A Quick Guide to Pain Control

By Elaine Bird
This is meant to be a quick guide to help members understand the reasoning behind their doctors choice of pain relief. It is not meant to replace medical advice.The WHO’s pain relief ladder is a guide to controlling pain:

STEP 1: Non-opioid agent, including NSAIDs and acetaminophenAdjucant analgesia, inculding corticosteroids and antidepressants

pain resisting or increasing

STEP 2: Opioid for mild to moderate painNon-opioid agent
Adjuvant analgesia

pain resisting or increasing

STEP 3: Opioid for moderate to severe painNon-opioid agent
Adjuvant analgesia

Paracetamol or acetaminophen as it is also known is a very safe and effective painkiller when taken in regular intervals. It has been used to reduce the levels of narcotics that patients have to use to control their pain. I would always recommend that a patient suffering chronic pain should be on regular paracetamol.

NSAIDs (non steroidal anti-inflammatory drugs) such as aspirin, ibuprofen, naproxen and mefenamic acid to name a few can be very beneficial BUT can be harsh on the stomach and kidneys. Anyone taking long term NSAIDs should be on tablets known as PPIs such as omeprazole or lansoprazole to protect the stomach from damage. NSAIDs should always be taken on a full stomach, a glass of milk and a biscuit is not sufficient, with a large glass of water. It is very important not to become dehydrated while taking NSAIDs as this can cause kidney damage.

Antidepressants also have a valuable role to play in treating chronic pain. This does not mean your doctor thinks it’s all in your head or you’re just depressed. Science does not completely understand how we perceive pain yet. However there is evidence that the increase in certain brain chemicals such as serotonin and noradrenaline that antidepressants cause help with pain relief. Also there is a link between chronic pain and depression so the use of antidepressants to treat chronic pain is two-fold. The most common antidepressant to treat chronic pain is amitriptyline, which is used at doses of 150mg to 200mg to treat depression but used at 10mg to 50mg to treat pain. Amitriptyline has the added bonus of causing drowsiness and so can help with the insomnia that often accompanies chronic pain. Of course it is not for everyone and if this dosen’t work or the side effects are too much there are alternatives available. This can be discussed further with your doctor.

As for opiates, yes they are addictive and cause drowsiness and are not the most effective pain killers for all kinds of pain such as nerve pain but they still have a role to play in treating pain. If you find you need to start on opiates adding a weak opiate such as codeine 15-30mg to your regular paracetamol dose is the best way to do it to keep your dose as low as possible for as long as possible. When or if this stops being as effective then a controlled release formula is the next best option so that your pain relief levels stay the same all the time rather than dipping and rising as you take your dose every four to six hours or as prescribed.

I would not be too worried about addiction when taking opiates for pain. Addiction is rare when taking them for pain relief, although not unheard of, however if you were to become addicted then detox is a lot easier to deal when you don’t have all the psychosocial problems that illegal users have. There is already a great article in the files regarding the difference between dependence and addiction so I’m not going to go into detail here but getting your pain under control is much more important in the short term.

If your pain is not chronic but only occurs when you have your period or when you are ovulating it might be better to start your pain relief regime before you actually experience any pain, say a day or two before your due your period or at the first sign of bleeding at the latest. Waiting until you are in pain means you’ve got to wait for the pain killers to kick in and may mean you have to take a stronger dose initially to get the same pain relief.

For more information on pain relief the British Pain Society www.britishpainsociety.org has some excellent resources.

Just to add that although the ladder here lists corticosteroids such as prednisolone as a treatment for pain they are not appropriate for endometriosis. They can cause a huge range of side effects and can be very effective in reducing the damage done by inflammation in diseases like arthritis but since the inflammation endometriosis causes doesn’t cause any real long term damage then the risk of side effects outweighs any potential benefits.