CEO Industry Perspective: Understanding Over-the-Counter (OTC) and Therapeutic Pain Management Treatments

August 28, 2018

By: Shital Mars, Chief Executive Officer of Progressive CareWe now fully comprehend the negative impact that opioids can have, both on an individual’s health and our society. However, we are only now beginning to realize that, in many cases, opioids are not even the most effective treatment for pain. As a society, we depend on painkillers to treat pain, but very few people truly understand how they work, what they are effective at treating, the involved risks, and what’s inside of what we are taking.For instance, a study published in the Journal of the American Medical Association showed that taking 400mg of ibuprofen and 1000 mg of acetaminophen (Tylenol) produced the same levels of pain relief as taking opioids with 300mg of acetaminophen.1In previous posts, we have discussed many of the prescription medications used to treat pain, but there are numerous therapies that do not require a physician prescription and can be effective at treating minor to moderate pain for acute and chronic conditions. Even some acute severe pains can be effectively managed with non-prescription grade pain therapies. Below we will discuss some of these treatments to provide a more thorough and nuanced menu of options for patients and healthcare providers looking for effective solutions.OTC Oral Pain Relievers

  • Aspirin – Non-steroidal anti-inflammatory (NSAID). Aspirin is best at treating most common pain inducing ailments including headaches, tooth aches, muscle and joint pain. Do not use if you have a risk of bleeding or for children with a viral illness.
  • Ibuprofen – NSAID. Brand Name: Advil. Ibuprofen is best at treating arthritic pains, menstrual cramps, headaches, migraines, and body aches.
  • Naproxen – NSAID. Brand Name: Aleve. Naproxen is best at treating muscle soreness, menstrual cramps, aches and pains that are the result of activity. Side Effects: prolonged use of NSAIDs can cause stomach irritation, bleeding, and kidney and liver problems.
  • Acetaminophen – Brand Name: Tylenol. Acetaminophen does not treat inflammation. It is best used by patients who have bleeding problems, stomach problems and/or do not tolerate NSAIDs. Common uses are headaches, tooth aches, and minor aches and pains associated with the cold or flu, or as a supplement to an NSAID.

All common oral pain relievers have harmful gastrointestinal effects, especially on the liver and kidneys after prolonged use. NSAIDS can cause stomach and intestinal ulcers. Patients should not use OTC pain relievers more than the recommended doses and should consult a doctor when taking these medications routinely throughout the day for pain management for more than seven days, as extended use can have harmful long-term side effects. OTC pain relievers are not interchangeable. Each has specified efficacies and risks. If you are unsure which medication to use, consult a pharmacist or your doctor.Topical Anesthetics

  • Benzocaine, Lidocaine, Tetracaine – Anesthetic (numbing agent). Low strengths of these medications are available over the counter for the treatment of minor musculoskeletal pain, pain associated with skin irritation, such as rash, sunburn, and nerve pain.

Topical anesthetics should only be used for localized pain where the affected area is clearly discernable. Do not mix anesthetics and do not apply more than the recommended doses. Patients with cardiac problems and/or allergies to anesthesia should avoid topical numbing agents. Only apply to clean, dry skin for optimal absorption.Marijuana and Cannabidiol (CBD) Oil**NOTE: Marijuana is illegal at the federal level and in many states. Before considering marijuana for pain treatment, refer to your state’s cannabis laws and a physician with experience in prescribing cannabis for pain management. More clinical studies are necessary to ascertain the therapeutic effects of cannabis and CBD oil.Marijuana and CBD are two different substances. Marijuana contains up to 30% of a psychoactive compound known as Tetrahydrocannabinol, or THC. Although marijuana is still illegal on the federal level and in 19 states, 31 states have approved marijuana for medicinal purposes. Of these 31 states, 22 have legalized or decriminalized marijuana for recreational use. In states where marijuana is legal for medical use, a prescription is required to purchase the product at a licensed dispensary. Medical marijuana products are not available over-the-counter at traditional retail facilities or pharmacies. However, if you live in a state where adult use is legal, you can simply register at the door and make purchases without a doctor’s prescription.Marijuana – Common pain uses include neuropathic pain such as diabetic neuropathy, fibromyalgia, shingles, Multiple Sclerosis, herniated discs, spinal arthritis, etc. Cannabis acts on neuro receptors to alleviate nerve pain, as well as provide relief from pain caused by inflammation.CBD products are derived from hemp, a cannabis family plant, containing contain less than 0.3% THC. Its legality can be murky depending on the state and federal agency. Hemp-derived CBD and marijuana-derived CBD are treated differently, and their legal status can differ. You should consult your physician before using CBD for pain management.CBD – Common pain uses include arthritis, Multiple Sclerosis, and muscle and joint pain. CBD does not contain enough psychoactive compounds to produce a “high” like effect and has a low risk tolerance buildup. Its anti-inflammatory properties have shown some clinical effectiveness for the treatment of localized pain. More studies are necessary to conclusively determine therapeutic uses and standardized dosing recommendations.When using any medicine to treat pain we must understand the difference between strength and effectiveness. When looking for a pain reliever, many of us seek out the “strongest” when we really should be looking for the most effective. When we think about pain relief in terms of strength, we leave ourselves at risk of abusing or misusing a medication that simply isn’t effective at treating the pain we feel. If you feel like you need to take a medication beyond its recommended dosage instructions to increase potency, it may not mean that the medication is “weak,” but simply that the medication you’re taking is not the right medication for your pain. Before you increase your doses or use a medication more frequently than what has been recommended, consult a pharmacist or physician about whether an alternative solution would work better. If you are taking an over-the-counter medication for longer than a week, you may need an evaluation to determine the root cause of your pain, whether you are taking the right medications, and to monitor any side effects that may come as result of extended use.Therapeutic Pain TreatmentsFor many patients, medicinal therapies may not be right choice or even an option. For those with certain injuries, pain that flares due to stress or anxiety, intolerance to oral pain medication, or even just for people who hate taking medication, non-medicinal pain treatments can be beneficial.

