Your medical pain management will be determined by your pain needs as an individual. It involves a multi-modal approach as there is no ONE pill that fits all; even though we wish there were!
You’re goal is to try and cover as many angles as you can when you’re struggling! But, backing off on those angles when you don’t need them anymore. You’re always striving for a balance between the most effective amount of medication with the least amount of side effects.
You are NOT aiming for pain free here… that just isn’t possible! We’d have to be unconscious!!
FIRST OFF: SET YOUR GOALS take a moment to think about what you want to achieve. Aim low at first we need to see some success.
I want to be able to go outside and walk at least 1-2x a week, I want to be able to participate in my kid’s lives. That doesn’t mean I’m on the field participating in the Parent vs. Kid soccer game… I’d be in a heap of pain and an embarrassment to my kids. But I can and do want to go shopping with my girls, go driving with my son or help him with his homework and hang out with my hubby. I wanna be able to get up out of bed most mornings.
MEDICAL PAIN MANAGEMENT IS NOT ENOUGH ON ITS OWN… IT WILL NOT WORK IN ISOLATION.
To treat the pain of Rheumatoid Disease you will be using a combination of many small things along side your medications (ie): time management, a nap before or after an activity, pacing yourself, distraction. In other words you will also be practicing ‘self care’ and all those bits and pieces you find work for you! They will work in tandem to allow you to meet the goals you set and hopefully this happens more often than not.
IT’S NO QUICK FIX!
PATIENCE, FINE TUNING AND THE OCCASIONAL TWEAK WILL BE REQUIRED
Just like life, your pain will change… sometimes you will need less, sometimes you will need more. It’s a fluid process and if you understand the roles of each medication you will have more control and can become an active participant in your plan of care! You and your Dr. are a team!
ACETAMINOPHEN is an over the counter medication. It may not be strong enough on its own but please don’t discount its worth! It plays an important part. If you are able to take Acetaminophen and have cleared it with your Dr. it can lessen the number of medications you need and the strength of their dose. This is an important role as lower doses of medications will decrease overall side effects. The role Acetaminophen plays in Rheumatoid arthritis vs. Osteo arthritis has not been as clearly defined. Only you and your Dr. can determine how effective it is for you. Sometimes trialling a medication is the only way to determine how helpful it will be.
SIDE EFFECTS OF MEDICATIONS CAN BE DOSE DEPENDENT Meaning by decreasing the dose you can reduce the side effects. Something worth asking your Dr. before you give up on a drug.
SOME STRONGER MEDICATIONS (IE): THE OPIOD/NARCOTICS ARE FORMULATED WITH ACETAMINOPHEN ALREADY IN THEM And for this reason you cannot add Acetaminophen to your regime if you are already taking it!
THERE ARE NOT AN INFINITE NUMBER OF PAIN MEDICATIONS. Make sure you have given each medication adequate time to work. With your Dr. you have attempted every tweak possible from the dose amount to the dose frequency to try and lessen the side effects or increase the drug’s efficacy. Explore all your options with each medication before you give up and subsequently lose one of your options. Can you take it with food to lessen the nausea, can you take it at bedtime to sleep through the nausea, can you decrease the dose and add a small dose of something else. Can you pre-medicate with an antiemetic/anti nausea medication or drink ginger tea prior to your dose. There is no one size fits all here, and you won’t be the first person to experience your particular side effects. Your Dr. or nurse may have some great suggestions. Finally, its your choice, if you are miserable, only you know whether dealing with the pain is better than dealing with the side effects. It is still all about living YOUR best life.
MAKE SURE YOU TELL YOUR DR. ABOUT EVERYTHING YOU ARE TAKING, including your herbal remedies, vitamins and supplements because of the possible drug interactions or side effects. There is a definite place for these adjuncts. But your Dr. has to know what you are taking in order to be able to prescribe the right drugs to go along with them. They will not tell you to stop taking your adjuncts unless there is an evidence based reason to do so. But ultimately you will know what works for you, and it’s your responsibiliy to vocalize that.
NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs)
NSAIDs are a type of analgesic or pain killer that acts directly on your inflammation. Like steroids they decrease the amount of circulating prostaglandins. They come in varying strengths starting from over the counter medications such as Ibuprofen and ASA to prescription strength such as Naproxen, Diclofenac or Indomethacin.
