Pain Medicine 101

Pain Medicine 101 Acute and chronic pain are common reasons to visit the ER. Obviously, the list of painful things is endless: acute injuries like smashing a finger in a door, ankle sprains and wrist fractures from falling, headaches, chest pain, abdominal pain, back pain, dental pain… The list goes on.

It’s quite common for patients not to try anything at home for their pain. There seems to be a widely held belief that taking something at home will cover up their symptoms and somehow lead to a missed diagnosis. I’ve never seen this happen in practice, and I’m not sure where the idea even comes from. If you actually have something serious going on, a couple of doses of OTC meds won’t cover that up. If you are already prescribed opioid pain medicine and you load up on that to the point that you’re barely awake, well, that’s obviously a different problem. For the sake of argument, let’s assume most people fall into the former category and not the latter.

Google “pain medicine pyramid,” and what you find at the bottom are the least risky options. This includes OTC creams like IcyHot and OTC oral medications like acetaminophen and ibuprofen. As you move up the pyramid, you get to things like cyclobenzaprine, tramadol, hydrocodone, and oxycodone—still all oral medications. At the top are IV opioids like fentanyl and Dilaudid. (There are more than these, but in practice, these are the most commonly prescribed pain meds.)

It’s worth noting here that there are pain meds like cyclobenzaprine, methocarbamol, and Valium that get referred to as “muscle relaxers.” None of them actually relax your muscles. Let me repeat that: None of them actually relax your muscles. In fact, there are no pain medicines that you can take by mouth or IV that go to a specific area of the body. The only things that target a specific location are topical treatments like lidocaine patches and local injections of anesthetics (like for nerve blocks or dental pain/procedures). (If oral and IV meds only went to a specific part of the body that was in pain, there would be no side effects to worry about—which is obviously not the case.) Even within the so-called muscle relaxers, they don’t actually relax muscles. They work in the brain and brainstem to essentially slow neurotransmission of pain signals.

Most meds beyond OTC options also have sedating effects. The higher up the pain pyramid you go, generally speaking, the more sedation there is—as well as greater chances of lightheadedness, dizziness, and nausea. Not to mention constipation, which goes along with all opioids, and addiction potential. The younger you are when you first get an opioid, the increased chance you end up with an addiction problem someday. (Pushing for an opioid for your kid’s pain, whatever the pain might be, is not in their best interest if it can be avoided.)

I’m amazed at the number of patients who have not attempted any OTC treatments before coming to the ER. Obviously, if you have a history of heart disease and prior heart attacks, chest pain should probably be investigated, and you don’t stay home and just take some ibuprofen. Things like that aside, most everything else deserves an attempt at feeling better at home before going to the ER.

Pharmacies and the pharmacy section of every grocery store have almost endless options for every type of pain. It’s reasonable to try any number of these things: Maalox for abdominal pain, Sudafed for sinus pain/congestion, ibuprofen and lidocaine patches for back pain. Try something—anything!

Know what the maximum dose is that you can take in a day. For acetaminophen, that’s usually 4,000 mg per day. That’s two 500-mg tablets 4 times per day. For ibuprofen, when you’re young and healthy, that’s 3,200 mg per day. That’s four 200-mg tablets 4 times per day. That’s a lot of pain medicine before you have to go to the ER. And yes, not everyone can or should take that much, or take that much for long periods of time. The healthier you are, the more easily your body can handle it.

When your doctor tells you that you can’t take a medication, it’s very important to clarify the details. I have many patients tell me they can’t take such-and-such because their doctor said so. As an example, ibuprofen can be hard on the stomach and kidneys, and acetaminophen can be hard on the liver. But I have patients tell me they can’t take acetaminophen because they have kidney disease. If you don’t have any pain, not knowing what you can’t take doesn’t matter much, so the conversation probably doesn’t come up with your doctor. But when you do end up with an injury or pain, knowing what your options are actually does matter. And knowing what your condition is and the differences in medications is important.

People come to the ER having Googled all kinds of things that are usually not helpful. However, in this case, asking Google if you can take ibuprofen and acetaminophen together—and what the max dosing is—will quickly give you a reasonable answer. Again, I’m not talking about taking these medications indefinitely, but they are almost always worth trying before the ER. Because when you get to the ER, most providers are going to start with these anyway. If you can tell me that you have already tried both—at recommended doses and over some period of time, as in, you legitimately tried to manage your pain at home—then we can have a discussion about moving up the pain medicine pyramid. But I’m not being a responsible provider by skipping medications that are less risky and jumping to medications with greater potential for harm if we haven’t tried the less risky ones first.

There is also a difference between a single dose of a medication and taking a medication chronically. Again, I’ll use ibuprofen as an example. Even those with a history of prior peptic ulcer disease or borderline kidney function are not going to be hurt by a single dose of ibuprofen. Should they continue on it indefinitely? No. But if you have an acute pain complaint, it’s probably reasonable to take a dose or two. Having peptic ulcer disease 10 years ago in the setting of using a lot of ibuprofen for your chronic back pain and drinking a lot of alcohol (which wrecks your stomach) is not the same as taking a few doses today when you don’t drink alcohol anymore. Details matter.