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Medication Approach to Chronic Pain
A Patient's Guide to: Medication Approach to Chronic Pain
Pain is the most common reason for visiting a doctor. Treatment for pain consists of non-drug therapy and drug therapy. Examples of the non-drug therapies are physical therapy, relaxation exercises, injections, and massage. Most patients with chronic pain will need to use both non-drug and drug therapies to get the best pain relief possible.
This guide will help you understand
The World Health Organization (WHO) developed the analgesic ladder. It is designed to help healthcare providers manage cancer pain with medications in a systematic way.
Step 1 of the Analgesic Ladder
The WHO recommends a non-opioid (non-narcotic) medication as the first step. This can be given with an adjuvant medication. Adjuvants are medications that can give additive pain control when used with the primary pain medication. Common adjuvants include certain antidepressants, antiepileptics, and topical medications.
Non-opioid pain medications include acetaminophen (Tylenol®) and the non-steroidal antiinflammatory drugs (NSAIDs). NSAIDs include drugs such as aspirin, ibuprofen (Advil®, Motrin®) naproxen (Aleve®), Naprosyn®), piroxicam (Feldene®), meloxicam (Mobic®), celecoxib (Celebrex®), and many others.
Step 2 of the Analgesic Ladder
If pain is not controlled with a Step 1 medication, then one should proceed to Step 2. This would be adding or changing the medication to include a weak opioid. Weak opioids include the drugs such as hydrocodone or oxycodone with acetaminophen, ibuprofen, or aspirin. Common brand names are Lortab®, Vicodin®, Vicoprofen®, Bancap HC, Percocet®, and Percodan®.
Step 3 of the Analgesic Ladder
If the weak opioid is not enough, then a strong opioid should be tried. Examples of strong opioids are morphine (Kadian®, MS Contin®, Avinza®), oxycodone (OxyContin®), fentanyl (Duragesic® patches), oxymorphone (Opana®), and methadone (Dolophine®.)
Problems with the WHO Analgesic Ladder
The WHO analgesic ladder has been a helpful guide to slowly step patients up as they need stronger medications. There has been some debate over where some medications fit on the ladder.
Tramadol is a synthetic analogue of the opioid codeine. The Drug Enforcement Agency (DEA) did not classify it as a controlled substance. This means that some see it as a Step 1 non-opioid drug. Others view it as a Step 2 opioid drug. It can be helpful for mild or moderate pain. It is one of the few medications that show benefit in patients with fibromyalgia.
The term weak opioid is a confusing term. Combining a low dose of an opioid with acetaminophen, ibuprofen, or aspirin, improves efficacy (gives the desired effect). Adding hydrocodone and oxycodone to other su...
Pain Management Medications
A Patient's Guide to Pain Management Medications
There are several types of medications that can be used to treat pain. No one drug works for everyone. The medications that work best for you will depend on the type of pain you have and your response to them. Your medication regimen will need to be designed just for you.
This guide will help you understand
If you have lived with pain for a long time, it is common to have other conditions as well. These may include depression, anxiety, and insomnia (trouble sleeping). These conditions can make pain worse. And it’s harder for you to cope with the stress of living with pain. In order to get control over the pain, these conditions usually need to be treated at the same time as the pain.
The goal of using medication, as part of your treatment plan, is to increase your activity level. This can be done by improving pain control with drugs that you can afford while avoiding side effects.
The medications most commonly used in pain management belong to the following groups
Opioid (Narcotic) Pain Medications
Pain management experts prefer the term opioid to describe narcotic medication. The word narcotic is a legal term that is often linked with the illegal use of drugs.
Opioid medications are expected to improve your activity level. They do this by decreasing the pain you feel when you are active.
Opioids such as morphine (MSContin), fentanyl (Duragesic), and methadone reduce pain by binding to opioid receptors in the brain. Most pain is responsive to opioid medications. However, some types of pain respond better than others. Nociceptive pain refers to skeletal or muscular pain. This type of pain is usually more responsive than neuropathic (nerve) pain.
Some problems such as fibromyalgia with diffuse (widely spread) myofascial (inflamed muscle and fascia) pain may respond at first. But studies show that patients with fibromyalgia do not do better over time on these drugs. Pain caused by headache may be relieved by opioids, but they can cause worse headaches later. These are called rebound headaches.
There are some possible risks associated with opioid use. Not everyone will have all of these problems. With the right management, you may not have any problems. Risks can include
Who Can Benefit the Most From Opioid-Based Medications?
Research is underway to find out which patients with chronic pain can benefit most from the use of opioids to control pain. The word opioid refers to substances that act like morphine in the body. These are natural or manmade and have effects like the opium poppy.
The specific focus of this article is the effectiveness of opioids for chronic noncancer pain (CNCP). Several questions were raised. Is there evidence that opioids can be used with certain subgroups of chronic pain patients? Are the current clinical guidelines in use actually based on evidence available?
The current biopsychosocial theory of pain explains why some people develop chronic pain and others do not. This model suggests there are multiple factors that interact with each other to produce chronic pain. This includes biologic, psychologic, emotional, and social factors.
The studies reviewed showed that there are some risk factors to predict a poor outcome. Such things as a previous history of abuse, younger age, and pain at multiple sites or a lower pain threshold may interact together to move someone from acute to chronic pain.
There's evidence that combining a wide range of treatment approaches may produce the best results. This could include psychologic or behavioral therapy, medications, physical therapy, or surgery. Whether or not opioids should be used right away or reserved for use when nothing else helps remains a hotly debated topic.
That's why more researchers are looking for ways to predict who might benefit from these medications -- not just who is more likely to misuse or abuse these drugs. The goal is to assess each patient and plan treatment that is individually tailored for that person. The final outcomes should be pain control, increased function, and improved quality of life. The idea is to provide these benefits while avoiding addiction or undermanagement of pain.
More information about pain mechanisms may be helpful. Genetic factors, psychologic health, and sensitivity to pain may be interconnected. Mood changes seem to be related to chronic pain more than intensity of pain. The results of several studies show that pain amplification and even catastrophizing pain may have an underlying genetic factor.
Other genetic factors are being considered. For example people metabolize drugs or move the drug through the body differently based on genetic traits. Type of pain receptors in the brain and in the body may be genetically determined. Even the t...