Chronic Pain Management FAQ
Q & A with Robert Bennett, M.D.
Chairman of the Arthritis and Rheumatic Diseases
Division at Oregon Health Sciences University.
Q – What is the number one medication that you prescribe for chronic pain and is there any rationale to help you determine what to prescribe?
A – Ultram (tramadol). By the time most patients get around to seeing us, they have already tried numerous types of NSAIDs, as well as Tylenol. Patients with severe pain control problems are often prescribed hydrocodone in the form of Vicodin and occasionally oxycodone in the form of Percodan or Percocet. My colleagues will often refer patients who require more powerful opioids to our pain clinic, headed by Dr. Brett Stacey. I have patients who I treat with the long-acting opioids, such as OxyContin (contains oxycodone) and methadone.
Q – What percentage of patients taking Ultram get significant pain relief and at what dose?
A – As a first-line analgesic, roughly 70% of my patients get reasonable pain relief with Ultram. By reasonable, I mean greater than 50% improvement. This degree of pain relief usually enables patients to become more functional and reduces their level of distress. A typical dosage range is 50 mg twice per day to 100 mg four times per day (100-400 mg/day). About half of our patients take Ultram on a regular dosing schedule, whereas the other half take it as needed—depending upon their severity of symptoms. For patients who are not getting adequate pain relief with a reasonable dose of Ultram, we consider using more powerful opioids.
Q – What about side effects to Ultram and how do you work around them?
A – About 15% of our patients complain of side effects on Ultram. The most common ones are nausea (which reduces with time or by using a slower-paced dose titration), drowsiness (although we have occasionally had patients feel energized), constipation, and an itchy rash. Paradoxically, some patients on Ultram develop headaches. If a patient is having good pain relief, it is worthwhile trying to overcome these problems. For instance, the nausea will often diminish with time, but I have a few patients for whom we prescribe anti-nausea medications such as prochlorperazine (Compazine). Constipation can usually be controlled with diet, but the occasional use of a mild laxative may be needed (e.g., Bisacodyl). If drowsiness is significant, I limit the use of Ultram to nighttime. An itchy rash seems to be a true hypersensitivity to Ultram in a small group of patients and usually recurs when it is reintroduced. These people are not good candidates for continuation of Ultram.
Q – If a person doesn’t respond well to Ultram, what drug alternatives do you recommend for relieving pain?
A – First one must understand how Ultram works. This drug is a weak opioid itself and it breaks down into a metabolite that has stronger opioid action. However, the analgesic properties do not rest entirely on its activity as an opioid. It also inhibits the re-uptake of serotonin and norepinephrine in the central nervous system (increasing their concentrations). These transmitters help filter out some of the pain signals coming down from the brain that would otherwise generate the sensation of pain in the tissues. So Ultram has the dual action of both an opioid and an antidepressant such as Elavil.
Those patients who cannot obtain adequate pain control on appropriate doses of Ultram will often be switched to more powerful opioids. The next in line is usually hydrocodone (e.g., Vicodin which contains 5 mg of hyrocodone plus Tylenol) in a dose ranging from one tablet twice daily to two tablets four times a day. For patients who are requiring high doses of Vicodin on a frequent basis, I will often try switching them to OxyContin (a sustained release form of oxycodone). OxyContin comes in various strengths (without Tylenol) and is usually used two, maybe three times a day. For a patient who has already been on Vicodin, I will usually start out at the 20 mg strength of OxyContin, but I do have some patients who take the 40 or 60 mg pills. For patients who do not respond to this level of opioids, I consider the use of methadone at 5-10 mg two to three times daily.
The use of opioids in non-malignant pain is still controversial, but it is slowly gaining greater acceptance as more doctors become educated on this topic. Although nearly all patients on opioids become physically dependent (they will suffer severe pain and anxiety if the drug is abruptly withdrawn), true addiction (which means craving the opioid for the psychological lift it might provide) is rare in chronic pain patients. As a general rule-of-thumb, if prescription opioids result in patients being less distressed and more functional, continued prescription is usually worthwhile. Occasionally a person may remain dysfunctional despite adequate relief of the pain, and in these instances I refer the patient to a comprehensive pain clinic or to a specialist who can discern if there is an addiction problem.
Q – What about combination pain therapies? Why might more than one drug be used for chronic pain?
A – Even when pain is fairly well controlled with a drug like Ultram, patients may still require the occasional prescription of Vicodin to help them cope with flare-ups. The same could be said for patients using OxyContin. I have not found that such rescue therapy is necessary for people taking methadone. I should point out, however, that the addition of one opioid to another will result in more side effects, including nausea, constipation, and even respiratory depression in some patients. Needless to say, the use of such combination drugs must be very carefully supervised. Patients and their family members also need to be educated on the adverse reactions that may occur with these agents.