Medications for Pain

Medication management is only one of the facets of comprehensive care. Several classes of medications can be used to treat pain including NSAID’s, antidepresasnts, anti-seizure, skeletal muscle relaxants, and opiates. Recent data on NSAID’s demonstrates some are safer than others. All NSAID’s carry kidney, ulcer, and liver risks.  Some also increase risk of heart attack and stroke. Antidepressant medications have been used for years to treat pain coming form inflamed nerves. Examples include Pamelor, Savella, Effexor, Elavil, and Cymbalta.

Anti-seizure drugs include Lyrica, Neurontin, Keppra, Topomax, and others. Muscle relaxants are useful as opiate sparing agents or for mild to moderate pain of musculoskeletal origins. Most muscle relaxants do not act on muscle, but rather they relax the mind and make you care less about the pain. Soma is a poor choice of muscle relaxant and has its own abuse and addiction potential. Valium is useful as a muscle relaxant in hospitalized patients, but is not prescribed in our outpatient setting. Many patients who experience chronic pain also suffer from anxiety. Our clinic does not prescribe Valium, Xanax, Klonopin or other drugs in this class known as benzodiazepines. These drugs are not part of our treatment regimen. If you feel you need these medications, they will have to come from your PCP or Psychiatrist. Adding these medications together with opiates increase risk of drug overdose and death, so extreme caution needs to be exercised and good communication between physicians must be maintained. The FDA has published a guidance paper on this and I have included a list of alternative medications. Opiates have significant risks and benefits when used for chronic pain. Please read our Informed Consent and Agreement for Treatment document regarding this topic. Patients who will be accepted and receive controlled substances will need to read and sign the ICAT which contains Dr. Lobel’s rulebook and details consequences of breaking the agreement. Dr. Lobel works for the Georgia Composite Medical Board, the DEA, and several branches of local and state law enforcement. It is necessary to verify several things in order to satisfy the legal requirements of providing this avenue of care. The Medical Board has a clearly written document with Dr. Lobel’s contribution in assisting to edit the Guidelines and Rules.

Clinic Rules:

  1. No opiate prescriptions will be issued to new patients. Our staff will make every effort to obtain records from prior physicians, other health providers, and imaging centers as soon as possible.  Urine drug screening may be performed at the initial visit and can take 1 week to return for review. If Dr. Lobel determines that opiate pain medication may be helpful, he will prescribe it only after all information is reviewed and the risks and benefits of these medications are weighed.
  2. No pain medication will be called to the pharmacy
  3. No pain medication refills will be issued for lost or stolen medications
  4. No pain medication will be refilled early unless dose changes were authorized by Dr. Lobel
  5. Dr. Lobel may contact your other providers, family, pharmacy, and employer to ensure safety and appropriateness of medication use.
  6. Phone calls requesting pain medication during the initial assessment and while Dr. Lobel is gathering clinical information are inappropriate. If Dr. Lobel feels that your pain warrants immediate treatment with opiate medication, he will do so at the time of the appointment. Any issues arising during the assessment period should be handled by your PCP or the Emergency Department.

It is common for our clinic to call your pharmacy, your employer, and your family should there be anything out of the ordinary in our evaluation. Criminal database background checks are performed, urine drug screening is mandatory, and screening for abuse potential is essential in preventing addiction, reducing abuse, and eliminating diversion. Georgia has an active Prescription Drug Monitoring Program and patients are monitored for compliance frequently.

Once screening is completed, and if you are felt to be a candidate for ongoing treatment for opiates  for chronic pain, we need to monitor for pain relief (analgesia), adverse effects of medication (side effects), activity levels (ongoing functional improvement in activities of daily living such as holding down a job, maintaining a household, and keeping family and interpersonal relationships), and aberrant behaviors (running out of medication early, obtaining pain medications from more than one doctor, etc). Common side effects include nausea, sedation, and constipation. Nausea typically improves within 1-2 weeks. Sedation is typically minimal with appropriate dosing and disappears within 1 week if medication is taken as directed. Constipation never improves without dietary adjustment and a handout is always available.