Non-Pharmaceutical Pain Management Options and the Vicodin Virgin

May 5, 2009

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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