The purpose of this article is to inform you of the various techniques and types of drugs currently available for pain control with medicines. The author, editor and the ACA do not recommend any one specific drug or intervention. Our intention is to educate and to inform. By having an understanding of what is available and how and why specific drugs and treatments work, you will be better able to discuss your options with your health care professionals and make informed decisions. You'll be better able to take an active role in managing your own pain, and in choosing among the treatment options currently available for treating pain, before surgery, immediately after surgery, and for the long-term treatment of chronic post amputation pain, both stump and phantom pain.
Medicines are only one of many types of pain treatment. Many alternative therapies are available, such as biofeedback, self-hypnosis, relaxation, and use of electrical stimulation (TENS) units. These will be addressed in future articles. The causes of pre and post amputation pain are as varied and individual as the number of people reading this article. Although very common after amputation, not all people go on to develop long-term chronic phantom pain. It is a major problem at first, however, the natural course of pain is usually to decrease in both frequency and severity with time. The degree of pain also varies from person to person, and therefore, the treatments will be different. Not all medicines or other interventions will be applicable to all people. Treatment may include a single drug or more commonly, a combination of medications, therapies and procedures. Each person's pain should be addressed individually; therefore, we highly recommend that you consult with a qualified pain management professional who offers a comprehensive pain management program near you.
AVOIDANCE OF PAIN:
What to do before surgery?
The advantages of early medical intervention in the treatment of pain cannot be overemphasized. The medical profession is just learning that the effects of chronic pain have long reaching importance. Besides the obvious advantage of greater comfort while you heal, early treatment of pain offers other important advantages. You may get well faster. New research has proven that chronic pain can cause changes in the body. "Stress hormones" released from injured tissue can effect breakdown of body tissue, increase metabolic rate, alter blood clotting, cause water retention, impair immune function, interfere with normal digestion and cause anxiety and depression. With less pain you can start your rehabilitation process sooner, become mobile faster, and get your strength back more quickly. You may leave the hospital sooner. Early mobility may also improve one's results, and avoid complications such as pneumonia or blood clots. Pain causes stress and emotional disturbances, and can interfere with sleep.
CHRONIC POST AMPUTATION PAIN
What can be done for phantom pain?
THERE IS NO MAGIC PILL. At this point in time there is no one medicine that specifically treats and will cure phantom pain; however, we do know that phantom pain is a type of chronic neuropathic pain (pain caused by changes in the nervous system), and there are now many varied effective medicines available for this other than the old standard "pain pill." The degree of pain varies from person to person, as will the specific reasons for causing the pain. Amputees may suffer not only from phantom pain, but from a variety of conditions that will result in chronic pain problems, and can also aggravate phantom pain. Stump pain and neuromas may be caused by a number of reasons, and therefore, the treatments will be different. Abnormal and excessive stress and strain on remaining limbs, muscles and joints, may also be the source of pain. Vascular abnormalities and diabetes may further complicate the pain management problems; therefore, your treatment plan should be tailored to your specific needs and circumstances. This may include a single drug or combination of medicines. The following is a list of drugs commonly used for treating chronic post amputation pain.
MEDICINES USED FOR CHRONIC PAIN:
Nonsteroidal anti-inflammatory drugs: NSAIDS.Examples: Acetaminophen (Tylenol), aspirin, ibuprofen (for example Motrin, Advil)
These drugs work by reducing swelling, inflammation and soreness, and relieve mild to moderate pain. Depending on your degree of pain, these may lessen or eliminate the need for stronger drugs. There is no risk of addiction, and they are the first drugs of choice to treat chronic pain. They may be very effective for stump pain, and local conditions such as skin irritation, swelling, joint problems, muscle aches in stump and remaining limbs, and may be all that's needed for mild phantom pain.
Antidepressants:
Examples: Elavil, Pamelor, Paxil, Zoloft, Prozac
Originally used only to treat depression, it is now well established that antidepressants are very useful in the treatment of many chronic pain conditions, including phantom pain. These drugs work centrally, in the brain by either blocking or increasing certain neurotransmitters, those chemicals that help regulate normal brain function and increase pain threshold. Since they act directly in the brain you may require less other pain medication. People in chronic pain have good reason to become anxious and depressed, and these drugs will help provide a feeling of well being, and decrease anxiety, which only makes the pain feel worse. Sleep deprivation is common with any chronic pain condition, and some antidepressants are also beneficial in helping a person sleep at night. Usually low doses of antidepressants are initially prescribed and many people will report an improvement in their pain with use of these drugs.
Anti-convulsants or Anti-seizure Medicines:
Examples: Tegratol, Neurontin
These types of drugs have been used successfully for post amputation pain, both stump and phantom pain, and are also effective in treatment of diabetic neuropathy. They work directly on the nerves both in the residual limb and in the brain, by altering neurotransmission. After amputation, the remaining severed nerves may become over-excited, which causes excessive or abnormal activity. This is similar to a seizure. These drugs act by calming down the nerves in the residual limb, and raising seizure threshold in the brain, like turning down the flame under a pot that is boiling over. It is usual to start with small doses, gradually increasing the dose to achieve pain relief and avoid side effects. As the phantoms become less frequent or severe with time, it is important to stop these drugs gradually. They should not be stopped abruptly.
