Features May 2003 Issue

When That Once-Wondrous Drug Works For You No More

The effects of pain-killing medications can wear off with time. Here's why, and what to do when your body builds resistance.

When arthritis becomes severe, and anti-inflammatory drugs no longer stop the pain, many people turn to stronger pain-killing medications, such as opiate-containing narcotics, for relief. But with narcotics, the more you use them, the less effective they become. To get the same effect, you have to increase the dose, a phenomenon known as tolerance. A specific receptor in the brain is “upregulated,” or activated, by opiates, explains Nagy Mekhail, M.D., chairman of the department of pain management at the Cleveland Clinic. “After a while,” says Dr. Mekhail, “the body adjusts and needs more of the drug to get the same effect.”

Take A Drug Holiday
One way to manage tolerance is to take a “drug holiday.” Stop using your current pain-killer—or use a different one—“to reset brain receptors to baseline,” says Dr. Mekhail. For example, if you’ve been taking morphine, your doctor might switch you to hydromorphone (Dilaudid) for a few weeks. When you go back on morphine, you will require a smaller dose to control your pain.

Avoid Break-Through Pain
At times, arthritis patients who are particularly active suffer more than usual pain. To avoid this so-called “break-through” pain, you may need a steady level of medication for 24 hours a day, with an additional dose of a short-acting pain-killer, such as Percocet, morphine, hydromorphone or Vicodin, to “fine tune” the pain relief. This concept usually involves, for example, a Fentanyl (Duragesic) patch worn on the arm and changed every three days. “Many patients,”says Dr. Mekhail, “prefer the Fentanyl patch over morphine pills because they get good pain relief and fewer side effects.”

Drug-Free Pain Relief
You can also alleviate pain without drugs. The TENS (transcutaneous electro-nerve stimulation) machine emits small pulses of electrical energy that cause your body to release its own, natural feel-good substances, called endorphins. The electrical impulses are fast-moving and travel quickly along nerve pathways to your brain, blocking slower-moving pain messages.

The TENS machine consists of a small box, about the size of an audio-cassette case. Leading out of the box are four wires connected to adhesive pads that are placed on your body. “Arthritis patients who use a TENS machine for one week,” says Dr. Mekhail, “will start to see its effect.”

Another pain-relief treatment is physical therapy, which uses heat, massage and hands-on manipulation to increase blood circulation. “This is very helpful for muscle pain, increasing flexibility and mobility of the muscles,” says Dr. Mekhail.

No ‘Wonder Drugs’
When it comes to pain relief, “there are no ‘wonder’ drugs,” says Dr. Mekhail. “You need to take medications according to a specific schedule, dosage and frequency.” Even seemingly benign pain-killing medications sold over the counter have side effects, including kidney or liver-function consequences. “Pain-killing medications should be taken according to a regimen—not just when you need them—to provide an adequate amount of analgesia all of the time,” Dr. Mekhail says.

Take More, Suffer Less?
If you've been on an arthritis medication that works pretty well, but you still have pain from time to time, is increasing the dosage the answer?

Sometimes you can increase the dosage of a medication, but “you always have to balance efficacy with side effects,” says Dr. Mekhail. His advice is to consult your doctor first, since “all arthritis medications carry a risk of side effects.”

When considering a long-term narcotics maintenance program, he suggests patients and their doctors sign a medication agreement which states that you are taking the medication for a specific reason and will not change the dosage or frequency without first consulting your doctor. “You need to come in every month to check for side effects and drug compliance, and get your next month's prescription,” says Dr. Mekhail. “This helps to identify patients who need these drugs most and are likely to get the best results.”