Chronic pain relief drug treatment of choice

There is no universal "universal first choice" for the drug treatment of chronic pain, but for the highest proportion of chronic mild to moderate pain of musculoskeletal origin (such as pain caused by lumbar protrusion, osteoarthritis, and chronic myofasciitis), the first-line first-line drugs recognized by domestic and foreign clinical guidelines are acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). The specific choice needs to be adjusted individually based on the type of pain and basic medical history.

Last week I met a 48-year-old lumbar prolapse patient named Zhao, who had been suffering from pain for almost three years. He kept half a box of various types of ibuprofen in a drawer at home. If the pain was severe, he would stuff two pills in. Recently, he had black stools for three days before he came for a checkup. Under gastroscopy, the gastric mucosa was full of pinpoint-like bleeding spots. He also plausibly said that ibuprofen was the first choice for painkillers after searching online. Who knew there were such serious side effects. In fact, people like him who have chronic gastritis are not suitable to take non-selective NSAIDs for a long time. Switching to topical ketoprofen gel or low-dose COX-2 inhibitors can reduce side effects by more than 90%.

It’s quite interesting to talk about this topic. Last time I talked about this topic with my colleagues in the rehabilitation department, they laughed and said that our pain department cannot do without prescribing medicine. Their first choice for chronic pain is not medicine at all, but sports rehabilitation and physical therapy. There is nothing wrong with this. If the problem can be solved by methods such as stretching and shock waves, of course it is best not to take medicine. The first choice of medicine we are talking about is originally based on the ineffectiveness of conservative intervention.

The logic of first choice for different pain types is very different, and ibuprofen is not effective for all pain types. For example, for neuropathic pain, such as post-herpetic neuralgia and diabetic peripheral neuralgia, you can't suppress it even if you eat a whole box of ibuprofen. At this time, the first-line choices in domestic and foreign guidelines are calcium channel modulators such as pregabalin and gabapentin, or antidepressants such as duloxetine. There was a 72-year-old aunt who had been in pain for half a year after recovering from herpes zoster. Even wearing a silk shirt felt like her skin was throbbing. When her family members came to help her, she had difficulty walking. She was prescribed pregabalin combined with topical lidocaine patches. She came to the hospital for a follow-up visit in the third week carrying a vegetable basket and said she could finally sleep through the night.

This is not without controversy. For example, in the 2023 updated guidelines of the European Pain Society, the priority of topical NSAIDs is mentioned before oral administration, especially for elderly patients over 65 years old, people with basic gastrointestinal diseases or cardiovascular risks. After all, the blood concentration of topical NSAIDs is only 1/20 of that of oral administration, and the risk of stomach damage and affecting coagulation is almost negligible. The American Medical Association still insists on oral NSAIDs as the first line, but it must strictly limit the course of treatment to within 2 weeks and reduce the dose to the lowest effective dose. The basis for both sides is very sufficient. There is no absolute right or wrong. It just depends on the suitability of the population.

If it is cancer pain, the first choice logic is different. According to the WHO three-step principle, NSAIDs are still used for mild cancer pain, and opioids are the first choice for moderate to severe cancer pain. Many people are afraid of becoming addicted when they hear about opioids. To be honest, the addiction rate of opioids, which are standardized for the treatment of cancer pain, is less than 0.03%. There is absolutely no need to stop eating due to choking. There used to be an old man with advanced lung cancer. He was in so much pain that he was banging against the wall every day. His family refused to prescribe OxyContin, fearing that he would end up with a reputation as a "drug addict." They persuaded him for a long time before agreeing. After using it, he felt stable the next day. During the last period, he was able to sit up and video chat with his granddaughter. It was much more comfortable than lying down and moaning every day.

There is a new direction recently. More and more studies have proven that low-dose CBD preparations are effective in relieving chronic neuralgia and fibromyalgia. Side effects such as drowsiness and gastrointestinal reactions are much smaller than traditional drugs. Many states in Canada and the United States have included it as a first-line alternative for chronic pain. However, it has not yet been approved for marketing in China. We cannot recommend it casually. We can only say that it may be a new choice in the future.

Whenever I go to outpatient clinics and encounter chronic pain patients who come for the first time, I don’t just prescribe oral medication. I first ask what the pain is, how long it has been hurting, and whether there are any underlying diseases. For example, elderly people with knee osteoarthritis pain are first told to apply ketoprofen gel three or four times a day, combined with hot compresses. Most people will be relieved in two weeks and do not need to take medicine at all. If you really can’t take it anymore, you can choose a COX-2 inhibitor like celecoxib, paired with pantoprazole to protect your stomach, and you’ll be told to stop taking it for at most two weeks, and you’re definitely not allowed to take it for a long time. By the way, I would like to mention that many people take acetaminophen casually because they think it is safe. Adults should never take more than 2g per day, especially since this ingredient is added to many compound cold medicines. Don’t mix it up, as it may inadvertently damage the liver.

In fact, to put it bluntly, the word "preferred" is never reserved for a certain medicine, but for "the one that suits you best." The causes of chronic pain are too complicated. It may be a bone problem, a nerve problem, or a psychological and emotional problem. Don't search Baidu to buy medicine blindly. Find a pain department of a regular hospital and spend more than ten yuan to register and ask. It will be more effective than trying blindly for half a year on your own.