pain medication

Because information about medications used to treat CRPS is constantly changing, the following list of medications is by no means comprehensive. For more detailed information about medications used for CRPS, refer to the Physicans’ Desk Reference at www.pdr.net. This is the resource most physicians use. Never use this information to treat yourself. It is no substitute for the experience and knowledge of your physician.
 

CRPS Medications

NonSteroidal Anti-Inflammatory Drugs (NSAIDs):

• Aspirin (Ecotrin, ASA)
• Diclofenac (Voltaren)
• Diflunisal (Dolobid)
• Celecoxib (Celebrex – a cox-2 inhibitor)
• Etodolac (Lodine)
• Ibuprofin (Advil, Nuprin, Motrin, etc.)
• Indomethacin (Indocin)
• Ketorolac (Toradol (only use for up to five days))
• Oxaprozin (Daypro)
• Piroxicam (Feldene)
• Sulindac (Clinoril)

Opioid-Like Drugs (Narcotics):

• Butorphanol Tartrate (Stadol)
• Nalbuphine (Nubain)
• Pentazocine Lactate (Talwin) (a category of drugs called opioid agonist-antagonists. They probably should not ever be used.)
• Codeine Phosphate (Codeine)
• Fentanyl Citrate (Fentanyl)
• Hydromorphone (Dilaudid)
• Morphine Sulfate (MS Contin, Noxamol)
• Oxycodone (Oxyir, Roxicodone, Oxycontin, Percocet)
• Buprenorphine (Subutex, Suboxone)
• Propoxyphene Napsylate (Darvon – N)
• Methodone
• Hydrocodone (Vicodin)

Opioid-Containing Combination Drugs:

• Hydrocodone/Acetaminophen (Anexsia)
• Propoxyphene/APAP (Darvocet)
• Butalbital/ASA/Caffiene/Codiene (Fiorinal with Codeine)
• Butalbital/APAP/Caffiene/Codiene (Fioricet with Codeine)
• Hydrocodne/Acetaminophen (Lortab)
• Hydrocodone/APAP (Norco)
• Oxycodone/Aspirin (Percodan)
• Hydrocodone/Acetaminophen (Lorcet)
• Carisoprodol plus Codeine (Soma with Codeine)
• Oxycodone/Acetaminophen (Tylox)
• Hydrocodone/Acetaminophen (Vicodin)
• Hydrocodone/Ibuprofen (Vicoprofen)

Other Analgesics:

• Acetaminophen (Tylenol, Panadol, Tempra, etc.)
• Tramadol (Ultram)

Anesthetics/Sedatives:

• Fentanyl Citrate (Fentanyl)
• Ketamine (Ketalar)
• Diphenhydramine (Sufentanil, Sleepinal)

Local Anesthetics:

• Bupivacaine (Marcaine, Bupivac)
• Lidocaine (Xylocaine)
• Mepivacaine (Carbocain)

Anxiolytics/Hypnotics (used when anxiety disorders and/or sleep disturbance is present):

• Lorazepam (Ativan)
• Temazepam (Restoril)
• Alprazolam (Xanax)
• Midazolam Hydrochloride (Versed)
• Oxzaepam (Serax)
• Diphenhydramine Hydrochloride (Benadryl)
• Chlordiazepoxide (Librium)
• Clonazepam (Klonopin)
• Clorazepate Dispotassium (Tranxene)
• Flurazepam (Dalmane)
• Buspirone (Buspar)
• Zolpidem (Ambien)
• Zaleplon (Sonata)
• Eszopiclone (Lunesta)

Anti-Epileptics (Anti-Convulsants):

• Carbamazepine (Tegretol)
• Clonazepam (Klonopin)
• Topiramate (Topomax)
• Gabapentin (Neurontin)
• Phenytoin (Dilantin)
• Valproic Acid (Depakene/Depakote)
• Tiagabine (Gabitril)
• Pregabalin (Lyrica)
• Diazepam (Valium)
• Lamotrigine (Lamictal)
• Levetiracetam (Keppsa)
• Oxcarbazepine (Trileptal)

Pregabalin is related to gabapentin and is approved to treat neuropathic pain, specifically diabetic peripheral neuropathy and postherpetic neuralgia. It is currently under review by the FDA for the adjunctive treatment of partial seizures and may have potential for treating CRPS.