COX-2 inhibitors are a newer class of prescription-strength NSAIDs. Examples of COX-2 inhibitors are celecoxib (Celebrex) and meloxicam (Mobic).
YOU CAN TAKE BOTH NSAIDS AND ACETAMINOPHEN ALONG SIDE EACH OTHER WHEN YOU NEED TO. These are two different drugs and act in two different ways! But just remember they have different dosing times. One is to be taken every 4-6 hours, the other is to be taken every 6- 8 hours. Follow your Dr’s directions. For some people this can be enough to get your pain to a level where you can cope again. For others there will be additional angles that still need to be covered!
When severe pain rears it’s ugly head! Your doctor can prescribe you an opioid, and they will do so with you under their direct supervision. Opioids or narcotics are stronger painkillers and can provide greater pain relieving effects for intense pain. They do so by altering your brain’s perception of the pain signals it receives. Most Dr’s will not prescribe Opiods as their first choice. They will try to gain control on lesser medications first, moving to the big guns when proven necessary. Oxycodone, Tramadol, Morphine and Hydromorphone are examples of narcotics
It’s important to note that you shouldn’t worry about becoming addicted to opioids as your doctor will be keeping you under close observation. Addiction becomes a concern when you continue taking the medication when you are no longer having pain. Please discuss your fears or issues re: addiction with your Dr. They will be able to reassure you or conversely come up with a plan to help you maintain control.
If your doctor prescribes an anti-depressant, that doesn’t mean you’re depressed, though with a chronic disease it wouldn’t be unlikely.
Anti-depressants are used for pain reasons too. They will help control your pain by changing your body’s brain chemicals.
THERE ARE 3 DIFFERENT CATEGORIES OF ANTI-DEPRESSANTS, EACH ONE WORKING IN A DIFFERENT WAY
- Tricyclic anti-depressants (TCAs) examples: Amitriptyline and Nortriptyline
- Serotonin and norepinephrine re-uptake inhibitors (SNRIs) examples: Cymbalta and Effexor
- Selective serotonin re-uptake inhibitors (SSRIs) examples: Prozac and Zoloft
- TCAs increase the levels of certain brain chemicals
- SNRIs block the re-absorption of certain brain chemicals
- SSRIs also block the reabsorption of certain brain chemicals but aren’t proven to work as well as the other two categories on chronic pain. If you are currently on a SSRI and it’s working DON”T CHANGE what AIN’T BROKE!
Also known as anti-convulsants, anti-epileptics or anti-seizure medications. These medications work to suppress the nerve signals going to your brain so pain messages aren’t transmitted as well. As with anti-depressants, if your doctor prescribes an anti-seizure medication, this doesn’t mean he or she is treating you for seizures. Anti-seizure medications can potentiate the effect of other pain medications and treat chronic pain. Examples of anti-seizure medications are pregabalin and gabapentin.
Steroids are powerful anti-inflammatory medications that can be taken orally or by injection. They are considered systemic when how and where they are administered allows them to spread through the entire body. They are sometimes added when other medications have not reduced your pain. Steroids work by stopping your body from producing the chemicals that causes inflammation. Two corticosteroids you may recognize are Prednisone and Dexamethasone
Steroids do have certain side effects and it will be up to you and your Dr. to decide if these side effects out way the benefits to you. REMEMBER you can’t just STOP taking Corticosteroids—your dose MUST be slowly decreased. Your body decreases the amount of steroids it produces on its own when we give steroids to it in the form of injectable or oral medication. If you stop taking them in medication form without titrating them down slowly your body will not recognize the need to start producing them on it’s own again. This slow titration downwards should occur with your Dr.’s supervision and direction. This will provide your body the time it requires to start producing it’s own steroids again and prevent an adrenal crisis and sometimes SHOCK.
These medications are typically used to reduce aches and pains associated with muscles strains, sprains, or spasms. But, muscle relaxants can provide the pain relief you need with Rheumatoid Disease to manage your daily activities. They help relax tight muscles that can exert pressure on the joints, ligaments, tendons and nerves that are already affected by inflammatory changes and swelling. By reducing this pressure and pain they can also improve our quality of sleep. Getting enough sleep allows us to cope better with the pain.
