OVMC:Pain and Substance Use Disorder

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OVMC Pain and Substance Use Disorder is a resource for providers and nursing staff on the topic of Pain Management and Substance Use Disorder. These resources are only a guideline. All clinical care decisions are left to the discretion of the treating provider.

Non-Medication Modalities

  • Cold/Warm compress-use one or alternate with both-cold has been found to decrease nerve conduction velocity (Herrera, Sandoval, Camargo, & Salvini, 2010)
  • Stop smoking-this constricts small blood vessels which decrease oxygen to the tissues.
  • Start anti-inflammatory diet – (detail below) (Hal, 2013)
  • Lose weight- Weight loss-5% weight reduction results in an 18% improvement in function. For every 1 pound lost 4 pounds of force is reduced on each knee. Weight watchers is covered for LA Care patients.
  • Encourage activity-Yoga type exercises are best for back pain. Muscle Strengthening and Stretching- especially of the quadriceps. Walking and swimming (although swimming may aggravate lumbar OA due to extension of the spine).
  • DME-Braces, Shoe wedges, walkers and canes
  • Encourage participation in Wellness Center
  • Physical and/or Occupational Therapy-Strengthening, Stretching, Iontophoresis, Phonophoresis, Taping, etc
  • Discourage bed rest - Any activity is beneficial. If exercises are intolerable, encourage them to do something, bed rest beyond a good 8 hours sleep, is counterproductive.
  • Psych Referral for Cognitive Behavior Therapy (CBT) (McBeth, et al., 2011) (Berkowitz & Katz, 2012)
  • Acupuncture
  • Transcutaneous Electrical Stimulation (TENS)
  • Meditation- Recent evidence has shown how meditation can produce better outcomes than medications. (Cherkin, et al 2016) (Hilton, 2017)

Non-Opiate Over the Counter Medications

  • Acetaminophen:
    • Consider starting Tylenol 500mg q 8 ATC. This will not eliminate all the pain but it will help.
    • Most pain studies consider a 30% reduction "meaningful pain relief"). (monitor hepatic function)
    • May be used in combination with NSAID.
  • NSAIDS- e.g. Ibuprofen - monitor for GI symptoms - efficacy over Tylenol may not be appreciated until the disease process is more advanced. Low dose should be sufficient since inflammation is minimal in OA. Consider using with PPI or misoprostol. (H2-blockers not shown to improve GI protection when used with an NSAID). There are 5 different classifications of NSAIDS with slightly different mechanism of action. While one may not work and another might.

Topical Pain Relievers

  • BenGay®, Icy Hot®, Salonpas®, and Thera-Gesic® three to four times a day (usually for up to one week).
  • Diclofenac topical gel three to four times a day.
  • Capsaicin (cap-SAY-sin) is the active ingredient in hot peppers, which produces a characteristic heat sensation when applied to the skin (dermal drug delivery). An adequate trial of capsaicin usually requires four applications daily, around the clock, for at least three to four weeks. Gloves should be worn during application, and hands should be washed with soap and water after application to avoid contact with the eyes or mucous membranes. Pretreatment with lidocaine ointment may decrease initial burning sensation.
  • Lidocaine 5% Ointment Max dose 6 inch strip of ointment / 20gm of ointment per day. Use smallest effective amount for shortest duration.

Alternative OTC Therapies

These medications are sometimes recommended for treating pain but may take longer to see an effect

  • Vit D3 1000-2000 units daily (check Vit D levels, some patients may need higher daily dosages)
  • Fish Oil 1000-1500mg/day- these are the omega-3 fatty acids-it helps with nerve pain. Mechanism of action is unclear, possibly through anti-inflammatory mechanisms.
  • Probiotics – lactobacilli and bifidobacteria - Help restore intestinal microflora
  • L-Glutamine 500mg to 4000mg qac and qhs- Poor diets causes poor absorption in the gut. Glutamine helps improve absorption. More than 80% of Serotonin which is important for pain relief and decreasing depression is made in the gut. (Lomax AR1, 2009)
  • Glucosamine and chondroitin supplements-naturally made in the body, may help joint pain.
  • Lipoic acid 600 mg daily or in divided doses has shown efficacy in the improvement of diabetic polyneuropathy (Ziegler 2006)
  • Vitamin B6 50 mg a day- reduces inflammation

