Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management

Pain remains as one of the most common reasons for visits to a doctor. Although all doctors are familiar with pain as a complaint, the majority treat pain as a symptom rather than a disease. This, however, only applies to acute pain, which resolves when injured tissues heal. On the other hand, there are a substantial group of patients with chronic pain, defined as pain that persists for more than three months, or beyond the healing period. We must first and foremost realize that chronic pain is different from acute pain, and therefore needs to be approached differently. While acute pain is a symptom, a warning signal of tissue damage, chronic pain should be seen as a disease in its own right ' a disease of the nervous system which should be managed independently of the underlying disease.

This is the group that continues to frustrate the health care provider, coming repeatedly with the same complaints of pain with only temporary relief from usual treatments for pain, including drugs and injections. In many cases these patients come back complaining of adverse reactions due to the drugs or injections. These complaints include constipation , drowsiness, cardiovascular and respiratory complications, ulcers and gastrointestinal bleeding, liver damage , kidney problems and in some cases even potential to be habit forming.

The bigger challenge in today's medical world is however, to manage pain effectively with minimal or without any side effects. Looking from this perspective, I came up with the topic of 'Non-drug modalities as an alternative to reduce side effects in pain management'

Side effects are peripheral or secondary effect, especially an undesirable secondary effect of a drug or therapeutic regimen [American Heritage Medical Dictionary, 2007].

Opioids can increase the risk of bone fractures in adults over the age of 60, especially when taken doses higher than 50 milligrams [Journal of General Internal Medicine, 2010].

Taking high doses of ibuprofen for as few as three days can cause gastrointestinal bleeding [American Gastroenterological Association, 2005].

We now have many modalities, including medication, interventional pain management techniques, along with physical therapy and alternative medicine to help reduce the pain [Dr. Sameh Yonan, MD, Hillcrest Cleveland Church].

Stimulating the nerves [Dr.Maya Nagaratnam, Fit4 life, Star. 22 December,2013]

Pain Management: Trends and Challenges [Mary Suma Cardosa, Medical Journal, June 2006]

Successful Pain Management [Dr. Syed Abdul Latiff Alsagoff, Health Today, April 2012]

Pain management also known as pain medicine or algiatry is a branch of medicine employing an interdisciplinary approach to easing the suffering and improving the quality of life of those living with pain. Pain Management is a relatively new field in this part of the world. In countries like United States, Europe and Australia there are medical personnel specially trained in Pain management.

In Malaysia the field of pain management is slowly emerging as an important and integral part of healthcare. The typical pain management team includes medical practitioners, clinical psychologists, physiotherapists, occupational therapists, physician assistants, nurse practitioners, and clinical nurse specialists.

The International Association for the Study of pain defines pain as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage'. In most cases, pain is a sign that a person has been injured,( eg, burning one's hand on a hot kettle or stepping on a sharp object).

In these instances, pain alerts the person that something is wrong and prompts him/her to take action to protect against it. So, without the sensation of pain to raise the alarm, one may seriously injure him/herself. All pain signals travel to the brain, which in turn, sends out its own pain killer (endorphins) to reduce the pain. (refer to the picture below)

Pain can be classified as either acute or chronic. Acute pain appears suddenly and is generally in response to injury or trauma. It may also be accompanied by anxiety or emotional distress. Chronic pain is when the pain persists even when the underlying injury has healed. It can last for weeks, months or even years.

A pain scale is usually used to measure the intensity of pain on a patient. Pain scales are based on self-report, observational (behavioral), or physiological data. Self-report is considered primary and should be obtained if possible. Pain scales are available for children and for adults. For children the Wong-Baker Faces Pain Rating Scale offers a more visual representation of pain. It helps the child to pin point the numbered face that best how the child feels.

As for adults, the numerical scale where patients put a number to their pain. This is a rough gauge of how much a patient may be enduring, from a scale of 0-10, with 0 representing no pain and 10 representing unbearable pain.

Numerical scale of pain intensity for adults.

In Malaysia, the field of pain management is generally practiced by anesthesiologists aided by physiotherapists and clinical nurse specialists. There are two types of pain, acute pain, pain that is usually temporary and results from something specific, such as a surgery, an injury, or an infection. The other is chronic pain, pain that lasts beyond the term of an injury or painful stimulus. This can also refer to cancer pain, pain from a chronic or degenerative disease, and pain from an unidentified cause. The combined effort of these people should lead the way in changing the approach to the management of pain.

