Intro: This is BayCare HealthChat, another podcast from BayCare Health System.

Joey Wahler (Host): With so many pain relief medications available, which types are best for you? We're discussing knowing the difference between your pain relievers. This is BayCare HealthChat, a podcast from BayCare. Thanks for listening. I'm Joey Wahler. Our guest, Dr. Fred Brennan, Jr., a family and sports medicine physician for BayCare. Dr. Brennan, thanks for joining us.

Dr. Fred Brennan: Thank you very much. Good to be here with you.

Joey Wahler (Host): Great to have you. So why is it in a nutshell important to know the difference between pain relievers?

Dr. Fred Brennan: Well, there's a lot of pain relievers on the market and some obviously are prescription. The ones on the market, some of them at one point in their “career” were prescription medications that later became not prescription. And in other words, over-the-counter medications. And because there are many, many different ones they all have, there are different, ability to relieve pain and they also have various side effects.

And so you really need to know what type of medication that you've been given or which one that you buy, so that you know it doesn’t interfere with your other medications and/or possibly could do on your body because again, pain relief is one thing, but there are always side effects potentially with pain medications, and you should be aware of what those side effects are.

Joey Wahler (Host): And indeed, we'll discuss those in more specificity in a moment, couple of things first, it's been said the best dosage approach with pain medication is low and slow. What do we mean by that?

Dr. Fred Brennan: Yes, I think because everybody reacts differently to all medications, especially pain medications, it's best to start off at a low dose and go slowly to increase the dose. And always staying in the range that you're supposed to. Two or three times the recommended dose is not always better. It tends to be potentially more dangerous. So start off at a low dose of the medication whatever's written on the bottle, what's prescribed for you or what you pick up like an Advil, which is ibuprofen, for example.

Start off with a low dose, and then if you need more, just go up a little bit more each time till you get the effect that you're hoping to get with that, but don't overdo it. So you go low with your dosing and you advance slowly until the recommended dose, so that you don't have an adverse effect from the medication and cause more problems.

Joey Wahler (Host): Exactly. Because the last thing you want to do obviously is take a medication that's meant to help and have it hurt. Next, what's the difference in treating acute pain versus chronic pain?

Dr. Fred Brennan: I think a lot of it is expectations. Unfortunately there a lot of people in the world and in our country that have chronic pain issues, whether it's abdominal pain or musculoskeletal pain. And I think that folks really have to have realistic expectations. And in our sports medicine clinic, for example, we see people with acute pain from an injury, which tends to clear up pretty quickly within several weeks, usually with some sort of pain medication, potentially, if it's really bad, might be a splint or a brace. It may just be some icing and time to calm down the acute injury. Something that just happens, usually some sort of an injury or maybe a recent surgery. For example, they had their appendix out, but chronic pain, unfortunately, it lingers and it doesn't go away. And I think that folks who have chronic pain have to be realistic and expect that it's not going to be like you were 20 when you had no pain, unfortunately. There will be days that you have good days and some days that are not going to be so good.

So the best thing to do is have expectations, like listen, I will have some good days and some days that no matter what I take, or no matter what I do, it's not going to be a great day. And I think people have chronic pain, if they can come to that in their head, that we'll do our best to help you with your pain. But realizing our goal is to have better good days than bad days. And so hopefully you'll be more functional and be able to enjoy your life.

Joey Wahler (Host): Sounds like a good plan. So that being said, let's talk about some of the different medication categories, their purposes, and their dangers, if not taken properly first. How about nonsteroidal, anti-inflammatory drugs? Like one, you mentioned a moment ago, Ibuprofen?