Muscle relaxants aren’t typically recommended for treating chronic pain and for some Dr.’s are controversial. There are many people they do NOT seem to help, but there are some people they work well for. You will see them used most often with fibromyalgia and low back pain symptoms but they can have their purpose in Rheumatoid Disease as well. Your Rheumatologist or Pain specialist can provide you with more information specific to your illness and whether or not this would be an appropriate medication trial for you.
Some medications are highly effective when used topically. They are also known as topical analgesics, topical anesthetics and topical medications. Lidocaine is a topical anesthetic and can be administered this way. NSAIDS can also be administered this way, one example would be Voltaren gel. The systemic effects can be lessened by administering specific medications topically but, it does not remove the possibility of side effects.
- Salicylates the same pain relieving medication you would find in Aspirin can be found in some topical heat/ice rubs (ie): products such as BenGay and A535. Salicylates are blood thinners so again please use them under a Dr’s supervision. Some people find these work better on joints closer to the surface as they are absorbed locally through the skin.
- Counter irritants are the active ingredients such as camphor, eucalyptus oil, and menthol found in some of these preparations that act as a distractant to your body’s interpretation of pain. They provide a hot or cold sensation which in some cases is very effective.
- Cannabis infused creams the scientific jury is still out on their effectiveness. As with all rubs no matter the ingredients, you are massaging the area when you apply them. This will increase blood flow to the painful area. The CBD oil is thought to decrease your body’s inflammatory response and decrease it’s sensitivity to pain. Some people SWEAR by it and some people don’t. It works great for me in the heat rub I use. It’s dependent on the individual.
- Capsaicin cream Capsaicin, which comes from chilli peppers, can temporarily reduce pain, but for maximum benefits, it needs to be applied several times a day and for at least two weeks.
JOINT AND SOFT TISSUE INJECTIONS
Injection of steroids and local anesthetic medications into the joint or soft tissues (ie): bursa, ligaments and tendons can relieve pain, reduce inflammation, and improve mobility. They can be very effective. Ask your Dr. if this is appropriate for you, depending on which of your joints is involved, the risks and effectiveness can vary. Your Dr. will be able to provide you the information you need to make a joint (purposeful pun!) informed decision. You are a integral part of the team.
NERVE BLOCKS are typically used for acute pain NOT the chronic pain of Rheumatoid Disease because they will only provide short term relief. Again, depending on which joint is involved this may not be an appropriate therapy for you. A nerve block involves injecting strong pain medication and/or steroids around the nerve to provide pain relief directly (with the analgesic) and/or by decreasing inflammation (with the steroid). It can work very well when the sacroiliac joint, spine or shoulder joint is involved.
YOUR TREATMENT PLAN
Don’t be afraid to ask questions—you have to be your own advocate.
BE ON THE LOOKOUT FOR SIDE EFFECTS. If you notice any new symptoms, tell your doctor. But don’t stop taking your medication unless your doctor tells you to do so. No one is more familiar with your body than you.
PAIN SPECIALIST OR CLINIC PAIN SPECIALIST OR CLINIC sometimes we need more contributors than just our Rheumatologist to formulate a successful pain regime. Ask your Family Dr. and/or Rheumatologist if there is a pain specialist or pain clinic they can refer you to. Let the pain specialist/clinic know which Dr’s are involved in your care so they can forward their recommendations to them. Identify which Dr. (ie): your Rheumatologist or Pain specialist will be directing your care and ultimately write the prescriptions for any new medication you will be trialling. This will leave less room for error by having one person in charge. A Pain specialist/clinic will also have other non- medicinal suggestions and therapies available to you and may even provide them all in one convenient location such as physical therapy, mental health, massage, acupuncture and exercise classes etc.
TRY AND REMAIN INFORMED AND EDUCATE YOURSELF
Only a few medical options were outlined here and not ALL the above angles will be necessary ALL the time. Keep this list for when you just can’t get on top of your pain. Maybe adding one of these angles will help you gain control. You will note I have not outlined the side effects of these medications. This on purpose as I am not a pharmacist or physician; you should obtain this information from them. Please share this post if you think it will help someone who’s suffering and I hope you can find something that helps you too!