Pain can either be managed by using pharmacological or interventional procedures. Both these procedures are drug based. Drugs are designed with the intention of chemically altering the natural processes of the body in one way or another. As such, side effects are quite common. Whereas some side effects are minor and relatively rare, there are others that can be extremely serious, often leading to serious personal injury or death.

Alternative pain management in the form of non-drug modalities may be explored in an effort to reduce the side effects caused my both pharmacological or interventional procedures. Non-drug modalities includes Acupuncture, Percutaneous Electrical Nerve Stimulation (PENS) and Transcutaneous Electrical Nerve Stimulation (TENS)

Pharmocological procedures in pain management.
Depending on the patient's acute or chronic pain condition, there may be several types of treatment available that can provide the patient with the pain relief and quality of life he/she deserve. Specifically, pharmacologic pain management focuses on the administration of prescription (Rx) or over-the-counter (OTC) medications to alleviate the pain symptoms.

During the evaluation period, the physician may decide whether a pharmacologic pain management plan will be effective in treating the condition and severity of the pain. If drug treatment is established, there are many types of medications from which the physician may choose to administer, prescribe, or recommend. Pharmacological Pain Management is administered in 6 ways:

(i)Hypodermically by way of a needle injection,
(ii) Intravenously with a catheter inserted into a vein,
(iii) Orally in the form of a capsule, syrup or tablet
(iv) Transdermally through a patch
(v)Topically as a cream,
(vi) Rectally via a suppository.

Narcotics (Opioids) / Analgesics
In pharmacologic pain management, narcotics (opioids) and analgesics may be prescribed to treat acute pain (severe, short-lived pain), post-operative pain, and certain types of chronic pain. Pain management physicians will help determine if pharmacologic (medical) pain management is the right course of action in helping the patient find pain relief and regain control over his/her quality of life. There are a variety of narcotics and analgesics available for pain treatment ,such as Alfentanil, Anileridine, Buprenorphine, Butorphanol, Codeine, Hydrocodone, Hydromorphone, Levorphanol, Meperidine, Methadone, Morphine, Nalbuphine, Oxycodone, Oxymorphone, Pentazocine, Propoxyphene, Remifentanil and Sufentanil.

Muscle Relaxants
Muscle relaxants (often called muscle relaxers or sedatives) are typically used to treat acute muscle problems due to injury, but can be used as part of a comprehensive treatment plan for the management of chronic pain conditions that involve painful muscle strains or spasms. In instances of chronic lower back pain or neck pain, muscle relaxants can reduce pain and increase mobility or range of motion. There are many categories of muscle relaxants available. Muscle relaxants work to reduce muscle tone and relax tight, tense muscles by interrupting the muscle-spasm-pain-anxiety cycle. Muscles are prone to spasm from a variety of causes, resulting in pain that can radiate throughout the body depending on location. Muscle relaxants do not produce a direct effect on the muscle, but instead produce relaxation through a depression of the central nerve pathway (or brain) for more of a total body relaxant.

Non-steroidal Anti-inflammatory Drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs (NSAIDs) are considered the most common pain relief and pain control medications. As part of a pharmacologic pain management plan, NSAIDs may be used for acute or breakthrough pain, and chronic pain, such as back or knee pain lasting for more than a few months. Most NSAIDs are taken orally and can be obtained over-the-counter or by a prescription from pain management physicians. Below are some popular over-the-counter and prescription non-steroidal anti-inflammatory drugs.
Over-the 'counter NSAIDs : Aspirin, Ibuprofen, Ketoprofen, Naproxen Sodium.
Prescription NSAIDs : Oxaprozin, Indomethacin, Etodolac, Nabumetone

NSAIDs work by blocking the production of certain chemicals in the body that cause inflammation, which is characterized by redness, warmth, swelling, and pain. More specifically, non-steroidal anti-inflammatory drugs effectively block the effect of an enzyme called cyclooxygenase that is critical in our body's production of prostaglandins, which cause inflammation. This enzyme interference decreases the production of prostaglandins and thus decreases pain and swelling.

Corticosteroids are a group of anti-inflammatory drugs used in pharmacologic pain management treatment. Short-term acute therapy of corticosteroid medications are often given to provide symptomatic relief of lower back pain, bursitis, cancer pain, and other conditions. Long-term chronic treatment is typically avoided due to the risk of toxicity.
Cortisol is a naturally produced hormone in our body that works to control salt and water balance, regulate metabolism of carbohydrates, fats, and proteins, and suppress inflammation, which in many conditions is the cause of swelling and pain. Corticosteroids are synthetic versions of cortisol and function similarly by blocking the production of substances in the immune system (such as prostaglandins) that trigger allergic and painful inflammatory reactions.

