Prescription opioids like oxycodone, hydrocodone, codeine, and morphine have long been considered some of the most helpful drugs for managing acute pain, where the body is immediately reacting to trauma or injury. Each year, over 200 million opioid prescriptions are given out in the United States.
Unfortunately, the rates of opioid abuse and overdose deaths have skyrocketed in recent years, leading healthcare providers and patients alike to be cautious about the use of opioids. And now it turns out that there is another reason to avoid opioids: they may not be the most effective treatment for acute pain after all.
Do opioids work better than other drugs?
A recent study in the Journal of the American Medical Association throws into question how well opioid drugs actually treat acute pain.
In the study, researchers assigned 416 emergency room patients with moderate-to-severe pain to one of four treatment groups. Three of the treatment groups received a combination of a common opioid painkiller (either oxycodone, hydrocodone, or codeine) plus 300 mg of acetaminophen, a common non-opioid pain medication often sold over the counter as Tylenol. The fourth group received 400 mg of ibuprofen, a non-opioid painkiller, plus 1,000 mg of acetaminophen.
The result? All four groups experienced the same levels of pain relief. While opioid drugs did help to reduce pain, they were no more effective than a combination of non-opioid painkillers.
What are other options for pain treatment?
While opioids are usually given for acute pain, some of the following options also work well for chronic pain, or pain that lasts longer than six months.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Ibuprofen, naproxen, and aspirin are known as nonsteroidal anti-inflammatory drugs (NSAIDs). They control pain, lower fevers, and reduce inflammation. NSAIDs are often considered to be the first line of defense for acute pain, especially pain that doesn’t respond to non-drug treatments.
NSAIDs are available over-the-counter with brand names including Advil, Motrin, Aleve, Bayer, and Excedrin. NSAIDs are also available in prescription strength, with common brand names like Celebrex, Naprelan, Anaprox, Voltaren, and Feldene.
One word of caution: long-term use of NSAIDs can lead to stomach distress or bleeding in your gastrointestinal tract, and the FDA warns that non-aspirin NSAIDs may increase the risk of heart disease and stroke.
Acetaminophen is used on its own as a painkiller and is also an active ingredient in many combination medicines for pain and colds. It is a popular over-the-counter option, sold under brand names like Tylenol. Acetaminophen is especially helpful in addressing acute pain for conditions like headache, arthritis, and cancer pain.
Acetaminophen does not cause the gastrointestinal or cardiovascular side effects of NSAIDs, but taking amounts in excess of the recommended dosage may lead to liver damage or even liver failure. Because acetaminophen is present in so many medications, check whether other medications you’re taking contain acetaminophen as well.
A category of antidepressants called tricyclic antidepressants have the most evidence for treating pain, especially nerve pain. Imipramine (Tofranil), nortriptyline (Pamelor), desipramine (Norpramin), and amitryptiline (Elavil) are tricyclic antidepressants. While these drugs can be helpful, they aren’t effective for everyone.
Some evidence shows that two other categories of antidepressants–selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), or serotonin and norepinephrine reuptake inhibitors (SNRIs) such as duloxetine (Cymbalta)–are also helpful for chronic pain, but more research is needed.
Anti-epileptics can be taken to address chronic nerve pain and chronic pain from conditions like diabetes, shingles, chemotherapy, herniated disks, and fibromyalgia. Research on how well anti-epileptic medications work for pain is unclear. Some people may receive significant benefits while others may not receive any pain relief at all.
Newer anti-epileptic drugs such as gabapentin (Neurontin), and pregabalin (Lyrica) have more evidence of being effective painkillers than older drugs, and they carry fewer side effects. But, some studies have shown that older antiepileptic drugs such as carbamazepine (Tegretol) and phenytoin (Dilantin) can also help for certain pain conditions. However, these older medications cause more side effects.
Corticosteriods, commonly referred to as just steroids, decrease inflammation and reduce the activity of the immune system. They can reduce swelling and pain for conditions like cancer, back injuries, arthritis, joint pain, and nerve pain. Steroids can be helpful for short-term treatment of acute pain and are also used for the management of some chronic pain conditions., Common steroids used for pain relief are dexamethasone (DexPak), prednisone (Deltasone), and prednisolone (Prelone).
Steroids can be taken orally, applied as a cream, injected, or inhaled. Steroids do come with side effects such as weight gain, high blood pressure, and weakened immune system. Taking low doses of steroids for short periods can minimize those side effects. Injecting steroids directly into an area of pain also reduces side effects and promotes targeted treatment of the affected area.
Non-drug treatments like exercise, physical therapy, yoga, acupuncture, cognitive behavioral therapy, biofeedback, chiropractic, and relaxation training can provide pain relief, especially for chronic pain., In fact, organizations as diverse as the American College of Physicians, the U.S. Department of Veterans Affairs, and the Centers for Disease Control and Prevention recommend non-drug treatments as the first course of action for chronic pain. Although side effects for non-drug treatments tend to be minimal, be sure to consult with a healthcare provider before beginning any new treatment activities.
