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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