"Ask Dr. Cook" is a series of questions and answers regarding endometriosis. The current subject and answer can be found on Current Ask Dr. Cook web page. The questions may represent a summary of questions I have been asked by several different patients. I hope you find this information helpful. If you have a question you would like answered, please Submit A Question.

Adequate Pain Relief

Question:
My pain is so bad I can't stand it. I had a laparoscope for endometriosis and did feel better for a while, but the pain just keeps getting worse over time. I feel like I am begging my doctor for pain killers. It is humiliating, but I just don't want to hurt so much. I am also afraid of becoming addicted to the pain medicine. Until I can find a doctor that can get rid of the pain, is there any way of controlling this pain?

Answer: Part II
This is a continuation of our discussion from last week (Adequate Pain Relief; Part I). This week we are going to discuss the basic types of pain relievers. These include Nonsteroidal anti-inflammatory drugs (NSAIDS), Ultram and narcotics, both short acting and long acting (sustained release).

Non-Steroidal Anti-Inflammatory Drugs
Nonsteroidal anti-inflammatory drugs (NSAIDS) are a group of pain relievers that includes Motrin and Anaprox. This group of pain relievers acts by blocking prostaglandin production. Prostaglandins are a group of proteins that cause pain. When you burn your finger on the stove it is prostaglandins which causes the pain. Prostaglandins are released by the endometrium during the menstrual cycle. Some women on average release more prostaglandin during menstruation than other women. These higher levels of prostaglandins in women with severe dysmenorrhea (painful periods) results in increased uterine contractions, muscular spasm and ischemia. Ischemia is a condition where there is a lack of oxygen in an organ that results in pain. The pain associated with a heart attack is the most common example of ischemia. NSAIDS inhibits cyclooxygenase, the enzyme that converts arachidonic acid into prostaglandin. This group of pain relievers is not a narcotic and thus does not have the risk of physical or emotional addiction. The most common side effect is related to the GI track, with stomach ulcers the most frequent. I have found that the combination of NSAIDS and birth control pills is often effective in treating mild endometriosis symptoms. Starting Anaprox DS two days prior to the start of menstrual cramps usually helps reduce both the amount of bleeding and the amount of cramps. Patients taking the birth control pills using the cyclic method usually know within a day when their cramps will begin. Starting the Anaprox two days prior to the cramps allows adequate levels to build up in the blood stream. This is usually much more effective than trying to "catch up" with the pain. The normal dosage of Anaprox DS is one orally every 12 hours.

Current NSAIDS include:

Aleve	Anaprox Tablets	Anaprox DS Tablets
Cataflam	Motrin	Naprosyn Tablets
Ponstel	Relafen	Toradol

Ultram
Ultram is a pain reliever that is not a narcotic but acts very similar to a narcotic. It is considered a centrally acting synthetic analgesic, which is not structurally related to opiates. Centrally acting means that it works at the level of the brain or spinal cord. Synthetic by definition means that it is manufactured, not produced in nature. Analgesic is a medication that provides pain relief. How this pain reliever actually works is not completely understood. Ultram and narcotics bind with the same opiate receptors. Ultram also apparently inhibits the uptake of serotonin. Ultram has a potential for both physical and psychological dependency, although much lower than that of traditional narcotics. Use of Ultram is indicated for the treatment of moderate to moderately severe pain. In some situations Ultram will offer adequate pain relief when NSAIDS are not effective, but without the same addictive potential of narcotics. The normal dosage is Ultram 50 mg orally every 4 to 6 hours with no more than 400 mg over a 24-hour period.

Narcotics
Narcotics provide the greatest degree of pain relief but can have significant unwanted side effects including physical dependence. Narcotics are a group of opium based pain relievers. Narcotics act centrally, meaning that it acts directly on the brain and spinal cord. In addition to pain relief, narcotics can produce a wide variety of effects including dysphoria (an unpleasant feeling), euphoria, somnolence (tiredness, lethargy), respiratory depression (slow or stop breathing), diminished gastrointestinal motility (results in constipation), and dependence. Motor vehicles should not be operated when taking narcotics.

There are some physicians that question long term administration of narcotics for chronic pelvic pain. Some argue pain relief is not improved with narcotics. I think most people with severe chronic pain would have difficulty with this reasoning. A Pain Management specialist (a subspecialty of anesthesiology) is usually the most proficient at managing cases that require narcotics over a long period of time. Most OB/GYN’s do not understand how to provide long term pain relief with narcotics.

Under-treatment of chronic pain is a real problem in the United States. This applies to patients with endometriosis as well as other forms of chronic pain including those suffering from terminal diseases such as cancer. Pain management is poorly understood by many physicians. Some physicians will withhold appropriate use of narcotics from chronic pain patients for the fear of prescribing narcotics to a patient who is seeking narcotics for the euphoric high. Physicians can also loose their medical license if the DEA (Drug Enforcement Agency) feels that the physician is "over prescribing" narcotics. All these factors combine to result in a situation that many physicians would rather not deal with. If you are a patient who is experiencing severe pain and are not in a position to get your endometriosis treated, or if you are sure that you have had your endometriosis adequately treated and still have pain, then a good pain management physician is probably your best option. A good pain management physician should be able to find a combination of treatments that will make living with the pain manageable.

Narcotics include:

Darvocet-N 50	Darvocet-N 100
Darvon Compound	Demerol Tablets
Dilaudid Oral Liquid	Dilaudid Rectal Suppositories
Dilaudid Tablets	Duragesic
Fioricet with Codeine Capsules	Fiorinal with Codeine Capsules
Hydrocet Capsules	Levo-Dromoran Tablets
Lorcet 10/650	Lortab 2.5/500 Tablets
Lortab 5/500 Tablets	Lortab 7.5/500 Tablets
Lortab Elixir	MS Contin Tablets
Mepergan Tablets	Narco
Oxycontin	Percocet Tablets
Percodan Tablets	Roxanol
Roxacet	Roxicodone
Talwin	Tylenol with Codeine
Tylox	Vicodan Tablets
Vicodan ES Tablets	Wygestic Tablets

The obvious concern of physicians is that patients will "abuse" the narcotics and use them for their potential euphoric effect rather than for legitimate pain relief. I have found that patients are often concerned about the possibility of becoming "addicted" to the pain medications and will even underdose the pain medications themselves in an effort to avoid this possibility. Next week we will talk more about the use of both short acting and long acting narcotics along with proper usage to minimize side effects and maximize pain relief. We will also discuss the issue of tolerance, dependence and addiction. I would also like to provide some pointers to help your visit/experience with your pain management physician go well.

Updatede October 29, 2005