Ask a Pharmacist Anything: September 24, 2018

  • Great! Going back to your discussion around cannabis for pain, here's a question we received in advance: I use medical cannabis to help manage my pain and I don’t feel comfortable talking to my pharmacist about it. Do I need to? Are there possible interactions it could have with some prescribed medications?

  • @Forum_Moderator
    Over the counter medications that can be helpful in alleviating pain include acetaminophen (Tylenol, Tylenol Arthritis & other generic brands), ibuprofen (Motrin & generics), naproxen (Aleve & generics). Acetaminophen is safe in recommended doses – no more than 4000 mg a day for adults; no more than 3000 mg a day for those over 65 years old; and no more than 2000 mg a day for people with serious liver disease. Ibuprofen and naproxen (which are NSAIDs) should not be used by anyone with heart failure, kidney disease, or a history of stomach or intestinal ulcers, and should only be taken infrequently by anyone with high blood pressure.
    There are also products that can be applied to the skin, and can be helpful for specific painful areas, such as diclofenac gel (Voltaren), menthol and wintergreen creams and ointments (e.g. Rub A-535) and capsaicin creams. These cannot be applied to areas of broken skin, or to large areas of skin, and can be irritating. A pharmacist can help you select the best product for your situation

  • Can a pharmacist advise me on supplements for pain?

  • @Forum_Moderator
    The most common non-opioid medications that can be helpful in managing chronic pain include acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs) like celecoxib (Celebrex and generics) and many other prescription drugs in this category, and over the counter ibuprofen and naproxen (Motrin, Aleve, and generics). Some patients may benefit from adding antidepressants such as amitriptyline or venlafaxine; others may find adding gabapentin or pregabalin is helpful for nerve pain. There are others that are generally only used if none of the above are helpful or have caused intolerable side effects. Medical cannabis (marijuana), as we just mentioned, also fits in this category, and is helpful for chronic pain in some patients. We are learning much more about cannabis with new research.

  • Terri, are there any alternative medications to opioids, whether prescription or over the counter medications, that can be helpful for some people with chronic pain?

  • @Fred8
    This is a difficult situation, for sure. Some of the newer opioids that have other actions than the usual opioid effects might be more helpful, but this is hard to predict. The ones I have in mind here are tramadol and tapentadol, that have some minor effects that are similar to some of the antidepressants. Having said that, for some people the side effects may be worse, or just as bad, but different - in other words not any better.
    It has certainly become more common, especially in the last year or so, for people in pain who don't tolerate opioids very well to look into medical marijuana as an option. It can be a challenge to find physicians who are comfortable with recommending and authorizing it, and experienced in prescribing it so they can advise you on how to choose products and what doses to start with. But, if trying new opioids has not been helpful, this may be worth considering if you can get access to good medical advice.

  • How long should I keep trying different opioids? It's hard to know whether I just have to put up with the side effects or if there's another, better opioid I could be using?

  • @Clearwater

    1. Opioids are mostly quite similar in their overall effects. However, in practical terms, some individuals find they tolerate some medications in this group much better than others! This probably reflects differences between people in how these medications are cleared out of the body and how quickly, whether they are broken down by the liver, filtered out by the kidneys, etc. For example, some people have no pain relief from codeine, because they do not break it down to its active form, morphine. Others have a very rapid peak effect from codeine because they are very efficient at breaking it down; others are in the middle somewhere! Elderly people generally have less capacity to break down and clear drugs from the body, and often have more trouble with side effects as a result.
      There are newer opioids available which have some unique effects, and may be more helpful for pain and better tolerated by some. Others may have more side effects because of these differences. Choosing the right medication from any group of drugs, including opioids, may be a process of trial and error.

  • Are there any opioid medications with fewer side effects?

  • @Forum_Moderator

    1. The most common side effects of opioids include:
      a. Constipation – those who take opioids on a daily basis should always be taking an effective laxative regularly; your pharmacist can provide advice
      b. Sedation – feeling sleepy and having difficulty concentrating, which may interfere with daily activities. If you notice these effects, wait until they pass before attempting anything that requires awareness and concentration e.g. driving.
      c. Nausea (sometimes with vomiting) – may be worse when opioids are first started, and may improve with time. Higher doses, and short acting opioids (those that must be taken every 3-4 hours) may also make this problem worse. Sticking with the minimal effective dose, and perhaps switching to long-acting (every 12 hour) products may help.
      d. Sweating – try to avoid overheating, e.g. dress in layers. Sweating may also be due to poorly controlled pain, so can be difficult to sort out, unfortunately
      e. Withdrawal effects if dose is reduced too quickly
      f. Mood changes, hallucinations can occur but are less common

  • Great, thanks for answering the first 2 questions Terri. Another question we received in advance asks if you can go over some of the common side effects of opioid medications.

  • @Clearwater

    1. Finding a good pharmacist is a very worthwhile goal, for all the reasons just described in the response to the first question! It can be helpful to ask friends and relatives who have health care needs, and attitudes toward their health care, that are similar in some ways to your own. If they are happy with their pharmacist(s), they will be willing to recommend them to you.
      Also consider any personal preferences, e.g. if you are more comfortable talking with a pharmacist who is of the same gender or in your own age group.
      Many people have used this approach successfully to locate a good family doctor, and it applies just as well to pharmacists. The advantage you have with pharmacists is that they are always able to take on new patients, and a good one will always find a time to talk with you later if they are very busy when you are at the pharmacy.

  • How do I find a good pharmacist?

  • @Forum_Moderator

    1. Pharmacists can help their clients with pain in several ways.
      a. When dispensing a new medication, they can ensure that you understand how to use it properly e.g. prescribed dose and best time(s) to take it, any special instructions for different dosing forms, most common side effects and how to manage, etc.
      b. The pharmacist can also help by giving advice on non-prescription medications that may be helpful and safe for you to use in combination with your prescription medications.
      c. If you develop problems that concern you, that you think may be medication related, the pharmacist can help you with advice, either something that can easily be adjusted or suggestions on how to discuss a possible change in medication with your doctor.
      d. Pharmacists can also do medication reviews, a sit-down session with you to review all your medications, any problems you may be having with them and how much benefit you feel you are getting from them. The pharmacist can then make recommendations directly to your doctor, or advise you about questions you can ask on your next visit.

  • @Forum_Moderator
    Hello, everyone, I'm happy to be here and ready to do my best at answering your questions about medications, pharmacies and pharmacists.

  • Welcome Terri! We're very thrilled to have you on today's Ask the Expert live forum discussion. Let's get started. Here's a question that was submitted to us in advance: besides dispensing medications, what can a pharmacist do for a person in pain?

  • Good morning and hello to everyone joining us on today's Ask the Expert series, where you'll be able to live chat with clinical pharmacist Terri Betts regarding your pain-related questions. We will be getting started in approximately 15 minutes.

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