Bone and Joint Pain Medication Options

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There are a variety of over the counter and prescription medications that are used to treat  bone and joint pain.  Which one should any particular patient take, how do they work, and what affect do they have on your body?  This blog will discuss the different medication options and hopefully help you create some educated questions to take to your doctor.

Over-The-Counter Medication options:

Topical Counter-Irritants work on minor joint pain by creating a feeling of warmth or coolness over a painful area.  They vary in active ingredients such as camphor, eucalyptus or menthol.  They are effective at providing short term relief in minor pain.

Topical Capsaicin is helpful at relieving pain that comes from the nerves near the surface of your skin.  It works well for localized joint pain.  This is hot pepper cream and will deaden the nerve endings so as to block the transmission of pain from the nerve endings.  Start with a small dose and gradually increase over the course of 1-2 weeks to decrease the chance of feeling the burn.  Please note there are two strengths of this cream.  It is important to first start with the lower dose and increase to the stronger strength after you have used at least one tube of the smaller strength capsaicin.  Be sure to wash your hands well so you do not get this cream in your eyes!

Glucosamine Sulfate is a natural substance that is found in healthy cartilage.  It is believed that glucosamine, in the sulfate form, can aid in the strengthening of the cartilage matrix of joints and decrease progression of joint deterioration.  Glucosamine sulfate is commonly taken with chondroitin which is another naturally occurring substance found in the cartilage.  Use of this combination may allow for a reduced dose of other prescription medications.  You may need to take the combination for up to 3 months before you notice a strong positive effect.   Sometimes the positive effects are so slow that many people do not even realize it is helping until they stop taking it and the pain begins to come back.

Acetaminophen (Tylenoltm) is an effective non-prescription medication for bone and joint pain and generally has very few side effects.  Acetaminophen does not have any anti-inflammatory effects; rather, it blocks the perception of the pain in the brain.  Acetaminophen has the benefit that there is no chance of addiction, it rarely causes stomach upset and you do not develop a tolerance to the medication.  The risk with acetaminophen is that it is easy to take too much of it, which may cause serious liver problems.  Please read the packaging and do not take more acetaminophen than is directed on the label.  Also, please be aware, many prescription medications contain acetaminophen in combination with another medication.  Be sure to keep track of your daily acetaminophen dose to be sure you do not get more than 3000-4000mg daily. 

Ibuprofen (Motrin IBtm, Adviltm) and Naproxen (Alevetm) are two non-prescription non-steroidal anti-inflammatory medications available.  Ibuprofen and naproxen work differently than acetaminophen to relieve pain, so, a patient in significant pain may take the recommended dose of acetaminophen alternating with the recommended dose of ibupofen and repeat this pattern as appropriate to treat the pain.  

Prescription Medications options:

Non-Steroidal Anti-Inflammatory Medications:  Celecoxib (Celebrextm), Diclofenac (Voltarentm), Edotolac (Lodinetm), Ibuprofen (Motrintm), Meloxicam (Mobictm), Nabumatone (Relafentm), Napxen (Naprosyntm. Anaproxtm), Piroxicam (Feldenetm)

These medications work best when taken on a regular basis.  The idea is that the medication builds up in the system and work to block the inflammatory process.  Decreasing the inflammation will help decrease the pain.    There are a number of potential risks and side effects, such as cardiovascular and gastrointestinal risks,  associated with each specific non-steroidal anti-inflammatory agent.  Please talk with your doctor to decide which medication would be best for your specific condition. 

Nerve Pain Medications:  Pregabalin (Lyricatm), Gabapentin (Neurontintm), Duloxetine (Cymbaltatm)

These medications work to interfere with specific signals in nerve pathways that have to do with the transmission of pain impulse recognition.  These medications are usually not addictive and may be taken safely for long periods of time.  That said, this category of medications is sometimes difficult for people to start.  The dose of any of the three will most likely be titrated up slowly over a course of 1-4 weeks to minimize the side effects.  It helps to know that the body will usually acclimate to the medication over the course of a few weeks and the side effects will diminish as the pain control increases. 

