Pharmacotherapy/Nutraceuticals

In the specialty of headache and pain it is becoming increasingly important to have a wide variety of options when it comes to pharmaceuticals and nutraceuticals, especially when minimizing or discontinuing opioids. Sleep and mood are integral to pain and should all be treated in a cohesive fashion. Every patient is an individual with different therapeutic goals, sensitivities, genetics and metabolism.

All of this needs to be considered when choosing the right pharmaceuticals and nutraceuticals that can have a positive impact for function, pain relief and overall improved quality of life. Some, but not all, of the following pain therapies are used in practice and are intended to a be a resource for patient education.

 

Pharmacotherapy

Opioids

Not all opioids are created equal nor have the same safety profiles. There are many intricacies between the various opioids that are available and used medically. Opioids should be minimized and used as a last resort along with non-opioid analgesics in a multidisciplinary treatment plan. It takes experience when choosing the right opioids and understanding how to taper or reduce them effectively.

• Atypical opioids such as Buprenorphine (Buprenorphine TD, Butrans, Belbuca) and Tapentadol (Nucynta IR/ER) offer properties that set them apart from many of the other typical opioids such as Oxycodone, Hydrocodone, Fentanyl, Hydromorphone, Morphine and Methadone.
• There is a better medical and public understanding now about the harm, fatality and epidemic we are facing with opioids and their abuse. It takes significant experience in understanding medically how to minimize opioids and utilize opioids that may have advantages over other ones that should often never be used in chronic pain.
• Opioid induced hyperalgesia, central sensitization, glial activation, respiratory depression, hormone and immune suppression are all important concepts to understand and how they may differ among various opioids.
• Opioid minimizing and the use of Buprenorphine for pain: We individualize our approach to each patient that is on opioids for pain but strive to overall minimize opioids.  Buprenorphine when used for pain offers unique properties and certain advantages over other full agonist typical opioids such as hydrocodone, oxycodone, hydromorphone, fentanyl and morphine.  Full agonist opioids should be minimized or avoided if possible and this can often be accomplished using Buprenorphine.  Please review the articles on Buprenorphine in the recommended resources section for further information and education.

 

Other Pharmacotherapeutics and Non-Opioid Alternatives and Tools:

 

Anticonvulsants: Gabapentin, Pregabalin, Topiramate

• These help to reduce the excitation of the nervous system. They are commonly used in the headache and pain world. Depending on the individual it is important to understand the different forms they come in and which may offer the least side effects while providing the most benefit.

 

Neurotransmitter Support Medications

• There is better understanding now for the roles of serotonin, norepinephrine, dopamine, histamine, glutamate, enkephalins and substance P in the modulation of pain, mood, sleep and neuroendocrine functions. Selecting the right medication to support the system can often be a valuable part of a therapeutic approach.

 

NSAIDs

• When used judiciously and with caution in the right situations these anti-inflammatories can be important in headaches as abortives or for acute and chronic pain conditions. There are various forms, deliveries and products that if chosen carefully based on the individual needs of the patient can be very beneficial.

 

Muscle Relaxants

• Muscle relaxants can be part of a non-opioid treatment strategy and depending on the form can help with overactive agitated muscles and sleep augmentation.

 

Triptans

• Triptans such as sumatriptan, among many others, help to block or inhibit the release of chemical messengers that promote inflammation and pain. Triptans are often used carefully as an abortive or for acute migraine attacks.  Again, depending on the form, delivery and product of triptan, it is important to understand the individual patient needs in making the right choice and proper education on how to use them correctly.

 

Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists

• This is a new class of migraine specific medications that will be available as primarily a preventative for migraine. The role of CGRP in the development of migraine is fairly well understood and may prove to be a very beneficial target and pathway in controlling migraine.

 

Low Dose Naltrexone (LDN)

• Naltrexone works on blocking or inhibiting the opioid receptor.  In very low doses of naltrexone it appears to have a paradoxical effect with possible anti-inflammatory properties and stimulation of the immune system along with release of endorphins. Clinical data and research is still needed to better understand this off-label usage of naltrexone, but it has been demonstrated to reduce symptom severity in chronic pain conditions and autoimmune disorders.

 

Controversial Pain Treatments

• Ketamine:  Ketamine has been involved in clinical practice for over 40 years.  It has been recommended as an anesthetic especially for pediatrics, trauma and burn patients due to its ability to induce so called “dissociative anesthesia”. It is also being explored in the psychiatric field as well for treatment resistant depression. When administered in subanesthetic doses it acts as an analgesic and for this reason has been used for the treatment of acute and chronic pain conditions.Ketamine primarily acts as an antagonist of the NMDA receptor for glutamate, thought to be important in the propagation of chronic pain and neuropathic pain conditions. Ketamine is a schedule 3 controlled substance by the DEA.  Although Ketamine has numerous medical studies reporting its efficacy in anesthesia and analgesia, there is a lack of long term studies on safety and outcome. Ketamine should be used in a medical setting reserved as a last resort in specific conditions that demonstrate efficacy.  It should be part of a comprehensive pain management program and instructions of dose, route and frequency should be followed closely. We will hopefully have similar medications in the near future that work in the same pathways as Ketamine.

 

• Cannabis and Cannabinoids:  it appears that this topic and the use of it cannot be ignored despite one’s beliefs and understanding of it. Despite the World Health Organization recommending cannabidiol (CBD) should not be internationally scheduled as a controlled substance, the DEA continues to list cannabis as a schedule I, and federally it is illegal. The range of conditions for which CBD has been evaluated is diverse, consistent with its neuroprotective, antiepileptic, anxiolytic, antipsychotic, analgesic, anti-inflammatory, anti-asthmatic, and anti-tumor properties. It has also been studied in drug addiction.

 

Nutraceuticals and Medical Foods

Nutraceuticals, medical food products and supplements can often be important in providing support for anti-inflammation, cognition, muscle and nerve function, mood, hormone, digestive and immune function.  Nutraceuticals can often augment pharmacologic approaches or be used alone without pharmaceuticals.

• Medical foods as defined by the FDA are a unique category of regulated products that are prescribed under the supervision of a physician and are intended for specific nutritional management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.  
• Medical food products have research supporting the use in migraine, mood support, cardiovascular conditions, neuropathy and cognitive impairment.

 

This article is not intended to provide advice on personal medical matters or to substitute for consultation with a physician. The material in this article is for informational purposes only and is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider. The use of Low Dose Naltrexone, and other medications and topics in this article may be considered “off-label” uses by the FDA.