Non-Pharmaceutical Pain Management Options and the Vicodin Virgin

Ok, it’s time to take a small break from all the jokes and wild stories, and time for a more serious article. Being outside the US for the past few days, I get a new perspective on certain issues like pain management for example. As a child visiting extended family, I can still remember my grandmother’s pure joy when my father gave her a bottle of Motrin. She had been using Aspirin to treat her osteoarthritis. She called him a few days later and thanked him for the miracle medicine. How much was she using? One 200mg tablet a day to control her moderately severe arthritis.

The country I am presently visiting is one of those places where you don’t need a prescription for most medications. You just go to the counter and ask for whatever … an antibiotic course, an asthma inhaler, a skin cream, an anti-emetic; whatever. So I did a little research on pain medicines recently. I asked the pharmacist at the counter what I could use for “severe” pain; you know, the good old “12” on a scale of 10 that we usually see in the ER.

The pharmacist reaches into one of the glass cabinets and pulls out some Cataflam (diclofenac) – an anti-inflammatory somewhat stronger than Rx-strength Ibuprofen. So I look at the box for a moment, and ask if they have something stronger, because my pain “is really bad”. I ask if maybe they have something like Ultram.

The pharmacist looks at me funny, and says that yes they have Ultram but only with a doctor’s note. She then asks me why I don’t try the Cataflam because it is one of the best pain medicines available. Clearly she was treating me like what I like to call a “Vicodin Virgin”.

What is a “Vicodin Virgin”, you might ask? It’s a person who has managed somehow to treat their assorted aches and pains throughout their life thus far without the use of narcotics. By this I don’t mean to say that the use of narcotics equals abuse, but somehow there is a large group of people out there who have gotten through their broken bones, wisdom teeth, headaches and even post-partum pains with non-narcotic methods. I am one of them and clearly this country had a lot of them too.

So this post is for such people. People who have no interest in Vicodin or Percocet for their pain management, and prefer something more natural or at least something that won’t make them goofy, nauseated and drowsy. This post is for you if you are concerned about using something that can be addictive and something which does little more than turn off the pain signal in the brain as opposed to helping pain at the site.

Again, I am not condemning people that use narcotic medications in the indicated way. So don’t get the wrong idea.

For the rest though, I like to divide non-pill based pain management into three broad categories: topical, behavioral and manipulative. Of course, there are other options available, but these are the ones I prefer when talking to patients.

Topical pain management is in my lowly opinion one of the truly underused modalities in medicine today. This is somewhat of a pharmaceutical option of course, but so unused that I wanted to discuss it. It includes creams and ointments like Tiger Balm, Icy Hot, Aspercream and even generic Walgreen’s brand “muscle cream”. The active ingredients are usually menthol (the smelly one), salicylates and capsaisin in any given combination. For most people with muscle aches, strains and sprains, these topical treatments can really go the distance in a safe way.

The second modality is behavioral and has Biofeedback and Progressive Muscle Relaxation (PMR) at the top of a short list. Biofeedback is a treatment technique in which people are trained to improve their health by using signals from their own bodies. Physical therapists use biofeedback to help stroke victims regain movement in paralyzed muscles. Psychologists use it to help tense and anxious clients learn to relax. It has become recognized through several well designed studies to be an effective part of a pain management program. It has even shown success with such severe pain syndromes as Sickle Cell crisis. Progressive Muscle Relaxation is also effective in pain control, as well as good modality in controlling the anxiety associated with pain; although these effects are lesser in degree and more dependent upon the ability of the patient to focus.

The last category involves manipulative techniques. Most people think of osteopathic medicine or chiropractic manipulation first when seeking relief from pain, and for a significant subset of patients these treatments are subjectively very helpful. The reality with all manipulative treatments though is that they are very dependent upon the person doing them. Massage is another manipulative technique which has been shown to be very useful and very effective in managing pain as was demonstrated in this review article in the Annals of Internal Medicine. In medical school, I had the opportunity to work in massage therapy for some time and personally witnessed the powerful effect it had on chronic pain.