  • Physical Therapy – This treatment is commonly recommended after major surgeries and injuries, or for people with certain conditions or disabilities. Some patients experience increased pain because of physical therapy. For instance, many patients that have knee injuries will avoid physical therapy because of the pain associated with moving the knee. However, proper joint movement is critical to prevent joint damage or a persistent limp due to atrophy. The key is to be honest about your pain level and tolerance with your physical therapist. In certain cases, some pain may need to be tolerated to allow for the full recovery of the injured area of the body. If your pain persists or gets worse, communicate with your doctor about altering your treatment and recovery plan.
  • Massage - According to Harvard Medical School: “Therapeutic massage may relieve pain by way of several mechanisms, including relaxing painful muscles, tendons, and joints; relieving stress and anxiety; and possibly helping to "close the pain gate" by stimulating competing nerve fibers and impeding pain messages to and from the brain.”Massage is a great addition to a pain management routine and in some cases is effective at relieving muscle pain by itself. Massage has been shown to be effective at treating chronic neck and back pain, muscle cramps, stress, anxiety, joint stiffness and tension in the extremities (hands and feet). Keep in mind levels of pressure for optimal relief.
  • Acupuncture – Arguably, the most controversial on this list. There are no definitive studies on the benefits of acupuncture or the mechanisms that would yield therapeutic results. Yet, for 3,000 years this treatment has been practiced in eastern cultures and to them is accepted science. Most doctors generally agree that acupuncture is better than no acupuncture when treating pain, but it’s unclear whether this is due to a placebo effect or not. What complicates matters is that most insurance plans do not cover acupuncture and the cost per treatment can range from $65 - $125.(Note: I have personally tried acupuncture to treat my stress-induced chronic neck and back pain and found it to be effective. Whether it’s the calm environment, the trusted practitioner, or the needles themselves that worked, I could not tell you. But for me, it was better at alleviating the tension buildup in my body with longer-lasting effects than massage or exercise. Since my pain is stress-related, I preferred not to take a medicinal approach.)
  • Exercise/ Stretching – For many people, a major cause of pain is muscle stiffness or weakness. Pain can be caused by a hard day at work, spending time with our kids, sleeping in an awkward position, and just living life. Exercise has a multitude of positive effects on the body if you can get past the muscle soreness. Physical activity helps to release endorphins, improves organ function (especially the heart and lungs), oxygenates and builds muscle mass, and relieves stress and tension.By strengthening the body, we are less likely to feel pain from daily movements and less likely to injure ourselves from overexertion. For stiffness and general achiness, stretching is a great way to keep our bodies and muscles limber and relaxed. It is important to know your body and your limits; don’t push yourself to the point where you risk serious injury. If you’re concerned about a certain exercise’s effect on your physical condition, discuss with your doctor if it is the best approach for you to take.
  • Diet and Nutrition – We all know that a healthy diet is one of the keys to healthy life. While most of us primarily focus on food’s impact on our waistline, the truth is that many foods can cause us pain. Food can cause inflammation in the body that leads to joint pain, stomach or abdominal pain, headaches, or even neuropathy. The foods we are told to avoid because of their caloric content, processed nature, or fattiness are often the primary drivers of diet-related pain. For instance, many people do not realize that dairy causes inflammation and constipation. If you have even a mild lactose intolerance, dairy can cause a great deal of pain and discomfort. We don’t have to give up all the foods we love, we just need to understand how they affect us and make sure we moderate our intake accordingly. Sugar, processed meats, and vegetable oils all have inflammatory properties, so watching our diet may also help in alleviating our pain.
  • Water – The standard recommended daily water intake is 64 -100 ounces, however, how much an individual should drink varies depending on his/her weight, gender, activity level, and thirst level. The average person drinks about 20 ounces of water a day, far below the standard recommendation.Dehydration causes pain and makes existing aches and pains worse. Dehydration causes headaches, muscle cramps, joint pain and stiffness, skin irritation, pain in the urinary tract, and a host of other problems that may not produce typical pain symptoms. When we feel pain, most of us don’t think to turn to water for alleviation, but that is precisely what should be done. Drinking an appropriate amount of water can help soothe chapped lips, dry skin, migraines, muscle soreness, joint stiffness, menstrual cramps, and even help mitigate pain produced from urinary tract infections, as well as speed up recovery time. Proper hydration also acts as a preventative measure to improve digestive tract function, joint lubrication, brain function, skin health, and muscle responsiveness. So, no matter what pain you suffer from, the first thing you should be looking for is a big glass of water.

The TakeawayPain can come in many forms and there’s not a one-size-fits-all medication for pain relief. There are a variety of treatment options for different types of pain, including OTC oral medications, topical anesthetics, cannabis, therapeutic treatments, and even water! Rarely are opioids the solution and should only be taken when necessary and prescribed by a doctor. If you are using a pain treatment that isn’t working, consult with a doctor or your local pharmacist to find a better option. I hope you were able to take something away from this and learn more about the many options to relieve pain. Thank you for reading!1. Journal of the American Medical Association, “Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department” – November 7, 2017

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