The study examined common pain medications like acetaminophen and ibuprofen, but also the promise of other drugs like ketamine and antipsychotics for pain relief. Photograph: Westend61/Getty ImagesThe study examined common pain medications like acetaminophen and ibuprofen, but also the promise of other drugs like ketamine and antipsychotics for pain relief. Photograph: Westend61/Getty ImagesAntidepressants and antipsychotics could serve as alternatives to opioids, study findsMedications that target depression, anxiety and poor sleep could help treat pain without opioids’ addictive properties
A range of other medications could serve as alternatives to powerful opioids for pain relief in emergency departments, according to a new study.
The review paper examined non-opioid medications available in the emergency department at San Francisco general hospital and examined existing medical literature to figure out which ones might provide pain relief.
Opioids have a strong track record of reducing pain effectively, but loose prescriptions with insufficient care towards their addictive properties led to the first wave of the US opioid crisis, which began in the 90s.
Akash Shanmugam, a medical student at the University of California, San Francisco (UCSF) and first author on the study, said the goal of the study was to “create a very targeted list for specific pain conditions”, to help add to the “toolboxes” physicians use to treat patients.
The study provides recommendations for the most common types of pain that patients experience in emergency departments; abdominal pain, back pain, chest pain, fracture pain and headache.
Shanmugam and Dr Kathy LeSaint, an associate professor of emergency medicine at UCSF and another of the paper’s authors, agree that opioids still have a place in medicine. “The desire to reduce opioids shouldn’t come at the expense of under-treating pain,” Shanmugam said.
However, alternatives can also have an important role as physicians have become increasingly aware of possible long-term consequences. LeSaint also pointed out that beyond concerns about opioid addiction and overdose, it’s important to have a variety of medications for pain available because what will work best varies from person to person. This variation is often genetic; for example “the enzymes that are responsible for metabolizing opioids can have different strengths in people”, LeSaint explained.
The type of pain that a patient is experiencing can also determine what medications work best.
In the study, common pain medications like acetaminophen and non-steroidal anti-inflammatory drugs like ibuprofen showed the potential to relieve every type of pain examined. But other drugs in the study had more targeted applications; ketamine, a common anaesthetic, showed promise for chest pain; a serotonin norepinephrine reuptake inhibitor (SNRI) antidepressant showed promise for back pain, and several types of antipsychotics showed promise for headache and abdominal pain.
Psychotropic medications have long been used for pain relief as well as psychiatric symptoms. Shanmugam pointed out that gabapentin was first approved as “a really mediocre” drug for epilepsy, but “now it’s used a lot for the management of neuropathic pain”.
While the mechanisms that make various psychotropic medications effective for pain are complex and not fully understood, Shanmugam said that their efficacy likely has something to do with the fact that “neural circuits that create the sensation of pain are also are involved in the emotional experience of pain, and the distress that pain produces for human beings.”
Neurotransmitters like dopamine, serotonin, norepinephrine and glutamate, which regulate mood also have a role in the sensation of pain. Gabapentin is thought to alter neurotransmitter release through its effect on calcium channels, while antidepressants and antipsychotics regulate them more directly. These medications help maintain the nervous system at a more even keel by altering how neurotransmitters send signals within the brain.
“In chronic pain conditions, the nervous system can become highly sensitive, and it’s thought that antidepressants and antipsychotics can maybe reduce this heightened sensitivity in the brain,” LeSaint said.
Drugs that help with mood can also help the body deal with pain. “Chronic pain is often linked to things like poor sleep, depression, anxiety, fatigue,” according to LeSaint. Medications that help people sleep better and experience less anxiety might also make pain easier to deal with physically and mentally.
While these alternatives might be helpful to some patients, LeSaint emphasized that doctors must both review the evidence and what’s going on with the individual patient in front of them.
“Talking to them and asking about their prior experience with opioids prior to giving opioids can be really helpful in tailoring the pain regimen for that particular patient, for that particular pain syndrome,” LeSaint said.
When physicians do prescribe psychiatric medications, it’s important to make sure patients understand this doesn’t mean the pain is in their head, according to Shanmugam.
“I’ve seen a lot of clinicians use the basic science approach of explaining that there’s a lot of overlap between the pain mechanisms and also the emotional understanding of pain,” Shanmugam said, “that really helps reassure patients.”
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