Medications for Spinal Cord Injury Pain
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- http://www.aci.health.nsw.gov.au/chronic-pain/resources/service-directory/nsw-chronic-pain-services-directory ACI Services directory
- http://www.mydr.com.au/topics/a-z-of-complementary-medicine MrDr.com
- http://www.chronicpainaustralia.org.au/index.php/neuropathic-pain Chronic Pain Australia
- https://www.nps.org.au/medical-info/consumer-info/medicines-for-pain-relief-what-are-the-options - Medicines for pain relief: what are the options?
- https://www.nps.org.au/medical-info/consumer-info/chronic-pain-explained Chronic pain explained
Transcript: Medications for Spinal Cord Injury Pain
We have a range of medications that are available for treating pain following spinal chord injury.
But it's very important to match the medication to the type of pain.
And this means using the classification of pain, which identifies the different types of pain that we've been talking about.
So this means working out exactly what type of pain you have and then using the appropriate drugs for that type of pain.
For example if you have musculoskeletal pain the type of drugs that we use would be quite different from those that if you had neuropathic pain.
As we've looked at before, musculoskeletal pain is pain that arises from bones, muscles, joints and tendons.
And this sort of pain responds fairly well to simple analgesics such as paracetamol, or anti inflammatory medications.
Some of these, such as Ibuprofen, are available over the counter from your pharmacist and other anti-inflammatory medications are available via prescription from your doctor.
What these medications are doing is to reduce the inflammation and to stop the messages that are coming from the source of pain in the muscle or joint, through the pain pathways up the spinal chord.
Sometimes we might use an anti-inflammatory medication if there's inflammation present but we do need to be careful.
Particularly with somebody who has a spinal chord injury that may make it more difficult to pick up sensations that may be coming from gastric irritation in the stomach.
For neuropathic pain we need quite different medications.
And that’s because as we've seen, the mechanisms that… …give rise to neuropathic pain are quite different from those we see with musculoskeletal pain.
And what these medications are trying to do is to actually target the nervous system directly, where the changes occur following spinal chord injury.
And there are two main groups of drugs that we use that do this.
The first group is the anticonvulsants or the antiepileptics.
And the second group is the antidepressants.
The anticonvulsant group of drugs includes drugs like Gabapentin and Pregabalin.
And they work in very much in the same way as someone who has epilepsy.
What they're doing is reducing the excitability and the abnormal firing that is happening in damaged nerves and the spinal chord after spinal chord injury.
The other big group of drugs that we use for treating neuropathic pain is the antidepressants.
These include drugs that have been available for a long time such as Amitriptyline or Nortriptyline and also some newer drugs that we have available.
Such as Venlafaxine or Duloxetine.
These antidepressants are not recommended because… your doctor thinks your pain is due to depression… but because these drugs actually change the chemicals in the spinal chord that close the gate and help to reduce neuropathic pain.
In fact the doses that we use for treating neuropathic pain are much lower than those that are used for treating depression.
Opioids work on opioid receptors that are found throughout the nervous system, in the brain and in the spinal chord.
But also they work in cells in the gut.
Which is one of the reasons that many people experience constipation with these type of medications.
These medications are very strong and they work extremely well for a short period of time.
Which means that for acute pain… they’re very good medications.
Because opioids work so widely through the body they can be used for all types of pain.
For musculoskeletal pain and also for neuropathic pain.
However it has been found… that neuropathic pain often responds poorly to even high doses of opioids which means that… many people find that they are not very effective in relieving their pain.
If you have pain that is short term and severe, such as after surgery or trauma following the early stages after a spinal chord injury, strong opioids such as morphine or Oxycodone can be very helpful in controlling the pain.
And they're often prescribed in these early stages… during the hospital visit after the initial injury.
One of the problems with opioids is that over time they can become less and less effective.
What we often refer to as tolerance.
The long term use of high doses of opioids can also result in other major side effects.
Such as effects on hormones.
They can actually have the effect of reversing the pain killing effect that they normally have and giving people what is referred to as hyperalgesia… or hypersensitivity to pain.
Other common side effects include drowsiness, blurred vision, dried mouth, headache, nausea, brain fog and memory loss.
It can also affect sleep… and make sleep apnea worse.
And it can also affect immunity and testosterone levels.
Opioids can also affect sex drive and fertility… and add further to depression.
And other major side effects can even include accidental overdose and death.
I've had some very serious side effects to some of the medications….
um… I was initially started on Gabapentin …um… and developed… um… pericarditis which is an inflammation around the heart.
…um… yeah…which shocked me because… then I had to stop… the Gabapentin which was an absolutely hideous… …um…process… of abruptly stopping… a high dose of that sort of medication.
I ended up having to go back on it and then ween it down slowly.
It was… it was a really bizarre and frightening…side effect of the medication.
Um… I've had issues with tolerance.
