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perspectives on pain
a d d r e s s i n g p a t i e n t n e e d s
Mixing up the
medicine cabinet
How to combine prescription, over-the-counter
and herbal meds logically and safely
why you may want to offer your pain patients treatments that are alternative or complementary to prescription drugs. First of all, and there may be issues of quality and other pathologies. Quite often, these days there’s an increasing control and purity in manufacturing. however, patients simply can’t sleep interest in alternative meds. Your Generally speaking, beneficial ef­ patients are using them, and if fects may take longer to occur, but problems as you select a treatment. you’re judging them for it, they side effects are fewer.
Patients rarely have chronic pain has the most evidence behind it as This can lead to duplication and in isolation. Pain leads to disrupted a pain killer, I prefer to use tricyclics adverse reactions. Secondly, when sleep, and caffeine and other sub­ treating chronic pain, we should stances may be used to combat day­ use all the help we can get. Our time sleepiness. More pain means all, we want these patients to become patients’ quality of life may well im­ less activity, translating into even less drowsy and more active. proaches, and adjuvant treatments of normal social patterns. Tissue plements that can be added to help may allow us to use smaller doses damage can also alter normal bio­ ment is one area of medicine where satory muscle spasms. Secondary now available at most health food polypharmacy is still favoured. depression emerges when lack of stores and many pharmacies. It Lastly, many of our patients, espe­ stage 3 and 4 sleep, poor nutrition works well at 1.5­6 mg, especially cially those with fibromyalgia and excessive catecholamine release in shift workers or travellers. If the spectrum illnesses, do poorly with overwhelm the brain’s ability to patient sleeps well but is groggy in prescription medications. These make the necessary neurotrans­ are the people who develop side mitters. Treating these coexisting Exposure to full spectrum light effects to even the smallest doses; conditions improves the patient’s first thing in the morning will many do better on non­prescription chance of satisfactory pain relief.
treating sleep disturbances
a vicious cycle
I preface my first discussion with ties, it’s useful to rule out apnea, phan and 5­hydroxytryptophan (5­patients about treatment options periodic leg movement disorder HTP), are also useful for sleep. with a few comments. Alternative Michael Zitney, MD, DAAPM is the director of the Headache & Pain Relief Centre medications may have less rigorous in Toronto, a multidisciplinary clinic specializing in the care of patients with scientific evidence behind them, chronic pain. March 2007 • parkhurst exchange • 27
perspectives on pain
a d d r e s s i n g p a t i e n t n e e d s
GABA is an amino acid that’s substance found in the seeds of active at the GABA receptors, and Griffonia simplicifolia, an African fore bedtime. They also produce as such is a natural anxiolytic and plant; it increases the production serotonin and will benefit depres­ secondary muscle relaxant. It’s given of serotonin in the brain. Many sion. The recommended dose for in doses of 100­1,500 mg just before of my patients find it extremely 5­HTP is 50­200 mg. Use the lowest bed; the predominant side effect is effective, but it tends to be ex­dose if the patient is on full doses drowsiness. Use lower doses in pa­ of a selective serotonin reuptake tients with low blood pressure. Mag­ In my experience, if the pain
gets better with treatment, the
depression improves along with it
should help and may be safer than nesium, vitamin D and B­complex bers of agents the risk of serotonin 5­HTP when combined with SSRIs.
enhance muscle function and may syndrome goes up.
be beneficial in chronic spasms.
Myofascial spasms are common
the role of opioids
How to deal with depression
panying myofascial spasms. This There’s a high incidence of depres­ may be due to a splinting effect as sion in the chronic pain population. tions, has helped relieve suffering the body is trying to protect an In my experience, if the pain gets and improved the quality of life of injured area; it can also be a com­ pensatory effect — surrounding sion improves along with it. For oids alone are usually not enough muscles working extra hard to this reason, I tend not to focus on the to break the chronic pain cycle, as make up for the injured ones. To depression first. Be more aggressive they are not particularly effective at treat this, I often use a combination if the depression interferes with the treating the coexisting conditions of of a muscle relaxant with opioids. patient’s compliance. I usually insomnia, myofascial spasms and Cyclobenzaprine shares structural choose the antidepressant with the depression. Fortunately, there’s a similarities with tricyclics and can most desirable side effect profile. growing list of prescription, over­be used in their place; a dose of 10­ 20 mg will enhance deep sleep and plains of insomnia, mirtazapine may that can be combined with opioids muscle relaxation. Tizanidine is a help. If a person’s too lethargic, to address these problems and newer muscle relaxant that has im­ venlafaxine hydrochloride may be improve the patient’s ability to deal portant central (alpha­2 agonist) a better choice. It has the theoretical with their pain. In this article, we’ve effects, is well tolerated and effec­ advantage of boosting more of the only touched on a few of the avail­ tive. Its use occasionally results in crucial brain neurotransmitters able options. Don’t forget about vivid, disturbing dreams — I sus­ The two amino acids tryptophan meditation, acupuncture, omega­ reaching REM sleep. Use cautiously and 5­HTP may also be useful. 3s, glucosamine, arnica and many with hepatic impairment. The latter is a naturally occurring others.
28 • parkhurst exchange • March 2007


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