How I Would Choose a Medication  

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Please Note-I no longer treat pain with any medicine besides Suboxone.  The following articles was writtent some time ago

Most doctors will treat pain with agents they are comfortable with.  Acute pain of various causes is a common problem.  Codeine, hydrocodone, and oxycodone are effective for this type of pain and so doctors are comfortable with these medications.  However, if the pain becomes chronic, these medications may no longer be optimal.  

The above medications are associated with tolerance. Regular usage for more thna a few weeks often leads to a situation where the relief of pain may only be for 2 ½ to three hours.  Patients may want to take the medication 6-8 times daily leading to more problems with even more tolerance as well as toxicity from the acetaminophen component.  They are trying to maintain a consistent blood level.  This cannot be done with the short-acting agents.  

I try to differentiate chronic intermittent pain or chronic exacerbating pain from chronic pain that continues around the clock.  In the first two situations, the use of pain medication will be irregular.  The patient would only be taking the drug when he has pain.  Therefore, a fast acting drug is best.   Vicodan or Percocet (or another short-acting agent) is appropriate.   

In chronic intermittent pain, the patient may have daily pain but the pain does not last all day long.  If the usage of the short-acting agent is two to three times daily or less, there is no reason to have to change to a long acting agent agent.  One of my favorite sayings is “More is less and less is more”.  It means you can get greater pain relief per pill if fewer pills are taken over all.   

In chronic exacerbating pain (like a recurrent back sprain) the pain may be all day but it only lasts a few days.  If the pain lasts for more than 10-14 days, one has to consider changing the regimen.  

If you have chronic pain that lasts around the clock, short-acting medications are not appropriate.  Pharmaceutical companies have created various formulations of delayed release drugs.  These are short acting drugs that are embedded into a matrix.  This results in delayed absorption of the medicine and a more prolonged period of therapeutic effect.  Morphine has been incorporated into a number of different agents: MsContin, Kadian, Avinza and a number of generic alternatives to MsContin.  Oxycodone has been incorporated into Oxycontin.  Fentanly is given in a patch.  There is word that a delayed-release form of hydromorphone may come to market.  

Morphine preparations have been around the longest.  As compared with other opiates, they tend to cause more fatigue and nausea and perhaps, more constipation for a comparable amount of pain relief.  MsContin is advertised that it can be given two or three times daily.    Unfortunately, clinical experience does not support this.  MsContin benefits may run out after 6-8 hours    Many doctors have addressed this problem by giving the drug more often.  However, the drug was never studied this way and so no one can really state the safety or efficacy of more frequent usage.  

The delayed release mechanism of these pills is easily bypassed, allowing a person to get a dump of medication in their system.  This makes the drugs more prone to abuse.  At the present time, this has been a far greater problem with Oxycontin but it can occur with MsContin.  

Kadian is a newer formulation of delayed-release morphine.  It supposedly can be used once or twice daily.  I do not have much experience with it but have found that a once daily regimen does not work well.  It is harder to bypass the release mechanism and this may prove to be an advantage.  Unfortunately, patients do not seem to like the drug as much as other morphine formulations.  

Avinza is the newest kid on the block.  It supposedly is a true once daily formulation.  However, it has a quick release of a percentage of the embedded morphine.  This may make it more susceptible to abuse than Kadian.   I don’t really understand why you need the quick release.  However, the drug is liked more than Kadian-perhaps the quick release has a psychological effect.  I suspect it will also make the Avinza more subject to abuse.        

Oxycontin is the most well known of the delayed release medication.  It uses oxycodone rather than morphine as an active ingredient.  It is less likely to cause fatigue and/or nausea.
The problem is that it may be more euphoric.  The addiction problems we had with this druh outpaced those from morphine even though those were around a lot longer.  In its original form, it was easy to break apart the pills to get a certain effect.  More recent forms of it are harder to abuse.

Fentanyl is an ultra-short acting agent that is embedded into a patch (Duragesic).  It is as well tolerated as Oxycontin and is quite effective.  It is harder to bypass the release mechanism and has been shown less likely to cause the emergence of addictive behavior as compared to Oxycontin. 

The patch is supposed to last for 72 hours providing very consistent pain relief during that time.  It does provide consistent pain relief but often starts to be less effective after 48 hours.  The manufacturers own literature seems to show a fall of in drug level on the third day of about 10-15%.  Most of my patients changed their patch every two days.  I felt more comfortable increasing the frequency of the patch because the old patch can be removed whenever a new one is placed.  I was not comfortable with increasing the frequency of Oxycontin.  After all, if you take a pill early; you cannot reach into your intestine and remove the remainder of the prior pill.  

The downside of the patch is related to its’ adhesion to the skin.  The patch falls off if not applied properly (and even if applied properly) and there can be skin irritation.  The manufacturer, Jannsen, does not advertise this but they will send a bio-occlusive dressing if a patient requests this.  These will help the patch stay on.  However, removing the bio-occlusive dressings from the skin can also be difficult.  

A generic version of the patch now exists.  It seems less likely to be abused as the medication is embedded directly into the patch and not into a gel which can be separated from the patch.  

There are two long acting opiates: methadone and buprenorphine.  Methadone was use for pain for thirty years until the sixties.  It was used for addiction then and has become synonymous with addiction treatment.  Many patients feel stigmatized by taking the methadone.  This is unfortunate since it is a highly effective medication.  It is also inexpensive.  It has a lower potential for abuse than some other drugs.  

There are some problems with it as well.  It is more likely to cause sedation and nausea.  It is thought of as harder to come off of than other opiates but this is unproven.  Besides, if we are looking for an effective treatment, ease of withdrawal is a secondary consideration.  

Recently, we have realized that methadone has anincreased risk for respiratory depression and heart arrythmias even when taken appropriately.  It is still a relatively safe drug.

Buprenorphine is another good medication. It is extremely well tolerated (better than any other opiate) and usually does not cause a medicine head.  However, it has a ceiling on its’ effectiveness and is not good for more severe pain.  It is expensive and hard to take; it is given as an injection or as a sublingual tablet or liquid. (recently it is available as a sublingual film) 

Its’ major advantage is its low risk of abuse.  It can act as an opiate blocker in some cases so a person using other pain medication should not take it unless directed to by a doctor experienced in its use.  

In the past, when I was faced with a new patient I considered many things.  Were they reliable?  Was their pain severe?  What other drugs were they taking?  How consistent was their pain?  Most of the patients who came to my office had been unreliable with pain medication in the past.  I tended to use buprenorphine or methadone with them.   

I liked methadone a lot.  For persons without insurance, methadone is quite inexpensive.  However, most patients do not like the idea of methadone as they equate taking this as having an addiction problem.  I would then use one of the various morphine products.

If they did not tolerate morphine well, I often switched to Duragesic.  I tended to avoid Oxycontin.  It may or may not be more addictive than the other drugs.  It certainly has a higher street value.  I felt that if I used Oxycontin frequently in my office, I would eventually be seeing more persons who would not be sincere in their need for pain medication.   Occasionally, I did use it.  When I did, I was insistent that it be used on an every 12-hour basis.  There may be more pain at the 10-12th hours However, there is greater relief at the twelfth hour when the medication is finally taken.  I had found that this regimen results in longer intervals of time before dosage levels have to be adjusted.
 
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