… My previous doctor's had me on very high doses of opiates and I was extremely tolerant and that's been changed… now.
But tolerance is a big problem because when you um… take the medication continuously and then you really have a flare up and need it, it no longer works for you because you're completely tolerant of it.
Despite some of the downsides and side effects that you get with using opioids they may still play a role in your pain management plan.
If you and your doctor decide to try and use an opioid to manage your pain, it's generally recommended that you have a trial, not only to see whether it helps but also to see whether it helps you to do more and whether you can get adequate relief with a small to moderate dose.
You need to make sure that the medications that you use for your pain relief have an adequate effect not just in reducing your pain intensity, but increasing your ability to function and maintain your activity levels without too many other intolerable side effects.
This means that sometimes a drug may work on the pain but the side effects may outweigh the benefits.
If you experience side effects or require higher and higher doses to control the pain it's almost certain that using opioids is not the best way to manage your pain.
Working out which medication is right for you is a matter of careful and monitored trial and error.
And it’s one of the many reasons why it’s important to have good communication with your doctor.
We’re working out what are the best medications for you.
Your healthcare team also have to regularly look at your medications.
The ones that they’re prescribing and making sure that they are actually the most appropriate medications for the type of pain that you’re experiencing.
You may also like to download the pain diary which is available from the website and use this as a way of recording your pain.
You can then take this to your health professional who can then look at how your pain is responding to the medications that you’re taking.
Often we use a combination of medications for treating pain.
That’s because there is no one individual drug that has been shown to be effective.
And there are different drugs even within the same family of drugs.
All of these work slightly differently and individuals will respond very differently even to the same medication.
I’ve found that I’ve got a number of ways of uh… managing my pain.
The medication is… the obvious one… um… And that is… a reasonably large part of it… for me at the moment… um… And… there’s been a great book produced by the Royal North Shore people that talk about… giving you all sorts of tools for managing pain in non-medication ways which has been very helpful to me and that is a lot about managing your… …your expectations and… …um… not… you know… like… …taking a lot of rest breaks when you need it and not pushing through the pain.
and… um… then when it gets really bad I… …I use meditation.
I used to be on lots of pain medication.
…um… Everything from- I was on Gabapentin as well as Oxycontin and as well as Endones and they were all very high doses.
…um… they used to… sometimes make me feel drowsy, …um… lightheaded… um… …and probably the best way to put it is, in plain terms, is lazy.
…um… I just didn’t… feel like doing as much as I thought I should be doing.
And I found myself sleeping a fair bit.
…Um… I - between me, my spinal doctor and my local GP I decided that the level of pain that I was at, …um… I think I could live with …and I wanted to try and come off the medication to see whether the pain went up, whether the pain stayed the same or whether I was getting any side effects from all that medication.
um… It took longer than what I was hoping it was going to take.
But I think the approach that we took, coming off over something like eight months, off that medication …Um… and not just trying to get off of it too fast limited the side effects of coming off of it.
Um… And I actually found that Um.
while the… …my pain medication doses were dropping… my actual pain wasn’t getting any worse.
So we decided that, well… is the pain medication actually doing anything for me anymore? …And lets try and come down off of it even more.
…And… I’m… …pretty happy to say that today… …um… I’m not taking any of those medications.
Um… And… …Um… my pain levels didn’t get any worse, they’re still the same as they were before.
I still do have pain.
Um… but, the joys of it is… I’m not taking twenty tablets a day and still having this same amount of pain.
With managing my pain and using medication- what I usually do is if I can avoid medications and do other things like I said, alleviate the pain in some other way I can.
I do take other tablets or medications, like Baclofen which is a muscle relaxant that stops me from spasming which I do spasm a lot.
And spasm causes me pain as well.
The pain that I get isn’t as intense at the moment because I’ve learnt to overcome it and control it.
I don’t take as much medication as I used to, uh… because… …like I said, I can control the pain and… uh… …it's like… yeah I do control the pain.
I don’t let it over power me.
I take over the pain.
Even though medications can be helpful and do have their place, they’re by no means an answer on their own.
The nature of pain after spine injury is that no one strategy, either medications or other things is likely to work in isolation.
And you can use a range of strategies or tools to manage your pain.
Which include both pharmacological, which is the medications but other non-pharmacological options.
And it’s best to use a range of strategies and skills to get the best effect.
Pain medications can be useful to take the edge off the pain which can then give you the energy to use some of the non-pharmacological or self management skills or strategies that we know are also helpful in treating the pain and reducing the impact of the pain on your life.
By using some of these skills and strategies that we’ve talked about and hearing some of the stories that are on the website we hope you’ll be inspired to try some of these ideas yourself.
To create your own plan for managing your pain click on the Health Plan button below the video and download the PDF.
Print it out.
After each video fill out the relevant sections.
You only have to fill it out once.
Take your completed health plan along to your GP or health professional.
This is a great starting point to managing your pain.