Anti-Inflammatory Diet

Reduce foods that contribute to systemic inflammation and ay aid with weight loss

  • Trans-fats (Including Hydrogenated fats)
  • Artificial sweeteners
  • Sugars (White sugar, white flour, white potato, fruit juices)
  • Soda

Neuropathic Pain

Definition - pain related to neurological dysfunction, such as brain, spinal cord, peripheral nerve damage - can be made worse by chronic opioid exposure

  • Gabapentin (Neurontin)... Calcium channel blocker which reduces the release of nociceptive neurotransmitters in the spinal cord. The half-life is 5-7 hours so qid dosing is recommended. Taper up to a dose of 800mg pill qid with 1/2 tab later at night prn. The prn 1/2 dosing at night gives patients a sense of control. (Argoff, 2003)
  • Pregabalin (Lyrica)100mg tid has the same method of action as Gabpentin but has better bioavailability.
  • Nortriptyline (Pamelor) to 150 q night, or duloxetine (Cymbalta) up to 60mg/day (good for OA pain). These medications are SNRIs. Blocking reabsorption of serotonin and more so, norepinephrine, helps stimulate the brain’s own pain inhibitory pathways. The higher doses help better with pain and may help depression. (Argoff, 2003)
  • Lidocaine- topical– 5% ointment/cream, 2% gel, 3% cream; Note - 5% patch (Lidoderm) is non-formulary - can prescribe 5% cream and use Seran wrap to cover the area

References

  • Anders A.F. Sima, Menotti Calvani, Munish Mehra, Antonino Amato Diabetes Care Jan 2005, 28 (1) 89-94; DOI: 10.2337/diacare.28.1.89
  • Argoff, C. (2003, May). Managing Neuropathic Pain: New Approaches For Today's Clinical Practice. Retrieved 2015, from Medscape: http://www.medscape.org/viewarticle/453496
  • Berkowitz, S., & Katz, M. (2012). Thinking Our Way to Better Treatments. ARCH INTERN MED, 172(1), 10-11.
  • Cherkin D.C., Sherman, K.J., Balderson B., H., et al. Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain:A Randomized Clinical Trial. JAMA. 2016;315(12):1240-1249. doi:10.1001/jama.2016.2323
  • Hal., B. (2013, April). Nutrition in Pain Modulation. Alternative and Complementary Therapies, 19(2), 71-74.
  • Hilton, L., Hempel, S., Ewing, B.A. et al. ann. behav. med. (2017) 51: 199. doi:10.1007/s12160-016-9844-2
  • Herrera, E., Sandoval, M., Camargo, D., & Salvini, T. (2010). Motor and Sensory Nerve Conduction Are Affected Differently by Ice Pack, Ice Massage, and Cold Water Immersion. Physical Therapy, 581-591.
  • Lomax AR1, C. P. (2009). Probiotics, immune function, infection and inflammation: a review of the evidence from studies conducted in humans. Current Pharmaceutical Design, 15(13), 1428-518.
  • McBeth, J., Prescott, G., Scotland, G., Lovell, K., Keeley, P., Hannaford, P., et al. (2011). Cognitive Behavior Therapy, Exercise,. ARCH INTERN MED, 172(1), 48-57.
  • Nadler, S. (2004, November). Nonpharmacologic Management of Pain. The Journal of the American Osteopathic Association, 104, 6s-12s.
  • Taylor CP1, A. T. (2007, Feb). Pharmacology and mechanism of action of pregabalin: the calcium channel alpha2-delta (alpha2-delta) subunit as a target for antiepileptic drug discovery. Epilepsy Res., 73(2), 137-150.
  • Woolf, C. J. (2010, October 18). Central sensitization: Implications for the diagnosis and treatment of pain.
  • Ziegler D, Ametov A, Barinov A, Dyck PJ, Gurieva I, Low PA, Munzel U, Yakhno N, Raz I, Novosadova M, Maus J, Samigullin R Diabetes Care. 2006 Nov; 29(11):2365-70.