Narcotic Pain Medications:  Oxycodone/Acetaminophen (Percocettm), Hydrocodone/Acetaminophen (Vicodintm, Norcotm, Lorcettm), Oxycodone Extended-Release (Oxycontintm), Fentanyl Patch (Duragesictm), Morphine Extended Release (MS Contintm, Avinzatm, Kadiantm)

Narcotic pain medications(opiates)  work very well at treating bone and joint pain for short term therapy like you might need after a surgery or an acute injury of some kind.   The opiates block the perception of the pain in the central nervous system.  They don't actually do anything to where the pain is coming from, they just block your perception of it so you have a decreased sensation of the pain.  One of the big issues with opiate pain therapy is that after 2-3 weeks of treatment, the body slowly begins to build up a tolerance to the medication.  This may sometimes be perceived  as an increase in pain, rather than a decrease in effectiveness and the dosage may be increased.   If not monitored and talked about regularly, this can lead to a self-defeating addiction to opiates  with an escalating need for pain control.  That said, there are some physicians who use low dose, long-acting opiates to treat chronic one and joint pain effectively for long periods of time.  Please discuss all aspects of narcotic pain control with your doctor or pharmacist before beginning chronic opiate pain control. 

Other:  Tramadol (Ultramtm)




Tramadol is an alternative to opiate pain medications for treatment of moderate to moderately severe acute pain such as you might have post-operatively or after an acute injury.  Tramadol is not a narcotic; however, it works by stimulating the same opioid receptors in the central nervous system that opiates do.  It also has decreases pain by increasing the levels of specific neurotransmitters, similar to how the nerve pain medications work.  This medication has a much less chance of addictive behavior associated with it; however, because it does work in the central nervous system, you still need to be aware of the potential of side effects such as light headedness, dizziness and drowsiness.  It is important to note that someone would usually not take Tramadol and an opiate at the same time because one may block the effects of the other.   Please discuss this option with your doctor as an alternative to taking short acting narcotic pain medications.
Corticosteroid Medications: Dexamethasone, Methylprednisolone, Prednisone

Corticosteroids are sometimes used for short term therapy(7-14 days)  to decrease inflammation in an acute situation.  There are generally only a few complications associated with short term use of corticosteroids such as upset stomach, restlessness and agitation.  Long term use of corticosteroids may be associated with osteoporosis, compromised immune system, stomach ulcers and possible other complications.  Please note that caution should be used when someone with diabetes is prescribed a corticosteroid because this medication increases blood sugar.  Also, if steroids are used in someone with an acute infection, the infectious condition may worsen.  Please make sure your doctor and pharmacist are aware of your current medical conditions and other medications before you begin a course of oral corticosteroids.

Injectable Steroids are sometimes used to help decrease inflammation in a specific location.  The injection may be in combination with an anesthetic agent.  When placed exactly in the right spot, these injections may be effective at relieving pain for 3-18 months or more.  This practice is usually not done more than 3-4 times in a lifetime  because of the potential for bone loss due to increased systemic corticosteroid circulation.    

Injectable Synvisc is a treatment for osteoarthritis of the knee  Synvisc is injected directly into the knee and help provide increased lubrication and cushioning in the knee joint.  It has been known to provide relief for 6-18 months in most people.

Topical Prescription Medications:

Voltaren Gel:  Topical anti-inflammatory gel massaged into the affected painful area 3-4 times daily.  Effective for localized joint pain.  Has the benefit of bypassing the GI tract, however, it is short acting and really needs to be used 4 times daily for a reasonable effect.

Flector Patch: The same medication that is in the Voltaren Gel, however, it is in a patch.  Again, effective for local pain control if placed directly over the pain.  The patch needs to be changed every 12 hours and the constant irritation of having a patch on the same location can cause skin irritation in some patients.

Lidoderm Patch:  Provides transdermal lidocane (anesthetic) to help numb the pain.  Quite effective for some patients.  The patch is only worn for 12 hours every 24 hours.

TNF (Tumor Necrosis Factor) blockers:  TNF promotes the inflammatory response, which in turn may cause many of the clinical problems associated with autoimmune disorders such as rheumatoid arthritis.  Enbrel, Remicade, Humira are examples.  These are very expensive, however, they have shown to be very effective at halting progression of autoimmune disorders such as rheumatoid arthritis.

This is meant as a general over view of the medications commonly used for treatment of bone and joint pain.  Please discuss with your doctor what the best course of treatment is for your situation.  If you have any questions about any of the medications listed here, I encourage you to contact your community pharmacist and engage them in a discussion.



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Thanks
Steve

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Alzheimer's Disease

As of today, there are no medication treatments that stop or reverse the progression of or cure Alzheimer's disease.  Alzheimer's disease is a neurodegenerative type of dementia that occurs when cells used for information transfer in the brain die.  This particular form of dementia is characterized by tangled nerve cells and clusters of degenerating nerve endings.  Alzheimer's sufferers also experience a progressive decrease in the production of neurotransmitters needed for transmission of nerve impulses.