One of the biggest downsides to taking a medication is side effects. After a dose of most drugs, the amount in the bloodstream spikes quickly, and then is flushed away within the course of a few hours. This means the amount of medicine in the body can vary at any point in time – and that spike can mean nasty side effects.
This problem is exactly what extended release (often noted as ER or XR) drugs were designed for. Typically taken once a day, these formulations keep the therapeutic dose at a steady level in the body for longer periods of time. So if you’re not getting the response you want from your current medication, it may worth talking to your doctor about trying an XR version. But bear in mind: the XR formulation can often be much more expensive.
How do XR drugs work?
Drugs are usually broken down by the liver or kidneys, which means that after taking a dose, the body begins to naturally clear the medication from the system. As their name suggests, XR drugs typically include special coatings or mixers that make the drug take longer to clear from the body than ordinary or immediate-release (IR) drugs. Many popular drugs are now available in XR; there are well over 30 for pain alone.
The graph below shows blood concentrations of the pain medication Ultram (tramadol) after taking the immediate-release version (the white dots) every six hours, compared to the extended-release version (the dark dots), taken once every 24-hours.
Notice how the amount of drug in the bloodstream spikes for the IR drug. XR drugs eliminate this problem. Though they typically have a slightly slower onset compared to their IR counterparts, they maintain a more consistent level of the drug in your body, which could mean better treatment outcomes for longer periods of time while also lowering the occurrence of side effects. You also don’t have to take the drug as often, which may mean that you are less likely to forget to take your medication, especially when multiple doses are needed throughout the day.
But about that price
So why doesn’t everyone just take the XR versions? Usually because of the price. Typically, XR formulations go through a new drug approval process with the FDA and are granted an additional patent as a new drug. This means that an XR version often doesn’t have a generic alternative, making it more expensive – and giving the drug company more time to make more money. This is why new extended-release versions of popular drugs turn up just before the patent expires (such as a new version of Lyrica). Some XR drugs – such as Adzenys or Concerta, for ADHD; or Zohydro for pain – can be nearly 10 times as much as generic alternatives.
But that’s not always the case. Extended release versions of alprozolam (Xanax) and metformin (Glucophage) are available in generic form, and aren’t much more than twice their regular version. Depending on how often you take your medicine, these versions can actually be cheaper than the old versions when you factor in the number of pills. Also keep in mind that some health insurance plans will only cover traditional immediate release drugs, so call your pharmacist or insurance provider – and check GoodRx – to check the price first.
Are XR drugs right for me?
If you are taking prescription meds every day, you should work with your physicians to ensure you’re taking the right form of medication for you. This may mean tracking your side effects and getting blood tests to get a better handle on what the highest and lowest concentrations of the drug is best for you personally. There’s also a small chance that your body might not be able to break down the slow release coatings or ingredients fast enough to hit that targeted therapeutic level in the bloodstream, so be sure to go back to your doctor if you don’t think it’s working.
What is Lyrica CR prescribed for?
Lyrica CR is for the management of neuropathic pain associated with diabetic peripheral neuropathy (DPN), and postherpetic neuralgia (PHN).
What does CR mean?
The CR means this is an extended release formulation (aka controlled release). This means that a drug dissolves over time and is released slower into the bloodstream.
Advantages of extended release tablets include better control of pain, increased tolerability, and the convenience of only taking the medication once daily. The benefit of Lyrica CR is that you will not need to take the medication multiple times a day.
What strengths will Lyrica CR be available in?
What are the common side effects of Lyrica CR?
Common side effects include dizziness, tiredness, headache, fatigue, peripheral edema, nausea, blurred vision, dry mouth and weight gain. Be sure to speak with your doctor if you experience any of these symptoms for a prolonged period of time.
Does Lyrica have a generic?
As of November 2017, there is no generic available for Lyrica. However, it may become available as generic pregabalin as soon as December 2018.
A glycated hemoglobin (HbA1c) is a preferred screening test for diabetes. Done easily with a fingerstick in your physician’s office, it eliminates the need for fasting (not eating) prior to the test. The diagnosis of diabetes is confirmed if two consecutive A1c levels are greater than or equal to 6.5.
What is the HbA1c?
Red blood cells are permeable to glucose (sugar)—so after they enter your circulation, glucose becomes attached to them. The degree to which your red cells become “sugar coated” depends on your blood glucose level. The A1c indicates the average blood sugar level over the lifespan of the red cell—and it lines up with average blood sugar over the previous 2 – 3 months.
Take home message here: your HbA1c will not be affected if you had pizza the night before, unlike a random blood sugar test. But because the A1c is influenced by the total life cycle of your red cells, the levels can be inaccurate in some folks.
Here are some times the HbA1c will not be helpful:
A1c falsely elevated (HIGH)
Your test may tell you that you have diabetes, but you don’t.
- Untreated anemia from iron deficiency or vitamin B12 and folate deficiency can result in a HbA1c value that is falsely high because your red cell turnover is low. Because you have more “older” red cells instead of making new ones (due to lack of iron, or other vitamins) your HbA1c will be higher than it should be.
