Chronic pain relief medication

There is no "universal analgesic solution" that is suitable for all patients. Clinical practice follows the principle of "stratified dosing and individualized matching", giving priority to non-opioid analgesics to control mild to moderate pain. Opioids are only used as a second-line option for moderate to severe refractory pain and strictly control the dosage. At the same time, auxiliary drugs need to be used as needed to correct the fundamental pathogenesis of pain. Any single drug treatment needs to be combined with non-pharmacological means such as life adjustment and rehabilitation training to achieve long-term and stable relief.

Last week, I met a 38-year-old programmer in the outpatient clinic. He had been suffering from lumbar pain for more than half a year and was afraid to come to the hospital. He stocked up on three boxes of ibuprofen at the drugstore and took two pills when he felt pain. He continued to take it for three months. Last week, he had black stools and was examined. He already had multiple ulcers on the gastric mucosa. When asked why he didn't see a doctor, he said, "I don't think there are just a few kinds of painkillers. You just need to read the instructions and take them yourself." This is also the pitfall that most chronic pain patients are most likely to fall into.

The most familiar non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and diclofenac are currently the first choice for mild to moderate musculoskeletal pain and inflammatory pain. There is currently no unified academic conclusion on the use period of these drugs: European and American rheumatology and immunology circles are more conservative and believe that continuous use should not exceed 14 days, otherwise the risk of peptic tract ulcers and cardiovascular adverse events will more than triple.； However, the clinical experience of many pain doctors in China is that if the patient does not have underlying gastrointestinal diseases, the benefits of using a gastric mucosal protective agent such as pantoprazole with low-dose intermittently for 3-6 months to control the chronic pain of osteoarthritis far outweigh the risks. Both views are actually based on different population samples. There is no absolute right or wrong. The core is not to secretly take it for a long time, and just check liver and kidney function and gastroscopy regularly.

After talking about the commonly used drugs that everyone is most familiar with, we have to mention the opioids that many people have heard about. The controversy over the use of opioids is almost the biggest point of disagreement in the field of pain: when ordinary people hear the word "opioid" they think of opium and addiction, and they refuse to use it. ； On the other hand, in the last century, the United States over-promoted opioid analgesics to please pharmaceutical companies, leading to an opioid crisis that spread across the country. Now the domestic academic community is very cautious about opioids: long-term opioid use is basically not recommended for patients with non-cancer pain and chronic pain. However, for patients with late-stage cancer pain and severe post-herpetic neuralgia who cannot be suppressed by conventional analgesics, the benefits of low-dose sustained-release opioids far outweigh the risks. Last month, I had a 72-year-old aunt with bone metastases from lung cancer. When she came here, she was in so much pain that she even turned over and shed tears. She was given a small dose of oxycodone sustained-release tablets. After a week's follow-up visit, she was able to sit up and video chat with her granddaughter. After using it for almost half a year, she has not become addicted. To put it bluntly, as long as it is used under the strict supervision of a doctor, opioids are not as scary as everyone thinks.

Oh, by the way, there is another question that many people often ask: doctor, how can you prescribe antidepressant/antiepileptic drugs to me when I am in pain? This is the category of “auxiliary medication” that everyone is unfamiliar with. Many chronic pains are not caused by inflammation at all. They are caused by abnormal discharge of the nerves themselves or amplified pain signals by emotions. For example, post-herpetic neuralgia can be relieved by taking ten tablets of ibuprofen, but most of it can be relieved by taking pregabalin for a week. ； There are also many patients with chronic fibromyalgia, accompanied by long-term insomnia and anxiety. Taking low-dose duloxetine is more than 60% more effective than simply taking painkillers. There is currently a school of thought in the academic community that believes that early addition of low-dose psychotropic auxiliary drugs to patients with chronic pain accompanied by mood disorders can reduce the risk of dependence on analgesics. However, this view needs more clinical data to support it, and currently only experienced doctors will use it as needed.

Oh, by the way, there are also topical analgesics. Many people think that plasters are "recipes." In fact, regular topical non-steroidal anti-inflammatory drugs are recommended in the first line of clinical practice. For example, for patients with knee joint pain and local muscle strain, flurbiprofen gel plaster is 80% less likely to cause gastrointestinal side effects than oral ibuprofen. The only disadvantage is that it may be a bit expensive. One tablet costs two or three yuan after being reimbursed by medical insurance. But compared with the cost of hospitalization for gastric ulcers after taking ibuprofen, it is really cost-effective.

When I sit in the clinic, I am used to giving a small form to patients with chronic pain who come for the first time, asking them to keep a pain diary: what day does it hurt, how painful it is (0 is not painful, 10 is painful enough to cry), what medicine is taken, how long it takes for it to take effect, and whether there is any discomfort. Bringing it to the next follow-up visit is 10 times more effective than if the patient himself says "I am in pain every day, and it is useless to take anything." In many cases, it is not that the medicine is ineffective, but that you take it at the wrong time and dose.

In fact, at the end of the day, chronic pain itself is a very individual problem. Some people can take two tablets of ibuprofen for lumbar pain, some people can only be effective after taking gabapentin, and some people still have pain despite taking all kinds of medicines, so they need minimally invasive treatment and psychological counseling. Medication is only a part of chronic pain management. Don’t regard it as a life-saving straw, and don’t completely reject it. Finding a reliable pain doctor for regular follow-up is much better than trying to figure out what medicine to take on your own.