Managing Chronic Pain

By Joe Flasher 

In my last article on mild to moderate pain, I said I would be focusing on chronic pain and those methods used to control it. As you recall one of the differences between acute and chronic pain is that chronic pain generally lasts longer that six months. You may not be aware of the source of your pain or you may have found out it's fibromyalgia, arthritis or any number of other conditions but you know it's chronic.


Knowing the source isn't enough to alleviate your discomfort. There often aren't any quick fixes for chronic pain. There is only so much your doctor can do and often it's up to you. If you want your life to improve then you must learn to manage your pain.


Managing chronic pain isn't about making the pain disappear. It's about keeping your pain at a tolerable level. It's about enjoying life despite your pain. Being in charge of your pain doesn't mean that we can't or shouldn't look for help from others.


A doctor can be especially helpful when you have questions or need assistance. Make sure it's a doctor who communicates well with you and understands your condition. It may be a specialist overseeing your condition, your family doctor, or a pain control physician. You can usually get a referral from your family doctor.


To make managing your pain easier, learn all that you can about your condition and your pain. There is much information to be found on the internet and also at your local library in medical dictionaries and books on pain control.


Understanding your treatment is especially important when your physician recommends specific treatments. Find out why these treatments are being recommended, what are the risks and the benefits and if there are any alternatives. Be careful of medications or injections being offered, without being aware of what each entails. Any intervention brings a chance of both benefits and complications. Talk to your doctor to make sure the balance is in your favor.


I covered OTC (over the counter) medications in my previous article. In this issue we will talk about those drugs used in pain control which require a prescription. There are many classes of medications used. Let's begin with anti-seizure medications.


Some of the most effective and commonly used medications to control pain are those drugs that were developed to treat other conditions. Anti-seizure (anticonvulsant) medications were developed primarily to control epileptic seizures, but they also help control stabbing or shooting pain from nerve damage. These drugs seem to work by quieting damaged nerves to slow or prevent uncontrolled pain signals


Anti-seizure medications used for chronic pain include:


* Carbamazepine (Carbatrol, Tegretol)                       Clonazepam (Klonopin)

   Divalproex sodium (Depakote)                                Gabapentin (Neurontin)      

    Lamotrigine (Lamictal)                                         Phenytoin (Dilantin)

* Oxcarbazepine (Trileptal)                                      Tiagabine (Gabitril)

* Topiramate (Topamax)                                         Valproic acid (Depakene)


These medications can cause dizziness, drowsiness, nausea and lack of balance and coordination, but most people are bothered only minimally. More severe, but less common, side effects include blood and liver disorders. To reduce your risk of side effects, your doctor will likely start you off on a small amount of the drug and gradually increase the dose while monitoring.





These medications can cause dizziness, drowsiness, nausea and lack of balance and coordination. But most people are bothered only minimally. More severe but less common side effects include blood and liver disorders. To reduce your risk of side effects, your doctor will likely start you off on a small amount of the drug and gradually increase the dose while monitoring you.


COX-2 inhibitors include:


    Celecoxib (Celebrex)                                       Rofecoxib (Vioxx)

    Valdecoxib (Bextra)


In addition, COX-2 inhibitors do not thin your blood like aspirin and other NSAIDs. If your doctor has prescribed aspirin for a heart condition, don't use COX-2 inhibitors instead.





Instead of prescribing pills to control your pain, your doctor might inject medication. Injections typically don't cure pain, but they may help you through an initial period of intense pain or a flare-up of severe pain. Injections are most effective for joint, muscle or nerve pain that's confined to a specific location. Injected medications may be an anesthetic to control the pain, a steroid to reduce inflammation or a combination of the two. In addition, a substance that improves joint mobility is also sometimes injected. One benefit of injections is that the medication works primarily in a limited part of your body. By targeting a specific area, injections may reduce the amount of medication needed and the number and intensity of side effects.





I covered this class of drugs in my previous article. The basic difference between the prescription and OTC tablets are the strength of the drug. The prescription tablets have more drug in each tablet than the OTC products but there would be no problem taking more of the OTC drug to equal the prescription strength. You must be careful to monitor the effects on your stomach.