So, what we have here is a disease that gets progressively worse, the exact cause is not known, there is no cure, and it affects more than 5 million Americans.  When I say it affects more than 5 million Americans, I mean, more than 5 million individuals are currently diagnosed with Alzheimer's disease.  The numbers that are affected by the disease is at the very least double that amount because this disease not only affects the sufferer; it also creates a big impact on the family and caregivers.

Medication treatments for Alzheimer's  disease patients focus on two main areas.  The first has to do with increasing the level of circulating neurotransmitters, while the second area has to do with slowing the progression of nerve ending death.   Neither of these two treatments will stop the progression of the disease, however, they may help improve memory, awareness, and possibly the ability to perform some daily functions.

Currently, I have three Medication Specific Counseling Sessions™ posted at www.AudibleRx.com that have to do with Alzheimer's disease related medications. 

Donepezil (Aricept-tm)

Memantine (Namenda-tm)

Rivastigmine (Exelon-tm)

To listen to any of the above sessions, pleaseregister to become a member at AudibleRx™ and have full access to all of the counseling sessions.

Thanks
Steve

Copyright AudibleRx, all rights reserved. Please do not copy or publish or distribute without consent and approval from AudibleRx.

RAAS

Has anyone ever heard the term Renin-Angiotensin-Aldosterone system (RAAS)?  Maybe, or maybe not, however, this is a hormone system in your body that helps regulate fluid balance and blood pressure.  After reading this blog, I hope that you will have just a little more amazement of all that our body does to keep us alive…while we are focusing on other seemingly important issuesJ

When the body recognizes that the blood volume is too low (i.e., when blood pressure is low), the kidneys release a substance called renin.  The renin is then circulated through the blood stream and interacts with another substance called angiotensinogen, which comes from the liver. 

The interaction of renin and angiotensinogen forms a substance called angiotensin.  Next, a substance called angiotensin converting enzyme interacts with angiotensin and this forms a substance called angiotensin 2. 

Finally, this substance called angiotensin 2 works directly on the blood vessels, causing them to constrict, which increases the blood pressure.  Angiotensin 2 also stimulates the production of aldosterone from the adrenal cortex.

Aldosterone works on the kidneys to decrease the amount of sodium that is lost in the urine.  This increases the amount of sodium circulating in the blood stream which in turn increases the volume of blood which will increase the blood pressure.

In a healthy individual this system works well to maintain adequate blood pressure.  In an individual with slightly elevated blood pressure, an increase in the levels of angiotensin 2 will only aggravate the situation, increasing the blood pressure higher than is considered normal for prolonged and healthy living. 

I took the time to discuss all of this so that you might have an idea of what the classification of some anti-hypertensive drugs means.  I currently have two categories of medications used to decrease blood pressure listed on AudibleRx.  Both categories work on the RAAS (renin-angiotensin-aldosterone system). 

The first category is the ACE inhibitors (angiotensin converting enzyme inhibitors).  These block the conversion of angiotensin to angiotensin 2.  As we remember from above, angiotensin 2 works to constrict blood vessels.  This class of medications limits the production of angiotensin 2, and therefore, it is helping to relax blood vessels.

The second category is the ARB's (angiotensin 2 receptor blockers).  This class of medications works directly on the blood vessel, blocking the effects of angiotensin 2.  By blocking angiotensin 2, the blood vessels are not stimulated and therefore stay relaxed.

Medication Specific Counseling Sessions™ for both of these categories can be found in the membership area of AudibleRx.  Please visit www.audiblerx.com and register to become a member.  Membership allows full access to all of the Medication Specific Counseling Sessions.

ACEI's (angiotensin converting enzyme inhibitors)

  • Benazepril (Lotensin-tm)
  • Enalapril (Vasotec-tm)
  • Lisiniopril (Prinivil-tm, Zestril-tm)
  • Quinapril (Accupril-tm)
  • Ramipril (Altace-tm)
ARB's (angiotensin II receptor blockers)

  • Candesartan (Atacand-tm)
  • Irbesartan (Avapro-tm)
  • Losartan (Cozar-tm)
  • Olmesartan (Benicar-tm)
  • Valsartan (Diovan-tm)
Steve
www.audiblerx.com

Copyright  AudibleRx, all rights reserved. Please do not copy or publish or distribute without consent and approval from AudibleRx.

Medication Specific Counseling Sessions (TM)

Click here to watch the short video!

There was a time when it was normal practice for a Pharmacist to not regularly counsel patients about their medications.  Regardless of the knowledge base a Pharmacist had about the medications, it was their job to fill the prescription accurately and get it to the patient per the Doctor's order.  Of course, your Pharmacist was always available for questions; however, it was not mandatory that they assure you know what you are doing with your medications before you left the store.