Dr. Fred Brennan: Yeah, they've been around a long time. They're still called NSAIDs like Advil or ibuprofen, Naproxen, which is Aleve, even aspirin, good drugs. They work well for pain. Not for everybody. And some work better than others. And I tell people the best one is the one that works for you. For example, So people will often ask me what's the best NSAID. And I say, well, the one that works for you and you might have to try some, but there are risks. And if you take them for a long-time and, it could even be just for a couple of weeks, you can have some bleeding, you can develop ulcers of bleeding in your gastrointestinal system. It also, if you use it and for those who do have risk factors for coronary disease, it can raise your risk a little bit of having a heart attack or a stroke, and it can also increase your blood pressure. So we tend to tell people, especially with NSAIDs, again, start slow, go at a low dose. The lowest dose is effective. And use it for as little time as you can get away with. And we understand that some people do have chronic pain and have to take it all the time.

But if you can get away with just taking it for a couple weeks or a week, that's the best thing because there are risk of bleeding and other complications when you take them.

Joey Wahler (Host): Gotcha, next. How about acetaminophen? AKA Tylenol.

Dr. Fred Brennan: Tylenol again has been around a long time. And for most people, if you take it at the recommended dose will be fine. The problem is that some people will unfortunately take a much higher than recommended dose and it can do injury to the liver. And a matter of fact, the emergency room physicians will tell you some of the worst overdoses, believe it or not, are sometimes purposeful, unfortunately, and sometimes not purposeful. And they overdose on Tylenol or acetaminophen, and it really is very toxic to the liver. So as long as you take it at a recommended dose, again, for as little time as possible, Tylenol is pretty well tolerated.

Joey Wahler (Host): Now, I guess on kind of the opposite end of the pain relief spectrum, we have narcotics such as oxycodone and people really have to be careful with these, right?

Dr. Fred Brennan: Oh, yes. Unfortunately it's, as you've noticed over the last five or 10 years, the narcotics have gotten a lot of press and deservingly so for overdoses and addiction issues, dependence. And so we have to be very careful with those and there are a lot of regulations in place for providers now and prescribing them for how long, etcetera. And because you can get addiction and dependence, constipation, of course you can't drive or use heavy equipment if you're taking narcotics, because it does alter your reaction time and your alertness. So narcotics they're strong, they're powerful, and some people need them, but we try to minimize the use of those if we can, because of those potential side effects.

Joey Wahler (Host): And isn't it sometimes a good idea, if a doctor prescribes them and says, you may not need them, don't take them unless you do. Isn't it sometimes a good idea, doctor, to try if you can, to avoid them, because why get started if you don't have to?

Dr. Fred Brennan: Yes, absolutely. Right. You would try to not use them if you can get away with not using them. And there are people, unfortunately, that they break a bone or something, and the pain is so intense that they do need a short-term narcotic because the pain of a broken bone for example, is very strong. And so there are times where people aren't getting a good night's sleep and I sometimes will tell people, listen, if you're going to take them, maybe just take them about an hour before bedtime so that you can get a good quality night's sleep, because I understand that sometimes the pain is bad at night. But yes, to minimize the use of narcotics, and again, use them only if you need it, is good advice.

Joey Wahler (Host): Next let's discuss anti-neuroleptics, which includes as a group meds like Gabapentin, for instance, which is used for a variety of conditions nowadays. Right?

Dr. Fred Brennan: Yes. I mean, some of these medications that we use for, especially the nerve pain, some chronic pain, and also people who have chronic nerve pain, for example, sciatica, these medications can be very helpful to basically bring down the pain threshold. For example, if the pain is usually a seven or eight, sometimes taking these medications, as you mentioned, can bring it down to a tolerable level, like a two or a three, because sometimes that's all they need. I just, I can't take a six or seven every day, but if you can bring my pain down to, for example, a two or three, I can function on that. And that's really the goal. So these medications, have been used secondarily especially for nerve pain and other chronic pain. And some people really do well with that.

Joey Wahler (Host): We hear so much also about antidepressants for years now, like effects, or just to name one of so many nowadays, what's your best advice for people getting started on one of these?

Dr. Fred Brennan: That would be something, of course, mostly for chronic pain. And it's one of those sometimes what came first, the chicken or the egg in that some people get acute pain, which then unfortunately develops into chronic pain and with chronic pain, then they develop as we all do at times we can get down on ourselves because of this pain and some people do get depressed. So these medications can help for people who have chronic pain.