Selective Norepinephrine Reuptake Inhibitors (SNRIs)
Selective norepinephrine reuptake inhibitors (SNRIs) are a class of antidepressant drugs used in pharmacologic pain management to treat chronic neuropathic pain and fibromyalgia, among others. Norepinephrine reuptake inhibitors acts as a reuptake inhibitor for the neurotransmitters norepinephrine (noradrenaline) and epinephrine (adrenaline) by blocking the action of the norepinephrine transporter. Essentially, SNRIs increase adrenaline levels by inhibiting reabsorption (reuptake) into cells in the brain for enhanced neurotransmission ' the sending of nerve impulses ' to improve and elevate alertness and energy. These medications for pain management are known to have both antidepressant and analgesic qualities.

Side Effects of Pain killers
According to the American Heritage Medical Dictionary, side effects are peripheral or secondary effect, especially an undesirable secondary effect of a drug or therapeutic regimen. Drugs are designed with the intention of chemically altering the natural processes of the body in one way or another. As such, side effects are quite common. Whereas some side effects are minor and relatively rare, there are others that can be extremely serious, often leading to serious personal injury or death. Now we will see the side effects of the various types of pharmacologic pain management we had discussed above.
Narcotics (Opioids) / Analgesics
The analgesic (painkiller) effects of opioids are due to decreased perception of pain, decreased reaction to pain as well as increased pain tolerance. The side effects of opioids include sedation, respiratory depression, constipation, and a strong sense of euphoria. Opioid dependence can develop with ongoing administration, leading to a withdrawal syndrome with abrupt discontinuation.

Opioids are not only well known for their addictive properties, but also for their ability to produce a feeling of euphoria, motivating some to use opioids recreationally.
A 2010 study by the Journal of General Internal Medicine revealed that a group of powerful prescription medications known as opioids can increase the risk of bone fractures in adults over the age of 60, especially when taken doses higher than 50 milligrams.

Muscle Relaxants
General side effects of muscle relaxants include double or blurred vision, dry mouth, nausea, sleepiness, and drowsiness, and it is recommended that these medications are not taken before driving or operating heavy machinery. As with most medications used in pharmacologic pain management, there is a risk for possible addiction or dependence. These drugs must be used with caution and under the strict direction of pain management physicians. Muscle relaxants may interact with some other medicines. It is important that the patient disclose all other medications, including over-the-counter or nonprescription medicines, to his/her doctor prior to initial use, and be sure to report any unusual side effects.

Non-steroidal Anti-inflammatory Drugs (NSAIDs)

Most people who use NSAIDs do not have any serious complications; however, some people may experience gastrointestinal problems, high blood pressure, kidney damage, and allergic reactions. Less severe side effects can include stomach pain and heartburn, or headaches and dizziness. Before one start taking NSAID medications or begin an NSAID therapy, he /she should talk to the pain management physician and let him know about any other medical problems he/she have, especially hypertension, asthma, kidney, or stomach problems.

When taken in high doses, aspirin and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) can cause damage to the lining of the stomach and upper intestine, resulting in an ulcer or gastrointestinal bleeding. Ulcers may induce vomiting and weight loss, or even require surgery if left untreated.
According to a 2005 study by the American Gastroenterological Association, taking high doses of ibuprofen for as few as three days can cause gastrointestinal bleeding. This can cause significant harm to the digestive system, as well as triggering stomach pain.

Typically, acute treatment with corticosteroids is well tolerated, but in some cases side effects may include hyperglycemia, fluid retention, and insomnia. However, more serious side effects, such as diabetes, osteoporosis, and decreased immune response, may occur with chronic administration or when this medication is taken over long periods of time. Before undergoing corticosteroid therapy as treatment for pain relief and control, potential risks and benefits should be discussed with a pain management physician.

Selective Norepinephrine Reuptake Inhibitors (SNRIs)
Side effects of (SNRIs) include cough and sore throat, nausea, insomnia, constipation, weight loss, sexual dysfunction, and dilated pupils. These medications for pain can cause high blood pressure as well, so pain management physicians may recommend that patients have their blood pressure monitored frequently during treatment or therapy. In some cases selective norepinephrine reuptake inhibitors may be administered as first-line therapy to reduce side effects.

Alternative Treatments in Pain Management
People are physiologically different, not all people are 'tolerant' to drug based pain killers. Some may be 'tolerant' to drug based pain killers and some may not be 'tolerant'. Those who are 'intolerant' to these drugs may feel the side effects and as a result has to discontinue the drugs. There may also be cases where patients who do not want to be too dependent on drug based pain killers. As a result they may seek alternative treatments.