- Kidney failure or chronic kidney disease. If you have abnormal kidney function your HbA1c may be falsely high.
- Very high triglycerides (over 1,750) may also cause a falsely elevated HbA1c.
- Splenectomy (spleen surgically removed) will give you a falsely elevated HbA1c, due to decreased red cell turnover. This is because the spleen can’t remove the red cells from the bloodstream—which is the spleen’s normal job.
A1c falsely decreased (LOWER)
Your test may show that you aren’t diabetic, but you are.
- Donating blood or major bleeding. HbA1c levels are likely to be underestimated after blood donation. Donating blood, or major bleeding puts the red blood cells in a hyperkinetic (overactive) state—which shortens the life of the red blood cell.
- Treated iron deficiency anemia or treated vitamin B12 deficiency anemia may lead to a falsely low A1c due to rapid turnover of the red blood cells during treatment. In other words, if you have iron deficiency and are taking iron supplements, your A1c may be falsely low—but if you just have iron deficiency anemia NOT on treatment it will be falsely high.
- Pregnancy. Through the first and second trimester of your pregnancy, the HbA1c may be falsely low due to decreased red blood cell lifespan.
- Vitamin E supplements. If you are taking high doses of vitamin E supplements, your HbA1c may be falsely low due to reduced glycation (less glucose attached to your red blood cells).
- Hemolysis. Folks with hemolysis (red cells being chewed up) have rapid cell turnover and falsely low A1c. Hemolysis from autoimmune diseases, medications (ribavirin, interferon-alpha), or genetic problems like hereditary spherocytosis limits the use of A1c as a diabetes screening test in these folks.
- Erythropoietin treatment (Epogen or Procrit) during chemotherapy or for profound iron deficiency anemia will cause a falsely low HbA1c level, again, due to more rapid cell turnover (more younger red cells).
Your A1c will be inaccurate either way (HIGH or LOW):
- Recent blood transfusion makes the A1c of limited use because transfusion does many things to the measurement, including diluting your red cells with someone else’s red cells. HbA1c results in a recently transfused person should be considered uninterpretable.
Well, what can I be tested with if I can’t do HbA1C?
Fructosamine. Diabetes specialists will check blood concentration of a protein called fructosamine to get a longer-term estimate of your glycemic/sugar control. This gives them a better idea of your sugar levels, over random or fasting blood glucose.
If you have diabetes, you’re probably used to checking your own blood sugar with a glucose meter. These blood sugar measurements are important for controlling levels on a daily basis but are less useful for understanding your long-term blood sugar levels.
Your doctor has a way to determine if your blood sugar has been in the recommended range by checking your hemoglobin A1C levels through a blood test. Your A1C shows how well you have been controlling your blood sugar levels over time and can help your health care team determine your average level over the past three months.
What does my A1C mean
An A1C level below 5.7% is normal whereas an A1C level between 5.7 and 6.4 signals prediabetes. For most, the goal is to lower A1C levels. Here’s what the A1C means in reference to average daily blood sugar.
6% A1C = 126 average blood sugar
7% A1C = 154 average blood sugar
8% A1C = 183 average blood sugar
9% A1C = 212 average blood sugar
10% A1C = 240 average blood sugar
11% A1C = 269 average blood sugar
12% A1C = 298 average blood sugar
How often should I check my A1C?
Your doctor or health care team will determine how often you should get your blood work, and A1C tested. Usually, you will be directed to get your A1C levels checked every three months. However, if your diabetes is well-controlled, your doctor may only require you to get your blood work done every six months.
Is there a way to check my A1C besides going to the doctor?
Yes. You can now purchase over-the-counter A1C test kids right from your local pharmacy.
However, using an at-home testing kit for your A1C is not a substitute for regular blood glucose measurements or regular visits with your healthcare provider.
What should my A1C goal be?
Your doctor will help you determine what your personal A1C goal should be. According to the 2017 American Diabetes Association, a reasonable A1C for many is less than 7%. However, less strict goals may be appropriate for those who have a history of low blood sugar, limited life expectancy, advanced complications, or extensive comorbid conditions.
How can I lower my A1C?
There are many things you can do to get your A1C within your goal.
- Take your medication properly. This means abiding by proper injection technique, and taking your medications as directed by your doctor.
- Adjust your medications with your doctor. In some cases increasing or decreasing your medications can help you reach your A1C goal.
- Increase your diabetes knowledge. Diabetes educators can be a great resource to help you with healthy habits.
- Abide by a healthy diet. Did you know that many grocery stores employ dieticians to help their customers including diabetics increase their food knowledge? Reach out to your specific grocery store to see if they have a dietitian to help. Also remember that fruits, veggies, and lean-protein can also help lower your A1C.
- Exercise. 150 minutes or more of moderate-to-intense physical activity over 3 days per week can help lower your A1c!
- Lose weight.
- Check your blood sugar as directed. Your doctor will help you determine a schedule for testing your blood sugar. A continuous glucose monitor can help you consistently check your levels without a fingerprick!