Medications for pain by class

Non-steroidal anti-inflammatory drugs (NSAIDS)

This class is the standard pain relievers, many of them over the counter. If the response is not enough, make sure you are using them effec­tively and at the right doses. For example, ibuprofen may be effective taken three times daily to prevent severe pain, but may appear not to work if used only at crisis times.

All can cause upset stomach, and even ulcers.

Acetaminophen (Tylenol ® and others)

This medication has no effect on inflammation, but can be useful for headache and muscle-joint pain. It is a reasonable first attempt.

It can cause liver problems if used in very high doses and should never be taken excessively. If the regular dosage does not help, either add a NSAID or move to another medication, do not push the dose.

New NSAIDS

For reasons I do not understand, sometimes other NSAIDS work better than ibuprofen and can be taken regularly and less frequently during the day. It is reasonable to attempt others in this class, usually by prescription, before going to stronger medication.

These would include: Diclofenac (VoltarenTM) 50mgs three times a day, or the long acting VoltarenTM XL 100 mgs once daily; Sulindac (ClinorilTM) 100 to 200 mgs twice daily, do not exceed 400 mgs daily; Naprosyn and many others.

ArthrotecTM is a brand that combines diclofenac with the drug misoprostal to protect the stomach (50mgs/200mgs up to four times daily). Do not take if pregnant, or even if pregnancy is likely.

Tricyclics

These drugs are the old fash­ioned antidepressants (taken in low doses) and provide pain relief, but must be taken regularly to be effective. They should be used to prevent pain, and never be taken just when the pain is bad.

This is one type of medication that must be taken regularly, good days and bad. CFS patients are usually sensitive to them and lower starting doses should be used.

Tramadol (UltramTM 50 to 100 mgs three times daily)

I like this medication partly because the name sounds like Kurt Vonnegut designed it.

It should be used with caution in conjunction with ProzacTM and tricyclics. It is a cousin of the NSAIDS and has some effect on the serotonin and norepinephrine systems as well as being a very weak opiate.

While it is unlikely to cause dependence, some persons say it is unlikely to be of value. But it is worth a try.

Baclofen®

This is a nifty drug, cheap, and when it works—great. Unfortunately, it does not work very often.

It is best when the muscle pain is of a cramping or spasm quality, which is why it is used in multiple sclerosis.

It is related to the benzodiazepines such as clonazepam or alprazolam and should be used cautiously with these. Some sedation is likely, and the dose should not exceed 10 mgs three times daily.

Seizure medications

These must be used with caution, as the side effects may be significant, but when they work they are great.

• Neurontin (GabapentinTM 900 to 1800 mgs daily). This medication was devel­oped for seizure disorders and may cause dizziness or increase fatigue. The mechanism of pain relief is uncertain. Significant side effects are possible and it should be reviewed carefully before use.

• Carbamazepine (Tegretol® 100mgs twice daily to a maximum of 1200 mgs a day. Tegretol® XR 100 mgs twice a day.) This seizure medication can cause excitation, bone marrow problems and allergic reactions, and should not be used with erythromycin, Prozac and other drugs. It is a cousin of the tricyclics and sometimes gives good pain relief.

Narcotics

While these drugs always have the potential for addiction, it is said that addiction rarely occurs when used to treat severe pain.

Intermittent use is best if possible. Doctors are usually reluctant to use narcotics because of the risk of addiction; you don't need any more problems than you already have.

Propoxyphene (DarvonTM) is my least favorite drug because it may have a high addiction potentia,l yet wimpy pain relief.

A note in conclusion

When people hear the side effects of medications, they frequently become afraid and unwilling to try medications. If you were to see the side effect profile of aceta­minophen (Tylenol®) you would probably never take it because it includes death.

When 280 million people use a drug, side effects are bound to occur. Keep in mind that if you saw the side effects and dangers of taking a shower (i.e. slip­ping in the bathtub, etc) people would not bathe. That, however, also has its side effects (loss of friends, physicians, etc).

Use common sense.

Any medication that does something will have side effects. Some of the safest medica­tions are only safe because they do nothing at all.

Consider medications as you would consid­er driving a car. They are both inherently dan­gerous, but are helpful if used properly.

 

Dr. David S. Bell is an internationally known ME/CFS clinician based in Lyndonville, NY, the site of a 1980s cluster outbreak. He has been researching the illness and treating patients in his rural practice ever since. While he has spe­cial expertise as a pediatrician in treating young people with ME/CFS, his practice encompasses adults as well as children. This column originally appeared in his publication, The Lyndonville News, and appears here by permission. [2015 Note—Dr. Bell is retired and his newsletter is no long available.]