Whether it's because medications are ineffective, too expensive, accompanying side 'effects or because they don't want to be too dependent on drugs, a growing number of people are turning to alternative medicine for pain management. Pain is a common complaint among people who seek out such alternative treatments. Pain management is a rapidly growing medical specialty that takes a multi-disciplinary approach to treating all kinds of pain.

Dr. Sameh Yonan, a pain management specialist at the Cleveland Clinic, in U.S.A. says "We now have many modalities, including medication, interventional pain management techniques (nerve blocks, spinal cord stimulators and similar treatments), along with physical therapy and alternative medicine to help reduce the pain," This clearly indicates, drug based medicines are not the only way of treating pain. This certainly gives hope for those who have a low level of tolerance to drug based medications.

Acupuncture is a component of traditional Chinese Medicine originated in China over 5,000 years ago. It is based on the belief that living beings have a vital energy, called "qi", that circulates through twelve invisible energy lines known as meridians on the body. Each meridian is associated with a different organ system. An imbalance in the flow of qi throughout a meridian is how disease begins. Acupuncturists insert needles into specified points along meridian lines to influence the restore balance to the flow of qi. There are over 1,000 acupuncture points on the body. (please refer to pictures in reference section)

Acupuncture is an alternative treatment in pain management which carries no side effects or adverse reactions to the patient. Acupuncture is thought to decrease pain by increasing the release of endorphins, chemicals that block pain. Many acu-points are near nerves. When stimulated, these nerves cause a dull ache or feeling of fullness in the muscle. The stimulated muscle sends a message to the central nervous system (the brain and spinal cord), causing the release of endorphins that block the message of pain from being delivered to the brain.

Acupuncture may be useful as an accompanying treatment for many pain-related conditions, including headache, low back pain, menstrual cramps, carpal tunnel syndrome, tennis elbow, fibromyalgia, osteoarthritis (especially of the knee), and myofascial pain. Acupuncture also may be an acceptable alternative to or may be included as part of a comprehensive pain management program.
Acupuncture is generally considered safe when performed by an experienced practitioner using sterile needles. Relatively few complications from acupuncture have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs. Additionally, there are fewer adverse effects associated with acupuncture than with many standard drug treatments (such as anti-inflammatory medication and steroid injections) used to manage painful musculoskeletal conditions like fibromyalgia, myofascial pain, osteoarthritis, and tennis elbow.

Transcutaneous Electrical Nerve Stimulation (TENS)

Transcutaneous Electrical Nerve Stimulation (TENS) is a medical method of relieving pain without using drugs. TENS equipment consists of a battery operated stimulator with lead wires and 2 or more electrodes which are taped to the skin. By adjusting control knobs on the stimulator one is able to start or stop the electrical impulses and control the intensity of each impulse.
The current, which produces a mild tingling sensation, travels from the stimulator through the lead wires to the electrodes which are placed over the painful areas. The exact electrode placement may be anywhere along this path, but often 1 pair of electrodes is located either at the pain site or near the spine where the nerve pathway connects to the spinal cord.

TENS works by cutting the pain signals off at the pass, stopping them dead in their tracks before they have a chance to arrive at the brain. TENS treatment also triggers the release of the body's natural pain-fighting endorphins.
TENS has been used to control acute and chronic pain in a wide variety of cases. These include back and neck injuries, pulled muscles, arthritis, migraine headaches, labour and delivery and post-operative recovery. The success of TENS depends in part on how easily the nerve pathway carrying the painful signals can be identified and how accessible they are for placing the electrodes.

Percutaneous Electrical Nerve Stimulation (PENS)
Percutaneous Electrical Nerve Stimulation (PENS) is another treatment which carries no side effects to the patients. This particular treatment has emerged in recent years and slowly gaining popularity among patients. In the past, acupuncture and Transcutaneous Electrical Nerve Stimulation (TENS) have been used to effectively treat various forms of arthritic pain. Now, PENS offers a more effective alternative to acupuncture and TENS.

According to Dr. Maya Nagaratnam, a pain specialist pioneering PENS therapy in Malaysia, PENS is similar in concept to TENS, but instead of placing the electrodes on the skin of the affected area, needles are inserted, either around or immediately adjacent to the nerves serving the painful area. The nerves are then stimulated by passing a low-voltage electrical current through the needles. PENS is generally reserved for patients whom fail to get pain relief from TENS. PENS, differs from electrical acupuncture in that the placement of needles for electrical acupuncture is based on traditional Chinese medicine theories regarding the flow of energy or qi through the body. In PENS, the needles are located based on the area of pain. Basically, PENS combines the benefits of acupuncture and TENS.