Narcotics (Opiod Analgesics):Examples: Morphine, Demerol, Codeine, Percodan, Percocet
Morphine is a naturally occurring substance obtained from the juice of the opium poppy. The other narcotics are chemical variations of the same natural substance. They work centrally in the brain to decrease our ability to feel pain. These drugs remain the mainstay of pain management for post surgical pain, trauma, and cancer pain. They may be given by IM or IV, PCA, epidural catheter, orally, or transcutaneous patch. They are highly effective and should be used in these situations; however, they are addictive, and as healing occurs narcotics should gradually be tapered off and management of pain should be switched to nonaddictive pain killers.
Although very effective for treatment of short-term pain, they are not effective in the chronic management of phantom and stump pain. Usually a person becomes tolerant of the narcotic and requires more and more to get the same degree of relief. The person may become addicted and dependent, with poorer and poorer pain control and with increasing depression and disability. It is the rare amputee whose pain is eliminated by narcotics over a long period, and even fewer who can be maintained on a level dose without developing tolerance and addiction. The only notable exception is cancer pain.
There is a valid use for oral narcotics on a limited basis for treatment of phantom limb pain. This is for those amputees who have only an occasional flare-up of phantom pain, where short-term use, perhaps one or two pills will be all that's necessary to stop the attack. If the phantoms cannot be controlled sufficiently by a short-term course of oral narcotics, other medications or pain control methods should be used.
Sedatives and Hypnotics:
Examples: Valium, Xanax, Haldol, Thorazine
It is generally agreed that these drugs have no role in the treatment of phantom pain because they are not only ineffective in relieving the phantoms, but also tend to be habit- forming. They may increase depression and in long-term use do nothing to improve sleep disturbances that may be due to chronic pain. The only exception to this would be the short-term use for severe, disabling anxiety, stress or psychosis, which may be a result of amputation in certain individuals.
Local Anesthetics:
Examples: Novocaine, Pontocaine, Xylocaine, Marcaine
These drugs have long been used to produce local and regional anesthesia. They act by changing the chemistry of the nerves cells, and therefore, making them unable to function and transmit pain impulses. They may be given by spinal, epidural, local injection and a wide variety of nerve blocks. They are extremely useful, not only for anesthesia, but can decrease pain by placing dilute solutions through catheters placed in various locations throughout the body. Nerve blocks may be valuable as a diagnostic tool to identify people who may benefit from specific surgical procedures used to treat phantom pain, and may be helpful as therapy in certain specific cases. Local anesthetics may also be used to relieve trigger points, and may help to treat certain stump pain.
Miscellaneous Drugs:
Many drugs have been used to try to treat or cure phantom pains. They work in a variety of ways to affect nerve conduction and chemistry. Overall, the results have been poor, only a few people have achieved success. Each of the following drugs has been very effective for only a small number of people: Propanolol, Mexilitine, Clonidine, Calcitonin, Clonazepam, and Ketamine.
All drugs have side effects, some are minor, and others may be more serious. All drugs may interact with other drugs you may be taking. The effect of mixing several drugs may be potentially very dangerous. In general, most drugs are broken down by the liver, and eliminated by the kidneys, and damage may be done to these organs in certain situations. People with preexisting liver or kidney disease should be very careful about taking only medicines prescribed by their doctors. Drugs may affect blood formation, clotting and may cause bleeding; therefore, certain blood tests may need to be done to make sure these organs are working correctly and to check blood counts and the effects of blood thinners on blood clotting. Be sure your doctor knows about your allergies, and any and all other medications you may taking. Before taking any drug it is imperative to ask the following questions. What is it, how does it work? How should it be taken? What should I expect? What are the side effects? What tests may be necessary?
Conclusion:There are many methods to control pain. Medications are only one way. Although we don't have a drug that is specific and will cure phantom pain, treatments are available that have proven effective in the majority of people. Many times this may be a combination of drugs, or other pain control techniques. Seek professional help, and inform yourself.
About the Author
Christina Skoski, M.D., has been practicing Clinical Anesthesia in southern California for 23 years. She is currently serving as chairman of the Department of Anesthesia at Huntington Beach Hospital, where she works full-time. She is an active member of both the California and American Society of Anesthesiologists.
Following a diagnosis of cancer at age 11 and multiple surgeries, she underwent a hemipelvectomy amputation while still a high school student. After learning how to walk with her prosthesis, she returned to school and pursued a career in medicine.
She graduated from New York Medical College, did her internship at Cedars Hospital in Los Angeles before surgery, and completed her residency training at UCLA in Anesthesiology.
Dr. Skoski's interest in the problems of post amputation and phantom limb pain began recently with her participation in the Amp L, a computer support group. Realizing that the degree of interest and misinformation concerning amputee-related pain issues were not being met appropriately, she joined the ACA and hopes to share her medical knowledge with her fellow amputees.