So, these are just some of the more widely accepted and evidence based therapies that exist out there for people coping with pain and trying to avoid narcotics for one reason or another. Speaking globally, they do work and there are millions of people around the world who have succeeded in managing their pain effectively without the use of narcotics and their associated dependence. I hope some of these suggestions may prove useful as a springboard to readers – whether they be dealing with pain themselves or interested in helping their patients to find alternative ways of managing their pain.

And enough already with the Toradol allergy. We know what that really means.

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32 Responses to Non-Pharmaceutical Pain Management Options and the Vicodin Virgin

  1. TUNDE says:

    GREAT POINTS.

    THERE ARE COUNTRIES THAT ARE WELL KNOWN EVEN OVERSEAS THAT PEOPLE WHO CAME FROM THERE THEY PREFER HEAVY DUTY PAIN MEDICINE. UNFORTUNATELY USA IS AMONGST THEM.

    I REMEMBER I WENT TO A VACATION TO MEXICO, A NICE RESORT, AND AS YOU ALL KNOW THEY HAVE THEIR OWN DOCTORS THERE 24/7. SO WHEN I GOT THERE I HAD A HEADACHE AND HAD NOTHING WITH ME, SO I CALLED TO THE RECEPTION AREA ASKING IF I COULD GET SOME TYLENOL OR MOTRIN. IN 5 MINUTES THE DOCTOR WAS AT MY DOOR, BRINGING IN HIS LITTLE BAG FULL OF MEDS. OFFERING PERCOCET VICODIN ETC. I TOLD HIM I JUST NEED TYLENOL, AND HE WAS SO HAPPY HE TOLD ME ,”OH YES I HAVE TYLENOL WITH CODEINE TOO”. TO HIS SURPRISE I CHOSE PLAIN TYLENOL. ON THE WAY OUT HE ASKED ME..”ARE YOU REALLY FROM THE USA SENORITA”.

    I AGREE WITH ALTERNATIVE PAIN MANAGEMENT, ALSO I COMPLETELY UNDERSTAND THE NEED OF NARCOTICS TOO. I GUESS WE JUST HAVE TO EXPERIMENT FIRST IF WE REALLY NEED TO TAKE NARCOTIC, MAYBE LIGHTER PAIN MEDICINE WORKS AS WELL SOMETIMES.

    THANK YOU AGAIN , THIS ARTICLE IS VERY INFORMATIVE.

    • ER Doc says:

      Hi Tunde – thanks for all your great comments; they really contribute a lot! Its so sad isn’t it that this doctor was totally expecting you to want narcotics. We really need a paradigm shift in prescribing practices to change this terrible trend.

  2. CrazyLady says:

    Too bad my insurance doesn’t cover massage for pain management. I suspect it would help my back more than anything. Alas, I slug along with trying to get the muscles to relax and the occasional Aleve.

    I have never understood why anyone would actually prefer a drug that would goof with their heads … I HATE that not-quite-in-control feeling.

  3. Nurse K says:

    One of our docs went to a conference recently where, and this is probably not exactly right, but people with back pain on anti-inflammatories and muscle relaxers were randomized to PT, reading a little pamphlet about back pain, or nothing other than medications and weight restrictions (ie don’t lift > 10 lbs), and the group that reported the least amount of pain after the allotted time was the pamphlet group, but only by a small difference. Time is what helps backs mostly :)

    • ER Doc says:

      Hi K – and thanks for your comment. I didn’t include physical therapy because there have been a number of studies that show a high recurrence of pain, especially low back pain, with a number of PT routines. At the same time, it is hard to properly interpret such studies because there is a HIGH number of patients who are sent to PT that have no real intention of getting better. During med school I rotated through a clinic that used PT and I really felt that their programs should work but recognized that for a lot of patients, the prospect of getting a disability check or being able to sue someone (car accident, work accident, etc.) just seemed to be too strong. So, I am not sure what to make of any of these results with such a suspect group.

  4. Warmsocks says:

    Great post! Thank you.

    One question: is it okay to combine topicals? ie solaraze gel, ray-nos, and tiger balm?

    • ER Doc says:

      Hi Warmsocks – I’m glad that you benefited from the post! I’m not sure what ray-nos is to be honest but the active ingredients in solaraze (diclofenac) and tiger balm (menthol) are different and shouldn’t interact with one another.