OPIOIDS (Narcotics)


Opioids are prescription medications and are regulated as controlled substances by the Drug Enforcement Administration. Opioids are often used to relieve pain from cancer, terminal illness, severe injury or surgery. Pain control after surgery is especially important. The sooner you're active, the less the risk of complications due to inactivity, such as pneumonia or blood clots.


Opioids, sometimes called narcotics, come in several forms. Some are natural compounds derived from the opium poppy, which are called opiates. There are also synthetic opioids that work in similar ways. Opioids include both these natural and synthetic forms and are the preferred term.


Frequently prescribed opioids include the following:


* Codeine                                               Fentanyl (Duragesic)

* Hydrocodone                                        Hydromorphone (Dilaudid)

* Levorphanol (Levo-Dromoran)                  Meperidine (Demerol)

* Methadone (Dolophine)                           Morphine (MS Contin, Oramorph SR, others)

* Oxycodone (OxyContin)                          Oxymorphone (Numorphan)

* Propoxyphene (Darvon)


Side effects of opioids include mild dizziness, drowsiness, sedation, and unclear thinking. These can make it unsafe for you to drive or operate machinery.


I am giving you just a short overview of these drugs. Each of these drugs is a book all by itself. If you want more information ask your doctor, go online, go to your library or email me. I'll answer what I can.





Topical medications are creams or gels that you apply to your skin. These drugs act on the surface of your body or are absorbed. Pain relief ointments can occasionally help relieve nerve pain and inflammation just below the surface of your skin. Three types of topical medications are available. They are local anesthetics, analgesics and counter-irritant products.


Local anesthetic is a prescription pain relief cream made from two topical anesthetics - lidocaine and prilocaine. Your skin becomes numb within an hour after application, and the benefits are greatest 2 to 3 hours following application.


Lidocaine patch is a patch (Lidoderm) which may be prescribed for relief of pain associated with neuralgia and nerve pain.

Over-the-counter products - Several OTC topical medications are available for pain relief. They include dibucaine (Nupercainal), lidocaine (Xylocaine, Zilactin-L), benzocaine (Lanacane, Solarcain) and pramoxine (Prax, Itch-X).


Capsaicin - This nonprescription drug is made from the seeds of hot chili peppers. You rub capsaicin (Capzasin-P, Dolorac, Zostrix) on your skin, typically three or five times a day. It usually takes up to 1 to 2 weeks before you begin to feel noticeable pain relief. Capsaicin is most effective for temporary relief of arthritic pain in joints close to your skin's surface, such as your fingers, knees and elbows. It may also help relieve pain after shingles (neuralgia), pain from diabetes (diabetic neuropathy) and chronic pain near healed surgical scars.



These nonprescription medications (ArthriCare, BenGay, Icy Hot) stimulate your sensory receptors of heat or cold to cover up or counter pain.


Tramadol (Ultram) is a prescription pain medication that works in two ways. Like an opioid, it interferes with the transmission of pain signals. Tramadol is used mainly to relieve moderate to severe acute pain. Its effect in treating chronic pain hasn't been well studied. Because it's not a true opioid, risk of physical dependence and addiction is less. Side effects from tramadol can include dizziness, sedation, headache, nausea, constipation and seizures.


Some of the more effective and commonly used medications for chronic pain are drugs that were developed to control other conditions. Among these are tricyclic antidepressants. In addition to relieving symptoms of depression, these drugs interfere with certain chemical processes in your brain that cause you to feel pain.

The tricyclic antidepressants most commonly used for pain management are amitriptyline (Amitril, Elavil) and nortriptyline (Aventyl, Pamelor).

Antidepressants don't cause dependence or addiction. However, tricyclic antidepressants can make you drowsy. Therefore, it's generally recommended that you take the medication in the evening before bed. In addition, these drugs may cause dry mouth, constipation, and weight gain, difficulty with urination, and changes in blood pressure.

I will be covering antidepressants in a future article. It is a fascinating subject and especially pertinent to us "strokers".


There are so many aspects to "pain control" that it is impossible to cover in a couple articles. There are alternative therapies to drugs that could be explored (ie: acupuncture, biofeedback, etc). If you would like to have me go into these alternatives in greater depth, please let me know. 

Copyright January 2004

The Stroke Network, Inc.

P.O. Box 492 Abingdon, Maryland 21009

All rights reserved.