tablets for standardized titration. In the last three months of his life, he could sit up in the sun and video chat with his grandson, and he did not show any signs of addiction until he passed away. When I held the National Pain Academic Conference two years ago, I also saw data compiled by experts: among patients with chronic non-cancer pain who use opioids in a standardized titration, the addiction rate is less than 0.03%, which is far lower than everyone’s inherent impression. Interestingly, doctors in different regions have quite different attitudes towards this type of medicine. Doctors in the Yangtze River Delta are generally more willing to use small doses for refractory pain, while many hospitals in the north still do not use them if they can. There is no distinction between them. The only difference is the medication habits and the policy environment.

You may not expect that many of the medicines taken by chronic pain patients don’t even have the word “analgesic” written on the instructions. Last month, an uncle with post-herpetic neuralgia came for a follow-up consultation. He brought me half a bag of home-grown sugar oranges and said that when he got duloxetine, he almost slammed the table. He thought I thought he was pretending to be in pain before prescribing antidepressants. After taking it for a week, it turned out that the pain, which was like an electric shock, was reduced by 70%. For neuropathic pain, neuromodulatory drugs such as pregabalin, gabapentin, and duloxetine are the drugs of choice. Ordinary analgesics cannot suppress the neuralgia caused by abnormal discharges at all. Oh, by the way, there is a big gap in understanding between different departments. Many dermatologists only prescribe antiviral drugs for herpes zoster, and forget to add neuromodulatory drugs to the patients. In the end, the pain lasts for more than half a year, which makes it more difficult to deal with.

If the pain is only as big as a palm, there is actually no need to take medicine at all. My mother sprained her knee while dancing in the square last year, so she secretly bought ibuprofen. When I found out, I quickly switched her to Voltaren ointment plus Flurbiprofen gel patch. The swelling subsided in three days, and her stomach was not hurt at all. Whether it is non-steroidal latex or lidocaine patch, the active ingredients of topical analgesics will only penetrate into local muscles and joints and will hardly enter the systemic circulation. The side effects are much smaller than oral medications. They are especially suitable for osteoarthritis, local muscle strain, and localized neuralgia. Unfortunately, most people don't know this and think of taking oral medications whenever they feel pain.

As for new products such as cannabinoid analgesics and calcitonin gene-related peptide inhibitors, which have been very popular on the Internet recently, there is now considerable controversy. Scholars who support it believe that this is a new hope for refractory fibromyalgia and cluster headaches. Those who oppose it believe that the cognitive impairment and addiction risks of long-term use are not yet clear, and it is not worth taking the risk. At present, it has not been approved for routine clinical use in China. If someone sells you the so-called "imported special pain relief cannabis cream", don't believe it, it is most likely an IQ tax.

I have been working in the pain department for almost five years, and I have seen too many patients who either suffer from pain and refuse to take medicine, or buy medicine randomly and cause problems. Chronic pain itself is a subjective feeling that is invisible and intangible. The medicine that others use on you may not work on you and may cause harm to your body. If the pain really lasts for more than 3 months, don’t search Baidu on your own. Find a pain department in a regular hospital. It’s better than anything else.