Bartecchi: Pain and pain medicine

Any discussion of pain and pain medicine can be difficult and confusing. You can have pain that appears to be treated by placebos or homeopathic preparations which are really no more than sugar pills or enhanced water. You can have pain that appears to be treated by needles, bruises or colorful tapes placed almost anywhere on the body, by meditation, by positive thinking, by getting enough sleep, by learning coping skills, by anti-depressants or anti-anxiety medications, etc., etc.

All of these make it difficult to evaluate any anticipated response to pain treatment. It is also known that individuals can respond differently to a particular pain control effort, from getting complete relief to no relief from a pain remedy. Pain relief can be brief or lengthy, at times related to the cause of the pain or to a variety of factors that can influence pain, such as the pain terminating on its own, free of outside influences.

In any case, as we move to consider actual pain relieving efforts, we would like to know that the treatment has been found, by respected researchers (not manufacturers or marketers), to be better than a placebo. For medicines, we need to know the content and quality of the medication, the reputation of the manufacturer, the side effects of the medicine and any complications that might occur when used in a person with kidney, liver or other disorders. We need to know the recommended dosages of the medicine and whether it needs to be taken with food or on an empty stomach, or whether it might conflict with other medications or supplements that are also being ingested. We need to know if the medicine is safe and if the safety is related to the patient’s age and mental condition.

Any questions generated by the above should encourage the individual to seek their health care worker’s advice.

All of the above being said, I would like to suggest, mostly for adults, a simple, safe approach to pain treatment. These are my recommendations along with those of the American College of Physicians (ACP) and several recognized medical centers. Progressing from the safest, rational pain therapies, it is reasonable to begin with non-drug treatments, if possible. These might include heat or cold packs, massage, exercise, hydrotherapy, physical therapy and relaxation techniques. Also in this category, transcutaneous electrical nerve stimulation (TENS), though a bit more complex, can be considered a non-pharmacological form of pain relief and can be used for a variety of painful conditions and may work in some patients with low overall risk of complications or side effects.

Progressing to medication treatments that are safe and inexpensive, over the counter medications (OTCs) might be tried, always adhering to the dose directions and recognizing the contraindications. Examples include: acetaminophen (Tylenol and others) is effective for many people, without stomach or bleeding side effects and is safe in prescribed doses. U. of Penn Med suggests that it is best used in treating arthritis, body aches, fever and minor headaches. I have found 1000mg twice daily useful for older adults. A  March, 2023, article in U. of Utah Health noted that acetaminophen is safe to use during pregnancy according to the College of Ob and GYN, in spite of earlier misleading suggestions that claimed otherwise. Capsaicin cream applied every 6 to 8 hours can help small joint pain.

The ACP recommends gels, liquids or patches placed on and absorbed by the skin as relatively safe for musculoskeletal injuries in areas other than the lower back. Lidocaine patches, applied only to intact skin can be tried. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) such as Voltaren or Motrin and aspirin cream have fewer risks than oral NSAIDs which increase the risk for stomach ulcers, bleeding, kidney and heart problems. However, it is known that delivering drugs through the skin can be difficult because the outer layer of the skin prevents most small molecules from passing through it.

Nevertheless, a recent (April 19, 2023) report from MIT researchers tells us that they have developed a wearable patch that applies painless ultrasonic waves to the skin, creating tiny channels that can allow drugs to pass through.

Lack of effectiveness from topical NSAIDs would suggest movement to oral NSAIDs for low back pain, osteoarthritis and inflammatory arthritis. These drugs might include ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn). There are many other drugs in this family including Celebrex which can be effective, but requires a prescription from a health care provider. Taking NSAIDs with food, milk or antacids may reduce the risk of gastrointestinal symptoms.

The value of this approach, along with the development of ones familiarity with the above safer approaches to pain treatment, might delay the progression to more problematic medicines with more side effects and complications, such as the opioids. This is especially true with the recent revelation, in the prestigious medical journal, Lancet (June, 2023), that opioids were no more effective than placebo at reducing acute lower back or neck pain after 6 weeks of treatment.

Individuals who do not respond, over a short period of time, to the previously listed efforts to relieve pain or have side effects or complications from the treatments, need to check with their health care providers who might proceed to evaluate the individual for more problematic causes of pain (cancer, vascular insufficiency, blood clots, occult fractures, etc.) that might require different specific treatments or movement to medications like tramadol, opioids, antidepressants, anticonvulsants, steroids, or a variety of other pain specialist treatments.

At this point, one might ask what are today’s thoughts on the place of cannabis in this scheme?  A recent journal of the American Medical Association (JAMA) article (July 12, 2023) claims that placebo contributes significantly to pain reduction seen in cannabis-based therapies. Another recent study of medical cannabis in the Annals of Internal Medicine (July 19, 2023) claimed that researchers found that in the U.S., where it is legal, prescriptions for the treatment of chronic, non-cancer pain, haven’t decreased. It was previously thought that the legalization of cannabis for medical purposes might cause patients to substitute cannabis for prescription medications to manage their pain, but this has not happened.

Dr. Carl E. Bartecchi, MD, is a Pueblo physician and clinical professor of medicine at the University of Colorado School of Medicine.