Anti-Depressants:

• Fluoxentine Hydrochloride (Prozac)
• Paroxetine (Paxil)
• Sertraline Hydrochloride (Zoloft)
• Amitriptyline (Elavil)
• Desipramine (Norpramin)
• Venlafaxine (Effexor)
• Doxepin (Sinequan)
• Bupropion Hydrochloride (Wellbutrin)
• Nefazodone (Serzone)
• Trazadone (Desyrel)

Muscle Relaxants

• Baclofen (Lioresal)
• Carisoprodol (Soma)
• Methocarbamol (Robaxin)
• Tizanidine (Zanaflex)
• Cyclobenzaprine (Flexeril)
• Dantrolene Sodium (Dantrium)
• Diazepam (Valium)
• Quinine Sulfate (Quinaam)

Trans-Dermal Patches and Ointments May Contain:

• Catapres (Clonidine)
• Ketamine (Ketalar)
• Capsaicin (Zostrix)
• Fentanyl Citrate (Fentanyl – local anesthetic)

Complementary Medicine for CRPS

• Acupuncture – Originating in China, this age-old practice involves inserting long, extremely slender needles into specific points along the body to relieve pain and discomfort.
• Biofeedback – This involves a learning process whereby certain visual or auditory (sound-based) feedback allows you to train yourself to initiate responses that help control or normalize your psychological response to pain.
• Chiropractic – According to the International Chiropractic Association, the primary focus of chiropractic is the detection, reduction and correction of spinal misalignments and nervous system dysfunction. Doctors of chiropractic attempt to get to the root cause of a health problem, rather than just treat the symptoms. Chiropractic seeks to maximize the natural strengths of the body and its capacity to heal itself without the use of drugs or surgery.
• Hypnosis – This involves entering an altered state of consciousness whereby suggestions inserted while in that state can lead to changes in behavior or, in the case of pain, altered physical sensations. Self-hypnosis involves inducing an altered state of consciousness – and thus controlling pain sensation – by yourself.
• Visual Imagery – The practice of using one’s imagination to create mental pictures can help relieve pain – why it works isn’t understood. Typically, this involves closing your eyes and imaging something like a healing energy washing over your body, or the “wires” to the pain being severed.

Medications for Fibromyalgia

• Tricyclic anti-depressants – You may be given one of these medicines whether or not you have depression. Research shows that this type of medicine may help you sleep better and feel an overall sense of well-being. Results also show that this medicine can decrease the intensity of pain but not the number of tender spots. Tricyclic anti-depressants are FDA approved but their treatment of FMS is called an off-label use. Some commonly used tricylclic anti-depressants are amitriptyline (Elavil), nortriptyline (Pamelor) and imipramine (Tofranil). Although these medicines can be helpful, you may have a problem with certain side effects. These may include weight gain (especially when taking amitriptyline), dizziness and dry mouth.

• Muscle relaxants – This type of medicine is often used for treating muscle spasm. However when given as treatment for FMS, this medicine may relieve pain and help you sleep better. Muscle relaxants are FDA approved but their treatment of FMS is called an off-label use. Commonly used muscle relaxants are cyclobenzaprine (Flexeril) and carisoprodol (Soma). Cyclobenzaprine is similar to a tricyclic anti-depressant and is sometimes used just at night to improve sleep. These medicines tend to lose their effectiveness over time.

• Pregabalin (Lyrica) – This is one of a few medicines approved by the US Food and Drug Administration (FDA) specifically to treat FMS pain. Lyrica is used to reduce pain associated with fibromyalgia and improve sleep and fatigue. In one study, patients taking pregabalin reported significant improvement in the quality of sleep based on daily sleep diaries and a sleep scale measurement. Also, patients taking pregabalin said they felt less tired and were better able to do their regular activities of daily living. Most common side effects of pregabalin include mild-to-moderate dizziness and sleepiness. It may also impair motor function and cause problems with concentration and attention.

• SNRIs – Serotonin and norepinephrine reuptake inhibitors (SNRIs) are used for both depression and pain management. SNRIs may be used to decrease pain and tenderness in FMS patients with or without depression. They may also help improve your sleep, concentration and moods. Examples of commonly used SNRIs are venlafaxine (Effexor) and duloxetine (Cymbalta). Duloxetine and another medicine called Milnacipran (Ixel) have recently been approved by the FDA specifically for treating FMS. All of these medicines have effects on the serotonin system as well as other neurotransmitters and are helpful in treatment of chronic pain. Side effects may include sleep problems, dry mouth and constipation.

• SSRIs – Selective serotonin reuptake inhibitors (SSRIs) are used for both depression and pain management. Research studies have shown that SSRIs are particularly helpful in treating FMS symptoms in women. These medicines are often given in combination with a tricyclic anti-depressant, as this makes them more effective in treating FMS symptoms. Commonly used SSRIs include fluoxetine hydrochloride (Prozac), paroxetine (Paxil) and sertraline hydrochloride (Zoloft). Side effects may include loss of appetite, anxiety and sleep problems.

• Tramadol – This is sometimes called a “weak opioid” or “narcotic-like” medicine. It works much like a regular opioid in relieving pain but has less severe side effects. It may be used alone or in combination with acetaminophen (Tylenol). Examples are tramadol (Ultram) and tramadol/acetaminophen (Ultracet). Side effects may include dizziness, nausea and constipation.

• Other medications – Trazodone is very effective for sleep and often has fewer side effects than the tricyclic anti-depressant medicines.

