How to think about managing pain control

Pain control is one of the most hand-wavey aspects of medicine, with a lot depending on what a doctor is comfortable prescribing. I worked with one physiatrist who gave me a helpful framework for thinking about how to manage chronic pain. His philosophy was to “attack the pain from different angles” by using small doses of multiple drugs. (This will differ from other doctors, who prefer to “max out” one class of drugs first before trying others, which has been shown in studies to be more effective.)

  1. anti-inflammatory: arthritis, disc pain, facet pain, carpal tunnel. NSAID
  2. muscle relaxant: muscle spasms or “tight” muscles
    1. baclofen
    2. flexeril (cyclobenzaprine) makes people sleepy
    3. Amrix (cyclobenzaprine) is less sleep inducing
  3. Nerve pain: sciatic, diabetic neuropathy, etc
    1. Gabapentin is a side effect driven med (fatigue/confusion, nausea, swelling)
    2. Lyrica is the better version and better for fibromyalgia
    3. Cymbalta
    4. Nortriptyline or amitriptyline
  4. Narcotics: work on the brain to reduce sensation of pain
    1. Short acting opioids. Remember: start low, go slow!
    2. Long acting opioids—give if too much breakthrough pain. This is the first thing you should wean off if a patient’s on both.
    3. Different “families” work differently on patients—some react better to hydrocodone, or oxycodone, or morphine…there are different agents for long and short acting. Also, some people process the drugs differently because of pharmacokinetics and genetics.

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