She further reiterates, in chronic pain, the affected nerves and muscles are hypersensitive and send incorrect electrical impulses. The nerves ' misbehave' by sending off random electrical messages, which cumulatively gives rise to the sensation of pain, along with causing shortened, tense muscles.(refer to the picture above) The hypersensitive spot will eventually also affect the surrounding area, causing the sensation of pain.
PENS therapy causes a tingling sensation (paraesthesia) in the area of the body associated with the pain. It alters the activity of the peripheral nerve, and reduces and controls the sensation of pain. The PENS treatment does not destroy the affected nerves, but makes them less sensitive to pain.
On the workings of PENS, Dr. Maya further elaborates, a low-voltage electrical current is delivered to the fatty layer just below the surface of the skin close to either a specific nerve, or all the nerve endings situated in that area. It is purported that the electrical pulses block the transmission of pain to nerve fibers or may stimulate the release of endorphins or serotonin.
As a concluding note Dr. Maya assures that PENS is useful in treating all forms of chronic pain, including non-specific low back pain, occipital headache, post-surgical pain, post-hernia repair and cancer-related pain (from either surgery or radiotherapy) PENS is also minimally invasive, avoids the risks and expenses of surgery, well tolerated with no side effects. It should be noted though, that PENS is not meant to be used as a single treatment option, but as part of a wider pain management programme.

Understanding the degree of a patient's pain can prove challenging to even the most experienced of doctors. When it comes to chronic pain 'where there is an impact on overall function and performance as well as quality of life, correctly assessing the pain and selecting the appropriate treatment is crucial. Considering the health and well-being of the patient has to be the doctor's first priority.
Pain management has to be tailored to the individual patient, bearing in mind a number of factors: any underlying causes, the patient's expectations, the functional needs of the patient, and the tolerability of the side-effects that often accompany treatment. Should a patient experience any side-effects due to drug based pain management, alternative pain management should be the next line of treatment.
Accupuncture points on the body.

Accupuncture points on the body.

Accupuncture points on the body.

For this assignment, I took up this topic to explore pain management further. This field of medicine is relatively new to our country. Pain management is an integral part of health all over the world and is constantly being improved. Besides, I also wanted to find out the mechanism of pain, how we respond to it, types of pain, medications to counter it as well as alternative methods to help patients who are intolerant to pain medications.
In doing this assignment, I have a better understanding of pain, medications used in pain management and alternative methods in pain management. I have learnt about the various drug-based medication used in the field of pain management. I also learnt about the side effects that may accompany the administration of these medications. Ultimately, I have learnt about the uses of alternative medicine in pain management.
In any setting, doctor-patient relationship is central to the practice of healthcare. Hence, it is essential for high quality healthcare in the diagnosis and treatment of pain. Doctor-patient relationship forms one of the foundations of contemporary medical ethics. Doctors must find one way or another to give the best medical care to patients since patient welfare is of utmost important. In doing so, doctors may look into alternative medicine if it suits the patient best.
This assignment has served as an eye- opener for me as it is the first step for me to explore the field of pain management further. While doing this assignment I have read and related articles from books, health magazines and most importantly, the internet that has provided various health journals. I also obtained a lot information and improved my knowledge on health through various internet websites.

1. Mechanisms of Pain'. HEALTH TODAY August 2012. pg.16-17
2. 'Assessing Pain'. HEALTH TODAY August 2012. pg.20-21
3. 'Pain Management: Trends and Challenges'. Medical Journal June 2006. Vol. 61 No2
4. 'Successful Pain Management' HEALTH TODAY, August 2012. pg. 22-23
5. accessed 27 Mar 2014
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7. http://Ezine accessed 27 Mar 2014
8. The American Heritage Pain Medical dictionary 2007 by Houghton Mifflin. Co
9. accessed 21 Mar 2014
10. 5423119 side-effects-painkillers accessed 29 Mar 2014
11. accessed 18 Apr 2014
12. http://med accessed 18 Apr 2014
13. tcm accessed 10 Apr 2014
14. accessed 18 Apr 2014
15. Dr. Sameh Yonan MD. 'Endocrine based interventional pain management'. Hillcrest Cleveland Church. accessed 18 Apr 2014
16. Dr.Maya Nagaratnam. 'Stimulating the nerves'.Fit4 life, Star. 22 December, 2013

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