Medicines that often are prescribed, but are of questionable benefit include:

• NSAIDs – These are also called non-steroidal anti-inflammatory drugs. These medicines may help decrease inflammation if you have another disorder in addition to FMS. Examples of disorders that cause inflammation are arthritis and lupus. NSAIDs are not helpful if you have FMS alone because inflammation is not a symptom of FMS. NSAIDs are sometimes used as simple pain relievers, although acetaminophen (Tylenol) has less risk of complications and may be a better choice. Examples of NSAIDs are ibuprofen, naproxen and celecoxib (Celebrex). NSAIDs may be helpful for treating FMS pain when given together with other medicines, such as tricyclic anti-depressants.

• Opioids – These medicines are best avoided, but some providers may prescribe them as a last resort if other drugs and non-drug treatments do not help. Examples of commonly used opioids are acetaminophen with codeine, oxycodone (Percocet), morphine and hydrocodone (Vicodin). Long-term use of these medicines does not necessarily decrease pain associated with FMS. They can even contribute to more pain in the long run. More research is needed to learn about the effectiveness of opioids for treating FMS.

Medications for Postherpetic Neuralgia

Depending on your situation, your health care provider may recommend medication to relieve pain and other symptoms. When taking any medication, follow all instructions and precautions given by your health care provider and pharmacist as well as those on the medication label and package insert.

Be sure you understand how and when to take your medication and its possible side effects and drug interactions. Contact your health care provider if you have any concerns.

NOTE: Because information about medications used to treat PHN is constantly changing, the following lists of medications are by no means comprehensive. For more detailed information about medications used for PHN, refer to the latest edition of the Physicians’ Desk Reference at www.pdr.net. This is the resource many health care providers use. Never use this information to treat yourself. It is no substitute for the experience and knowledge of your health care provider.

Medications used to treat PHN include:

• Simple analgesics (pain relievers) – Medicines given to relieve pain may include acetaminophen (Tylenol, Panadol, Tempra), and non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil, Motrin IB), naproxen (Aleve) and celecoxib (Celebrex).

• Opioids – Your health care provider may have you try an opioid analgesic (narcotic) for severe pain that does not respond to more conservative treatment, but these medications must be used with caution because of the danger of serious side effects. Examples include tramadol (Ultram, Ultracet) or oxycodone (OxyContin, Percocet). Some studies suggest that oxycodone may also help lessen allodynia.

• Tricyclic anti-depressants – These medications may help whether or not you have depression. They affect how neurotransmitters send pain signals to the spinal cord and brain. In addition, they also may improve your sleep. Examples include amitriptyline (Elavil), nortriptyline (Pamelor), desipramine (Norpramin) and duloxetine (Cymbalta).

• Anti-convulsants – Certain medications originally used to treat seizures help reduce some people’s PHN pain. The US Food and Drug Administration has approved gabapentin (Neurontin) and pregabalin (Lyrica) to treat PHN, and there are others that are used “off label” such as topiramate (Topamax), oxcarbazepine (Trileptal) and carbamazepine (Tegretol).

• Cortisone shots – Injections (shots) of corticosteroid medications into the area around the spinal cord sometimes provide pain relief.

• Topical pain relievers – Skin patches, creams or ointments contain medication that may provide temporary pain relief or reduce skin oversensitivity. Examples include prescription lidocaine skin patches (Lidoderm), prescription and over-the-counter lidocaine creams, and creams or ointments containing aspirin. Carefully follow all application instructions. In particular, do not apply products containing lidocaine to your face.

• Capsaicin – Capsaicin (Capzasin-P, Zostrix) is a cream made from hot chili pepper seeds. Some people find it helpful for PHN pain. It can cause burning and irritation to the skin, but these side effects may lessen with time. Carefully follow all application instructions. Do not apply capsaicin to unaffected areas of your body, and avoid contact with your eyes.

Prevention

Certain antiviral medications may help prevent or lessen the severity of shingles, thus reducing the risk of PHN:

• Chickenpox vaccine – The varicella virus vaccine (Varivax) is now a routine childhood vaccination, but also may be recommended for older children and adults who have never had chickenpox. This vaccine does not guarantee that you will not get chickenpox or shingles, but can reduce the length and severity of symptoms and the risk of complications such as PHN.
   
• Shingles vaccine  – The varicella-zoster vaccine (Zostavax) is available to people age 60 or older who have had chickenpox but not shingles. The vaccine does not guarantee that you will not develop shingles or PHN, but it can help reduce the length and severity of symptoms of both shingles and PHN. Zostavax is not recommended for certain people (for example, people receiving cancer treatments or who have weakened immune systems or certain medical conditions, such as bone marrow or lymphatic cancer or active tuberculosis).
   
• Other antivirals – Antiviral medications such as acyclovir, valacyclovir or famcyclovir given within the first 72 hours of the appearance of the shingles rash can help lessen the duration of shingles and reduce the chance of developing PHN. These medications do not help if you already have PHN.