Not only to help downregulate or decrease the amount of baseline pain they have. But honestly, if they're getting depressed because of their pain, which is totally understandable, these medications are almost a twofer. They can help decrease the amount of pain and also help maybe your low-level depression that you've developed because of your pain issue.

Joey Wahler (Host): Switching gears. Let's talk about topical drugs, like Lidoderm?

Dr. Fred Brennan: Yeah. Some of these things, especially from musculoskeletal pain, joint pain, muscle pain, muscle strains, things like a Lidoderm patch or a capsaicin cream, which is an over-the-counter cream. Even some people are Biofreeze and Bengay and other things like that. Some of these topical agents for things can be very helpful for decreasing, especially acute pain, but for even some chronic pain like arthritis pain.

So I often tell people let's try that first because typically there's no effects in your body, in your system because the topical stuff is not absorbed too much to affect things very much in your body. So go easy with a topical, if you can get away with it and it may take your pain away without having anything in your body that can have other side effects.

Joey Wahler (Host): And if that doesn't help, or perhaps if some of these other things we've mentioned, don't either there are steroids, both oral and injectable. How about those is an option for pain?

Dr. Fred Brennan: Yeah, they have their place. Steroids are really excellent drugs. And they are for people who have inflammatory conditions, like some sort of rheumatism of some sort, they can be really helpful. And people that take these intermittently really tell us, wow, my goodness. I feel so good. My joints don't hurt my muscles don't hurt and really for inflammatory conditions and people will get injections of steroids occasionally for arthritis. And that can be very helpful. but they do have their issues in long term use of steroids. And these are not anabolic steroids.

These are not the ones that make you a weightlifter, these are anti-inflammatory steroids. And unfortunately though, if you take them for a long time, they can have a lot of adverse effects, including blood sugar problems and osteoporosis and cataracts and things of that nature. So short term use is really, we prefer that, and we don't use them that often, but there are folks that do need steroids intermittently to help control pain.

Joey Wahler (Host): And then finally, people may not typically consider this quote unquote, a pain killer, but what about good old fashioned topical treatments like ice, heat? There are manual techniques, acupuncture for musculoskeletal pain, how about those more tried and true methods, if you will?

Dr. Fred Brennan: Right. It's a very conservative approach, which is good. And I usually tell folks when we're treating folks, especially for musculoskeletal conditions or problems, I tell them, we can go from the conservative to the aggressive and the aggressive can be things like medications and injections. So the conservative where we like to start off with, and that can be things like you said, muscle, massage therapy, acupuncture, topical agents, like ice and heat, because a lot of those things can help people with their pain just enough to again, make them functional.

And for acute things, especially when you sprain your ankle hurt your knee, ice tends to help as an anti-inflammatory at least for the first three to seven days. And we do like people to start off conservatively and then work their way up to the more aggressive things like medication. So absolutely a firm believer in manual techniques, osteopathic manipulation, acupuncture, heat, ice, all the things you mentioned are absolutely the way to start for a lot of people. And it can augment the other things that you're taking. For example, the NSAIDs for Tylenol.

Joey Wahler (Host): So if you've got that old ACE bandage still laying around in the drawer somewhere, don't throw it away, right, Doctor?

Dr. Fred Brennan: Don't throw it away. That's right.

Joey Wahler (Host): You never know. Well, folks, we trust you're now more familiar with the difference between your pain relievers, Dr. Fred Brennan, Jr., thanks so much again.

Dr. Fred Brennan: You're very welcome. Thanks again for having me on.

Joey Wahler (Host): And for more information or to reach a provider, please do visit BayCare.org. Again, that's B A Y C A R E.org. Please also remember to subscribe, rate and review this podcast and all the other BayCare podcast as well. For more health tips and updates, follow BayCare on your social channels. If you found this podcast helpful, please share it on your social media. And check out all their other podcasts too. And thanks for listening to BayCare HealthChat, a podcast from BayCare, hoping your health is good health. I'm Joey Wahler.