Pain and the medication cycle

Pain medications can effectively relieve discomfort but may also cause a range of side effects, including gastrointestinal issues, addiction risks, and cognitive effects.

Types of pain medications

Over-the-Counter (OTC) Medications: Common OTC pain relievers include acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil) and naproxen (Aleve). These medications are generally used for mild to moderate pain and can have side effects such as stomach upset, dizziness, and allergic reactions.
Prescription Painkillers: These include opioids such as morphine, oxycodone, and hydrocodone, which are used for moderate to severe pain. While effective, they carry a higher risk of side effects, including addiction, respiratory depression, and overdose.

Common side effects found in pain medication are:

Cognitive Effects: Opioids can lead to drowsiness, confusion, and impaired judgment, which can affect daily activities and increase the risk of accidents.

Allergic Reactions: Some individuals may experience allergic reactions to pain medications, which can range from mild rashes to severe anaphylaxis.

Addiction and Misuse: Prescription opioids have a high potential for misuse and addiction, particularly when used outside of medical guidance. This can lead to serious health consequences.

Endone is classified as an opioid and known to affect gastrointestinal motility. Nausea (23%), vomiting (12%), dyspepsia (1% to 5%), gastritis (1% to 5%),
Xerostomia (6%), abdominal pain (1% to 5%), and anorexia (1% to 5%) are commonly reported in most literature reviews.
Constipation (23%) is a very common problem and associated with a significant morbidity. Diarrhoea (1% to 5%) is also a significant problem and can be the result of chronic constipation or a direct result of Endone.
Norspan (Buprenorphine)
Pharmacologic Category: Analgesic, Opioid; Analgesic, Opioid Partial Agonist
Mechanism of Action: Buprenorphine exerts its analgesic effect via high-affinity binding to mu opiate receptors in the CNS; displays partial mu agonist and weak kappa antagonist activity. Due to it being a partial mu agonist, its analgesic effects plateau at higher doses and it then behaves like an antagonist.

Opioid Dependence

Subdermal implant: Maintenance treatment of opioid dependence in patients who have achieved and sustained prolonged clinical stability on low to moderate doses (≤8 mg/day) of a transmucosal buprenorphine-containing product for 3 months or longer with no need for supplemental dosing or adjustments.

Sublingual tablet: Treatment of opioid dependence.

Types of pain management

Buccal film, transdermal patch: Management of pain severe enough to require around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.

Injection: Management of pain severe enough to require an opioid analgesic and for which treatments are inadequate

Limitations of use: Reserve Buprenorphine for use in patients, for whom alternative treatment options (eg, nonopioid analgesics, opioid combination products, and immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain. Buprenorphine buccal film and transdermal patch are not indicated as an as needed analgesic.

Transdermal Patch – Adverse Events

>10%:

Gastrointestinal: Nausea (6% to 23%), constipation (3% to 13%)

1% to 10%:

Gastrointestinal: Vomiting (4% to 9%), xerostomia (6%), anorexia (1% to <5%),

diarrhoea (1% to <5%), dyspepsia (1% to <5%), upper abdominal pain (1% to <5%),

abdominal distress (2%)

Celebrex is in a class of drugs known as non-steroidal anti-inflammatory or NSAIDs.

NSAIDs are also recognised to cause significant GI side effects particularly affecting the upper GI tract.

It is accepted that on occasions the effects on the stomach can be serious and on occasions cause serious GI bleeding.

The most common adverse reaction occurring with NSAIDs is gastrointestinal.

Nausea/Vomiting
Epigastric pain/Gastritis
Heartburn
Diarrhoea/Constipation
Abdominal cramps or pain
Fullness of the GI tract – bloating and flatulence

A small number of cases (less than 1%) have serious complications:

Gastric/Duodenal ulcer
Perforation
Gastrointestinal hemorrhage
Melena

Adverse effects

Oral: Celebrex

≥2%:

Gastrointestinal:

Abdominal pain, diarrhoea, dyspepsia, flatulence, nausea, vomiting 0.1% to 1.9%:

Gastrointestinal:

Anorexia, constipation, diverticulitis, dysphagia, eructation, oesophagitis, gastritis, gastroenteritis, gastroesophageal reflux disease, gastrointestinal ulcer, haemorrhoids, hiatal hernia, increased appetite, melena, stomatitis, tenesmus, and xerostomia

***Cymbalta (*Duloxetine)**

Cymbalta is an antidepressant (Serotonin/Norepinephrine Reuptake Inhibitor). Patients report nausea 20%, dry mouth 15%, constipation 11%, Insomnia 10%, dizziness 9%, fatigue 8%, diarrhoea 8%, somnolence 7%, diaphoresis 6% and anorexia 6%.

Drug information and adverse effects – Voltaren /Nurofen

Serotonin-norepinephrine reuptake inhibitors (SNRIs): Pharmacology, administration, and side effects; (Authors Michael Hirsch, MD Robert J Birnbaum, MD, PhD)

Lyrica (Pregabalin) although well tolerated do report adverse gastrointestinal event.

Xerostomia (1% to 15%) is quite a common problem, and patients report constipation (≤10%), appetite increased (2% to 7%), nausea (5%), flatulence (≤3%), vomiting (1% to 3%), abdominal distension (2%), abdominal pain (≥1%) and gastroenteritis (≥1%)

Endep (Nortriptyline) is used to treat depression and mood disorders, and adverse effects are reported in patients who require short and long-term treatment.

The degree of anticholinergic blockade produced by amitriptyline is high relative to other antidepressants. Adverse events documented that relate to the gastrointestinal tract include disturbance of taste, anorexia, constipation, diarrhoea, nausea, paralytic ileus, parotid gland enlargement, stomatitis, vomiting, epigastric discomfort and xerostomia.

Nortriptyline may cause anticholinergic effects and used in caution where patients may have GI motility disorders. Nortriptyline should be used with caution in patients with decreased GI motility (eg, paralytic ileus) as anticholinergic effects may exacerbate underlying condition.

Temazepam

Oral route (capsule)

Common (1% to 10%): Abdominal discomfort, diarrhea, dry mouth, nausea

Risks From Concomitant Use With Opioids; Abuse, Misuse, and Addiction; and Dependence and Withdrawal Reactions. Concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death.

Reserve concomitant prescribing of these drugs in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. The use of benzodiazepines, including Temazepam, exposes users to risks of abuse, misuse, and addiction, which can lead to overdose or death. Abuse and misuse of benzodiazepines commonly involve concomitant use of other medications, alcohol, and/or illicit substances, which is associated with an increased frequency of serious adverse outcomes.

The phrase “intestinal motility disorders” applies to abnormal intestinal contractions, such as spasms and intestinal paralysis, and is used to describe a variety of disorders in which the gut has lost its ability to coordinate muscular activity because of endogenous or exogenous causes. Intestinal motility disorders can be categorized as upper gastrointestinal (GI) or lower GI motility disorders.

Author:

Dr Anthony Greenberg
MB BD FRACS (Eng.) FRCS (Edin.)
General & Gastrointestinal Surgeon