I’m back from my summer break (I’m in Aotearoa/New Zealand – we shut down over Christmas/New Year just like the US and UK do over July/August!), and I want to begin with a cracker of a topic: medication management!
Now I am not a prescriber. I don’t hold any ability to write prescriptions of any kind, not even exercise ;-). Yet most of the people I’ve seen in clinical practice have started their journey living with pain by being prescribed medications.
All medications have side effects, true effects (well… maybe), adverse effects, and the human factor: taking them in the way that optimises the pharmacodynamics of the drug. It’s this last part that can sometimes be omitted by prescribers. Or at least, that’s my take after listening to hundreds of people over my clinical career.
What do I mean? Well, all drugs have a kind of ‘release profile’ as the active ingredients are metabolised (broken down) in the body. Most drugs will be released gradually into the system, peak after a certain time, and then gradually reduce in concentration until there’s no active ingredients (metabolites) left. There’s a difference between what we feel (the effects we experience) and how long the metabolites remain present – people using cannabis, for example, will know that the effects of euphoria/calm/sedation/relaxation wear off reasonably quickly, but the metabolites hang around in the fatty tissues for months (Lucas, Galettis & Schneider, 2018). Alcohol is metabolised at a fairly predictable rate, but the experience of being intoxicated differs for each person depending on their tolerance, the food present in their belly, fatigue, gender and so on (Greaves, Poole, & Brabete, 2022).
When prescribing a drug, the prescriber usually holds some assumptions about how it’s going to be used. Most medications are intended to be taken regularly at the same time of day every day – the prescriber should take into account things like any sedating effects, any other side effects, and the effect the person and prescriber are looking for. But people do some weird stuff with medications and may not take them in the way the prescriber thought they would.
Why do some people not take a pill at the same time every day? Well, some groups of people don’t find it easy to hold to a schedule – people with ADHD, people working shiftwork, people who have kids (especially newborns!). Some people think of pain medications as a bit like optionally taking paracetamol (acetaminophen) - take it as needed, no worries if you don’t take it all the time. This is OK for acute (short-term) pain, where you’re pretty confident the pain will reduce over time, but not so good for chronic pain where the pain is present to a greater or lesser extent for months. And some drugs given for chronic pain need to be taken consistently to get the effect you’re looking for. Some people might worry that medications used routinely could lead to dependence or tolerance. Dependence is about physiological adaptation to the presence of a drug leading to a ‘withdrawal’ effect if the drug isn’t present. Tolerance is the process of the body adapting to the presence of a drug and needing more and more to get the same effect. There’s no doubt that both of these processes can occur in some an analgesics (pain relief), particularly opioids, and careful prescribing and taking the medications as they are intended to be taken is critical.
Sometimes the side effects of a medication can be almost as useful as the active ingredient. A case in point is the sedating effect of tricyclic antidepressants. For someone with persistent pain, sleep can be something we’d dream of if only we could get some sleep! So, knowing how long it takes before feeling the sedative effects of a tricyclic antidepressant, and how long that sedation can last, can be used thoughtfully to decide the best time to take a dose. For example, some tricyclic antidepressants begin to give that sedating feeling about two hours after taking the dose – and that sedated feeling remains for around 12 hours. Taking this kind of drug ‘at bedtime’, or when you want to get into bed to fall asleep, might mean you have a hangover effect because most of us don’t have the luxury of a 12 hour sleep! But taking it a couple of hours earlier, or around 12 hours before you want to get up, might mean you fall asleep more easily and wake up without the hangover. Checking with your prescriber or your pharmacist-dispenser to work out the best time to take a drug is really helpful to optimise both the side effects and minimise the negatives.
Medications are an important part of pain management for some people. The hit rate for getting the gold standard ‘50% reduction in pain’ is pretty low, and for many people there is no medication to touch the sides of pain (see Katz et al., 2015 for a nice discussion about NNT; and Patel & Dickenson, 2021 for info on just how poorly individual drugs work. They advocate for ‘multimodal’ prescribing, but unless this is done very carefully I’m not 100% convinced, and the evidence for this approach is, as they say, scant). I’m one of these people who find nothing I’ve tried has reduced my pain at all. So the effectiveness of any medication depends a lot on you and how your body metabolises the medication. I wish you all the very best if you are one of those who gets a good response to medications – hoorah!
What should you do if you’re thinking about using medications as part of your pain self-management?
Be prepared to try a few out, because it is always a trial in YOU and YOUR experience with a medication that matters.
Give the medications a decent trial – two weeks at the recommended dose, noting all the effects of the drug on you, your pain, your ability to think straight, your sleep, and your ability to do the things you want and need to do in life. This might mean using a diary to record the dose, the time you took it, bedtime, wake time, and then any medication effects you notice.
Most important, make sure the medication has a positive effect on your ability to do things. If you have so much sleepiness with a drug that you can’t do things, it might reduce your pain, but does it do much for YOU?
ALWAYS WORK WITH YOUR PRESCRIBER! Prescribers are responsible for what they write down on the prescription, and for ensuring the benefits outweigh any harms. They should know how the drug is thought to work, and the effects, side effects, pharmacodynamics and interactions with other drugs and substances you are using. Prescribers need to recognise that in pain relief, YOUR experience is YOUR experience. There are good reasons why some medications don’t help some kinds of pains (the ‘analgesic ladder’ was developed for cancer pain, not for chronic pain. Many types of chronic pain don’t respond to opioids – fibromyalgia being one of them).
Ask questions about the medication you’re prescribed. Ask about how long it takes to kick in, how long it will hang around in your system, why you need to take it at a certain time, and what you can expect as side effects. Ask if you need to take it with food, or on an empty stomach. Ask if you should avoid things like grapefruit juice (it can interfere with processing some meds). Ask what the therapeutic dose is, and how to build to that dose. Also ask how to reduce the dose if you don’t like the effects. If your prescriber is too busy to answer these questions, ask your pharmacist-dispenser (they know SO much about drugs!).
In the end, only YOU can tell whether it’s worth it. And it is OK to stop taking a drug if it’s not doing anything for you – just do with with the support of your prescriber. Clinicians, if you’re not a prescriber, get familiar with the current prescribing practices, understand the drugs and their presumed effects, become aware of the side effects and be ready to listen to the person and recommend they see their prescriber or pharmacist-dispenser for a detailed conversation about timing and managing meds long-term.
Greaves, L., Poole, N., & Brabete, A. C. (2022). Sex, gender, and alcohol use: implications for women and low-risk drinking guidelines. International journal of environmental research and public health, 19(8), 4523.
Katz, N., Paillard, F. C., & Van Inwegen, R. (2015). A review of the use of the number needed to treat to evaluate the efficacy of analgesics. J Pain, 16(2), 116-123. https://doi.org/10.1016/j.jpain.2014.08.005
Lucas, C. J., Galettis, P., & Schneider, J. (2018). The pharmacokinetics and the pharmacodynamics of cannabinoids. British journal of clinical pharmacology, 84(11), 2477-2482.
Ryan Patel & Anthony H Dickenson(2022)Neuropharmacological basis for multimodal analgesia in chronic pain,Postgraduate Medicine,134:3,245-259,DOI: 10.1080/00325481.2021.1985351
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