      • Warmsocks says:

        Thank you.
        Ray-Noz (sorry I spelled it wrong before) is a stinky gel being tested as a treatment for Raynauds. The active ingredient is niacin.

  5. Sabra says:

    I personally get little to no help from the topicals. Know what my favorite thing in the whole world is? A heating pad. Or, for on the go, the charcoal pads (I forget the brand name) that heat up upon contact with the air.

    I’m not a total Vicodin virgin. I’ve tried a few different things for my back, but none of them ever worked any better than Motrin the Wonder Drug (which the ex & I started calling it because it’s what the Navy gives you for everything), so I never took more than one dose of anything.

    After the IV painkillers were done, I recovered from 2 c-sections on heavy duty ibuprofen. Didn’t take care of the pain 100%, but when you deal with chronic pain the stuff you know is going to go away becomes easily dismissed.

    • ER Doc says:

      Thanks for mentioning that Sabra – I love heating pads too and they really do make a HUGE difference with so many people. I also actively recommend the Thermacare patches, which are the activated charcoal ones you mentioned. They provide wonderful and consistent heat over the course of 8 hours.

      I also understand about how the topicals don’t help you – some people don’t have great results, but for those that don’t get so much help from the topicals there’s always something else that helps – in your case heating pads.

      I also agree about Motrin – I think its a great medicine that people really pass over too often. You would be surprised how many young people I see in the ER who are using Vicodin or Tylenol #3 or some narc for things like sore throats or simple contusions. I personally never rx these meds to people unless they have a serious injury of some sort because this is just abuse from a prescribing perspective and just setting people up for future failures.

      Thanks again for your comments which always contribute so much.

  6. Texas Reader says:

    I’m not sure what kind of pain is helped by Toradol. I was given it once for migraine and it did nothing. Was given it for severe upper back pain when hospitalized for pneumonia and it did nothing – ended up on both darvocet and dilaudid.

    My usual pain relief is naproxen if I am able to eat first (i.e. not sick and vomitting) and acetaminophen if I need something I can take on an empty stomach.

  7. Hi, cool post. I have been wondering about this topic,so thanks for blogging. I will definitely be coming back to your blog. Keep up great writing

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  9. Tim Pointer says:

    I usually go “cross arms” if I am using that variation.

  10. Mary says:

    Hi,

    This is the assistant editor for Hospital.com which is a medical publication offering hospital news,

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    Please email me back with your URL in subject line to take a step ahead and to avoid spam.

    Thank you
    Mary Miller,
    may.hospital.com@gmail.com

  11. for you to do it charge really a new blog?

  12. LiLLy Abbott says:

    Last year when in Maryland for business, I got hit by a car and ended up in a hospital in Baltimore where they gave me Vicodin for the pain. Since this time I have suffered from pain in my legs due to damage to the nerves in my lower back and legs. I cannot buy Hydrocodone in my country where Oxycontin is the only medication prescribed for more severe pain, and while I have no problems obtaining a prescription for this drug, I find it considerably more addictive. When recently reading about findrxonline I was wondering if US online pharmacies (or regular ones) can ship Vicodin or Lortab to other countries if I obtain a prescription from a doctor in the USA? Any knowledge regarding is much appreciated. Thanks.

  13. Percocet is the brand name of the generic drug oxycodone and acetaminophen Vicodin and is a brand name of the generic drug Hydrocodone and acetaminophen. Both Hydrocodone and oxycodone is a narcotic drug and are often used in combination with acetaminophen or APAP to non steroidal anti inflammatory drug which helps in increasing their potency. Findrxonline mentions that Other brand names available under oxycodone are Endocet, Magnacet, Narvox, Tylox, Roxicet etc and under Hydrocodone are Anexsia, Dolorex Forte, Hycet, Liquicet, Lortab, Lorcet, Xodol, Zydone, Zamicet, Maxidone, Norco, Polygesic, Zolvit etc. Both are used for the treatment of moderate to severe pain. However Percocet is a better ways than Vicodin pain as it is a stronger opioid.

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