In 1990 the Federal Government passed a law titled the Omnibus Budget Reconciliation Act of 1990. (OBRA 90).  This law was passed, in part, because of a growing concern about improper medication use.  The law required that all Medicaid patients receive counseling from a pharmacist with any new prescription.  This isn't a situation where the patient is asked if they would like counseling, it is mandatory that the pharmacy offer counseling to each and every patient with a new prescription.  The patient may deny the counseling if they choose. 

It did not take long until all of the State Board of Pharmacy Legal departments took this on as standard of practice for all patients, not just Medicaid participants.  So, for 22 years now, the law has stated that each and every time a patient receives a new prescription at the pharmacy they will be offered a counseling session with their Pharmacist.

These counseling sessions need to include specific information in order to be complete.  The American Society of Health System Pharmacists developed a set of guidelines that includes all of the information necessary for a complete Pharmacist based patient education session.  Each State Board of Pharmacy Legal department has also developed their own specific guidelines on what information needs to be discussed in a Patient counseling session about a new prescription. 

The FDA has developed guidelines for Useful Written Consumer Medication Information.  AudibleRx follows these guidelines in the development of each and every audible CMI session.

It is encouraged that these counseling sessions be face to face so that the Pharmacist may evaluate directly if the patient understands what they are going to do with their medication and why they are taking it.  It is difficult to overcome many of the barriers to effective counseling over the phone, however, telephone consultation is the only way a mail order prescription may be counseled. 

It is my impression that this does not always happen.  Like I have said before, regularly I get patients who have had their prescriptions filled through mail order pharmacies or at big store chain pharmacies, and have not had all of their questions answered for one reason or another.  They happen to be walking by the Clinic Pharmacy that I work in and see that there is a Pharmacist accessible and stop in for a question. 

AudibleRxTM   offers Medication Specific Counseling SessionsTM in digital/audio format in both a web and App based platform.  After a patient or a care giver listens to a medication education session they will have a clear idea of what they do and don't know about their medication and be in a clear position to take educated questions back to their own health care provider.

It is important to realize that the recordings at AudibleRxTM are meant to supplement your knowledge and understanding of your medications and are not a replacement for a counseling session with your own pharmacist.  Please, talk with your Pharmacist or Doctor if you have any questions about your medication.


AudibleRxTM has many sessions posted, and more are added each week. Please visit the Alphabetical Page at AudibleRx to see which Medication Specific Counseling SessionsTM are currently available.

AudibleRx is Free for individual users; however, a licensing agreement is necessary for an institution or practitioner to recommend its use as a medication education tool.  Please visit the AudibleRx website for more information about licensing agreements.  Also, visit the Possibilities page to see all the different ways this service may be utilized.


When patients are educated about their pharmaceuical care it is much more likely that they will be motivated to take their medications appropriately, decrease the chance for improper use, and lead to their best possible outcome!


If you haven't done so yet, please visit our Facebook page and give us a LIKE and you may also be interested in following our Pinterest page to see what Pharmacy Topics looks like in pictures.  If you tweet, please follow us on twitter.

Thanks
Steve


Copyright  AudibleRx, all rights reserved.

Cushing's Syndrome

Cushings's Syndrome Awareness Day was April 8, 2012. 

I have a sister-in-law who is doing her best to bring Cushing's Syndrome out into the public spotlight so it may gain awareness and understanding.  This is a huge task.  Cushing's Syndrome affects the patient and family in so many ways, and I appreciate how Rene is able to continue to move forward in getting this message out.

Please take the time to visit her blog.  Rene has put years of effort into understanding Cushing's Syndrome and she is doing her best to educate the rest of the world!

http://missdiagnosis-rene.blogspot.com/

Thanks
Steve

Copyright  AudibleRx, all rights reserved. Please do not copy or publish or distribute without consent and approval from AudibleRx.

Migraine Headaches

Migraine headaches are a huge issue and affect many people.  Everyone knows someone who suffers from migraine headaches; however, few people understand what makes up a migraine headache.

Migraines are most commonly broken up into four distinct sections. Everyone who has a migraine experiences all four distinct sections, however, the duration and intensity of each section can vary greatly between individuals and migraine episodes.

The prodromal syndrome (sometimes called the pre-headache) is the warning time that a migraine is lurking on the horizon.  This phase is usually experienced a couple hours to even days prior to the onset of the migraine pain.  When someone has experienced migraines over the years, they come to recognize the specific symptoms of the prodromal phase of their migraine.  These symptoms can be quite variable and may include significant mood changes, cravings, fatigue and a host of other symptoms.  When someone recognizes these pre-headache symptoms, quite often they are able to take measures that will help avert or lessen the migraine pain.

