Pain Killers! The real Picture

Pain Killers! The real Picture

“I won’t take pain killers, Doctor”. We hear this from a lot of patients and when we check their medicines pouch we find that this is exactly what they are taking. People have a lot of notions about painkillers not all of them being true. In fact it has been our experience that most people have mistaken ideas about these medications.

So let us try and address some important questions in connection with these unwanted and yet necessary drugs:
  1. What exactly are pain killers and what is their role?
  2. What are the different kinds of pain killers that are available?
  3. What are their side effects?

What exactly are pain killers and what is their role?

Pain killers are medicines meant to relieve you of pain and keep you comfortable for the duration that they are acting in your body. They do not kill the pain permanently and neither are they a replacement for the underlying cause of the pain. You will still need to take appropriate medication for the cause of your pain whether Arthritis or Vasculitis or any other rheumatic disease or even non rheumatic disease for that matter. However those medicines take time. For example in Rheumatoid Arthritis the antirheumatic drugs such as methotrexate or Sulfasalazine take a minimum of 6 to 8 weeks to even begin taking effect after which over the next few weeks they would show benefit. So imagine a patient of rheumatoid arthritis limps into our clinic. She says she is not able to manage her household work or manage her family duties. Forget that some of our patients coming initially are not even able to have a bath or comb their hair properly or even go to the toilet for that matter. What if we tell them “we are starting the medication you will start improving after 2-3 months”. What do you expect will be the patient reaction? “This doctor is mad. I can’t even go to the toilet or comb my own hair and he is telling me wait for 2 – 3 months!!!” I need immediate relief NOW. I want to make my child’s Tiffin and my husband lunch box tomorrow. The house is in a mess the Servant has not come the Bills have to be paid and the groceries to be bought. How can I even wait 2 months? That’s where Painkillers come in for a short but necessary role. They help to buy time till the main medications help in controlling the root cause of the pain.

However painkillers are not anti rheumatic dugs.

They are temporary and will keep you comfortable for a few hours after which the pain will recur and you will need to take the next dose. Similarly the pain killers will not prevent the damaging effects of the disease. So for example if you have Rheumatoid arthritis and keep taking pain killers then the joints will still get damaged. So the way we usually manage these disease is to first make you comfortable while we quickly investigate you and then start you on appropriate antirheumatic drugs while continuing the pain killers. Over time as your condition improves the pain killers are tapered off and only the antirheumatic drugs are continued. Not every patient gets the same pain killer and the choice is individualized depending on the patient’s condition other associated diseases that the patient is suffering from such as Diabetes , Hypertension , bronchial Asthma etc.

Types of Pain killers:

Broadly there are 2 types of pain killers.

  1. Anti Inflammatory and non Inflammatory pain killers (NSAIDS):

    Anti Inflammatory Pain killers are those which will work in those conditions where there is inflammation. They are also called NSAIDS (Non Steroidal Anti-inflammatory drugs). These are the ones which would help a patient with an inflammatory disease such as Rheumatoid arthritis tide over the time period till his anti-rheumatic drugs take effect. Having said that these drugs provide dramatic relief in 2 conditions: Gout and in the Spondyloarthropathies both of which we will deal with separately. In Gout use of these drugs provides dramatic relief in 24 to 48 hours. Particularly in Ankylosing Spondylitis NSAIDS are considered as drugs of first choice and are in fact considered to be anti-rheumatic drugs since studies have shown that these tend to retard disease activity in the long term. However this does not apply to any other Rheumatic disease. These drugs have to be given only up to a certain dose for pain relief. If the dose is exceeded beyond the permissible limit they are liable to cause side effects. The common side effects of these drugs are acidity with Vomiting and sometimes even a gastric or a duodenal ulcer. Hence these drugs have to be compulsorily taken after food only and that too preferably in combination with an Antacid which is taken before meals. These drugs can only be used in patients with normal Kidney function. Additionally Kidney function parameters need to be monitored on a regular basis by your doctor as chronic use of these drugs can also cause harm to the kidneys Use of these drugs in Asthmatic patients can sometimes cause a flare of their Asthma again stressing the need for caution. Examples of these drugs include Ibuprofen, Naproxen Sodium, Diclofenac Sodium and Diclofenac Potassium, Indomethacin etc. Amongst Anti-inflammatory drugs there is another class of drugs called COX 2 Inhibitors. These drugs were specifically designed to minimize gastrointestinal side effects such as Gastric and duodenal ulcers. However usage of these drugs is not without controversy. Some years ago, one of the drugs in this class called Rofecoxib was withdrawn from the market as it was shown that patients taking this drug on a regular basis had a higher chance of getting a heart attack. Thereafter another drug of the same class was also withdrawn for the same reason. Currently these drugs are used mainly in the younger and middle age groups who tend to have acidity and they are better avoided in the elderly or in patients with a history of cardiac ailments. The only two drugs available presently from this class of drugs are Celecoxib the oldest of the COX 2 Inhibitors and Etoricoxib the last of these drugs. Like NSAIDS, COX 2 Inhibitors can also affect the kidneys and hence need to be monitored regularly for the same.

  2. Analgesics (Pain killers without Anti Inflammatory properties)

    These drugs as the heading describes do not have anti inflammatory properties and would help in providing additional pain relief to NSAIDS in cases of Arthritis. They have a better safety profile compared to NSAIDS but on their own are not capable of keeping a patient comfortable. Though these drugs will not cause a gastric ulcer nor affect the kidney. Hence these drugs can also be used in patients with compromised renal function or patients with acid peptic disease or even ulcers but they are not completely without side effects either. Some of them can be habit forming because they can make you “feel good”. They can sometimes cause drowsiness and also nausea or constipation and hence the doses have to be either adjusted in case of significant constipation or sometimes even stopped if they are habit forming. These drugs comprise of molecules such as Paracetamol (brand names: Calpol, Crocin, Dolo etc) or Tramadol (brand names: Tramazac, Contramal etc), Codeine, Dextopropoxyphene (brand name: Proxyvon) etc Combinations of these drugs are also available such as Paracetamol with Tramadol or Paracetamol with Dextropropoxyphene with both compounds being in relatively lower doses than the individual drugs so as to reduce the incidence of side effects and yet achieve the same amount of pain relief.

  3. Other Analgesics

    There are other drugs which help in providing relief in Neurological causes of pain. These drugs are not actually pain killers and are of no use in patients suffering from pain due to inflammatory causes. One example is a condition called Trigeminal neuralgia where patients have severe shooting/cutting type of pain on their face on even attempting to smile or eat food. Such patients would benefit from an Anti epilepsy drugs such as Carabamazepine or Pregabalin. Pregabalin would be also help in relieving pain in Diabetic patients having burning sensation in their feet due to Diabetic Neuropathy as also in a condition called fibromyalgia. However in some patients these drugs can cause drowsiness, Lethargy Lack of concentration etc .

    To conclude:

    All in all Pain killers or analgesics are a necessary evil in treatment of rheumatic diseases at least for a short period till the main drugs take effect.

    1. Prescribing these requires taking the patients disease and overall medical condition into consideration.
    2. They cannot be continued indefinitely and are definitely not a substitute to antirheumatic drugs.
    3. Finally possible side effects have to be monitored while using them to achieve an optimum benefit to risk ratio.