Monday, August 4th, 2014 at
Because of the growing problem of addiction, misuse, and diversion, 49 states have now adopted a state prescription drug database. You may have read an article recently in The New York Times about Missouri being the only state that has not adopted such a database. In New York, as a prescriber of controlled substances, each time a patient is prescribed any type of controlled substance, I must log into the NYS website to confirm that a patient is not receiving other medications from other doctors.
I found a few patients who had not been honest with me and had received medications from other doctors. Unfortunately, the small occurrence of dishonest behavior has obliged all doctors to be alert for the possible misuse of medication. At the Norman Marcus Pain Institute, I implement several rules for patients receiving any type of controlled substance from me. Here are a few of them:
• Only one physician can prescribe all pain medications.
• Only one pharmacy should be used to obtain all pain related medications.
• All medications, including herbal remedies and over the counter medications, need to be reported since all medications can interact with one another.
• Medications must be kept in a safe and secure place, such as a locked cabinet or safe.
Following these simple rules will help protect my patients and their families from improper use of pain medication.
Wednesday, March 26th, 2014 at
Many patients with chronic pain become depressed; therefore it is not surprising that many of these patients will receive antidepressant medications. What is very interesting is that these antidepressants not only can decrease depression associated with pain, but they can also decrease pain itself. They are frequently used to treat persistent pain associated with problems in nerves. The reason that antidepressants are effective for pain is that the chemicals in the nervous system that are associated with depression also are associated with pain.
Antidepressants increase the available amounts of chemicals which affect your mood. These chemicals include serotonin, norepinephrine, and dopamine. The two most common types of antidepressants are:
- SSRIs (Serotonin Specific Reuptake Inhibitors) – Antidepressants which only increases the amount of serotonin available. Examples of SSRIs are escitalopram (Lexapro), fluoxetine (Prozac), citalopram (Celexa), and sertraline (Zoloft).
- SNRIs (Serotonin/Norepinephrine Reuptake Inhibitors) – Antidepressants which increase the amount of serotonin and norepinephrine available. Examples of SNRIs are venlafaxine (Effexor) and duloxetine (Cymbalta). Examples of Tricyclic Antidepressants (a type of SNRI) are amitriptyline (Elavil), and nortriptyline (Pamelor).
SSRIs are not as effective for pain relief as SNRIs.
Even though the antidepressants may help diminish pain, their side effects can be unacceptable. A recent review found that although approximately 1/3 of patients who took antidepressants for neuropathic pain experienced moderate pain relief or better, 1/5 discontinued use due to adverse side effects.
Common side effects of antidepressants are nausea, dizziness, insomnia, weight gain/loss, dry mouth and diminished interest in sex (decreased libido). If you’re not having reasonable pain relief with one of these medications, it should not be continued.
 Saarto, T., and P. J. Wiffen. “Antidepressants for Neuropathic Pain: A Cochrane Review.” Journal of Neurology, Neurosurgery & Psychiatry 81.12 (2010): 1372-373. Print.
Friday, March 14th, 2014 at
The next series of blogs is a brief discussion of different types of medications used for pain.
Non-steroidal anti-inflammatory drugs (NSAIDs) are generally one of the first line of medications used in the initial treatment of pain. They are exactly what their name means – they are not steroid medications (like cortisone or prednisone) and they reduce inflammation which is the body’s response to any damage from any cause. When inflammation occurs there is pain along with redness, swelling and heat, which are collectively known as the cardinal signs of inflammation. Examples of NSAIDs are ibuprofen (Advil/Motrin), naproxen (Naprosyn), meloxicam (Mobic), and diclofenac (Voltaren). Aspirin is similar to the NSAIDs in almost every way but curiously it helps prevent heart attacks whereas NSAIDs may cause them (see below).
Although NSAIDs have a number of side effects, the two most common are stomach irritation and an increased tendency to bleed. That’s why you are advised to eat when taking NSAIDs and why you have to stop taking NSAIDS before any type of intervention that may cause bleeding (such as injections or surgery). In order to decrease the side effect of stomach irritation, many have switched to a topical NSAID, most commonly diclofenac which is offered as a patch (Flector-patch) or gel (such as diclofenac or Voltaren gel). Other potentially serious side effects include kidney failure – if your kidneys are not working properly the NSAID can cause them to stop functioning, asthmatic episodes if you are prone to having asthma, and heart attacks if you have cardiovascular disease (heart disease, high blood pressure, history of stroke).
Image courtesy of anekoho/FreeDigitalPhotos.net