The aura phase follows the prodromal symptoms and usually lasts somewhere between 30-120 minutes.  During this time frame the migraine sufferer will usually have some level of sensitivity to light, smell or taste.  Usually, the aura phase is much more familiar to people than the prodromal phase, and quite often the two phases blend together so quickly the terms are used interchangeably.  A migraine sufferer realizes that at this phase of their headache, the pain is most likely eminent.   If someone is aware and awake at this time, it is reasonable to take their migraine medication before the pain of the headache sets in.  This may help shorten the intensity or the duration of the painful phase of the migraine.

The painful phase of a migraine headache may be so debilitating that it is difficult to comprehend for those who have not experienced it.  This pain quite often affects the entire body and is not just limited to the head.  The intense pain usually lasts about 1-3 hours; however, quite often it may last up to 3 days.  This pain may be accompanied by a host of other uncomfortable symptoms involving the entire body.   

The final phase of a migraine is the postdromal  (post-headache) time.  After the pain is gone, the migraine lingers on for a couple hours to a few days.  During this time the migraine sufferer is in a recovery phase where they might feel hung over or dazed.

I am fortunate that I am not a migraine sufferer; however, I am very close to someone who does suffer from migraine headaches.  I have a relative understanding of how significantly a migraine headache can disrupt someones day to day activities.

To listen to the Medication Specific Counseling Sessions for the medication alternatives used to treat and prevent migraine headaches, please follow this link to AudibleRx.  Once there, register as a Member of AudibleRxand have full access to all of the Medication Specific Counseling sessions for the life of your membership.

Thanks,
Steve
www.AudibleRx.com

Copyright  AudibleRx, all rights reserved. Please do not copy or publish or distribute without consent and approval from AudibleRx.

Be Aware

Not too long ago I had one of my regular customers call me to get a refill on her Vicodin.  This particular patient has some significant pain issues and picks up a reasonable amount of medication every 30-40 days.  After talking with her on the phone for a few moments, we realized that she had filled her prescription only 14 days ago, and here it was, almost empty.   I realized we needed to take some time here and figure out what happened.

There are many ways to handle this, however, I like to take some time and "walk around the barn" with the patient to try and figure out what is going on.  First of all, this patient has been with us for the 15 years I have been at this pharmacy, and this is the first time she has ever called in for an early refill on her pain medication.  After a short discussion, I am convinced that she is not taking more than is prescribed for her.  Next we talk about those 7 day pill boxes, asking if she fills up pill boxes for the next couple of weeks and perhaps that is where the extra tablets are.  She said no, she does not use pill boxes.

She told me that she always keeps her pills in the original container, in an open shoe box, along with all of her other medications.  I asked her where she kept the shoe box.  She said that she keeps it on the dresser in the hallway just outside her bedroom.   The following question got to the root of the situation.  I asked her if anyone else has been in her house recently. 

She thought about it for a few minutes and talked about her granddaughter coming sometimes, and then she talked about a group of workers she had in her yard the previous week working on her patio.  She had let them know that the door was open and they could use the restroom whenever they needed.  The dresser in the hallway with the open shoebox of medications is in the direct path to the restroom. 

I am convinced that this happens much more often than we would like to believe.  An invasion of medication privacy and possibly theft of our medications is an issue that we all need to guard against.  It is far too common for a guest in your home to step into your restroom under perfectly reasonable circumstances, and then proceed to open your medicine cabinet and examine what lies within.   

When people hear of drug theft, the first thing that comes to mind is something illicit involving bad guys and guns.  Over the last 15 years at the pharmacy that I am currently working at I have had at least 10, and most likely more, conversations where we figured out that their medications had been stolen from them by either a caregiver, family member, or a guest in their home. 

Keep in mind, this does not include the multitude of conversations I have involving people who claim their medications were stolen but also have a long history of their pain medications regularly being stolen, lost, damaged or some such thing on a regular basis.  This topic we will discuss in a future blog. 

Please, store your medications in your bedroom.  Choose a location that is dry and maintains a relatively constant room temperature.  For security reasons, keep your medications in a dresser drawer or in your closet so they will not be seen if anyone enters your bedroom.  Your medications are your private business.  Your guests in your home should not be tempted to pick up your prescription bottle so that they can read the name of the medication.

Thanks
Steve

Copyright AudibleRx (TM), all rights reserved. Please do not copy or publish or distribute without consent and approval from AudibleRx (TM).