Pain Medication Advice Please

[Charlock]

Hi, I've been suffering from some combination of tennis/golfer's elbow in both arms for a year, and more recently should impingement and I think cubital tunnel syndrome. I've tried various physio exercises via my practice physio, steroid injection (ineffective). I just went back to the doctor again because I don't have decent pain relief as both co-codamol 30/500 and ibuprofen give me a sore stomach and I find paracetamol alone pretty ineffective and I'm getting pretty worn down with it all as it's uncomfortable through the night and affects my sleep. I've also tried ketoprofen gel, not effective. She's referring me for xrays and doing bloods again to rule out inflammatory stuff (done in October, all normal). I was hoping she might prescribe me a different NSAID perhaps with a PPI to protect my stomach but she said that's a no-go because the ibuprofen gave me a sore stomach. So she prescribed me co-codamol 8/500 to see if I could tolerate the lower dose better. Well, I thought I was but on my 3rd dose and my stomach is doing what it did on the higher dose. She said I could try dihydrocodeine next as this can be better tolerated. And then it's tramadol.

I'm confused as to why it's only opiates I'm being offered, esp as you can only take them for short periods and this pain has been bad for a year and showing no signs of let up. Does anyone have any suggestions on what I could try? Can I do anything to help me tolerate these things? I'm 48yo F and on Sertraline 50mg and HRT. Thanks for any input!

I had a customer who had literally tried everything for pain and then started taking curcumin with bioperine in it and swore by it. They had been in and out of hospital for pain

Ok does moving your head up/down/left/right/ear to shoulder either side bring your arm pain on at all? If it does ask gp/physio for nerve conduction studies and or neck mri. having tendon based elbow pain on both sides is unusual (but possible of course).

The gold standard for exercise is eccentric loading (hand over the table holding a weight, and gently lowering it against the weight). I imagine physio will have tried this with you. If that’s not helpful then shockwave therapy can help the tendons to repair.

the other avenue is considering why the tendon is not settling. There are tendon changes with perimenopause-could this be a factor? Any other tendon pains?

Ohhhh I know all of this. I'm bombarded with it constantly in menopause land, just adds to my sense of failure and frustration. I have really tried with physio when I attempted it, but found it so disheartening to find things the same/worse after a month, and the implication from physio is that it should resolve it or at least start to see benefits after a few weeks. I think if I'd had better pain management I'd have been more inclined to stick with it. Having read a bit more about it physio can be retraumatising if it's done every day without rest/recovery days which no physio has ever advised. Maybe I should do one day on one day off.

@Charlock Scotland definitely has pain clinics.

Is this a herbal supplement?

If you’re menopausal are you on HRT. My boss reckons it cured her aches and pains and I do contemplate trying it again. Took it for two weeks and put on 7lbs so am reluctant to try it again.

I have chronic pain and have done a bit of research into acupuncture. It seems Stamford university has done research and are of the view that acupuncture is a good treatment for pain. They think it uses neuro pathways. Their research is trying to understand how. They also said if done badly acupuncture can worsen pain.

I have had acupuncture before on NHS and by a physio and I think it does work. I am a bit reluctant at the moment to do it as I think it's important to find someone who knows what they are doing and I haven't yet. The previous physio is no longer in my area. My GP is in agreement but can't suggest a practitioner.

Acupuncture is available on NHS in some places https://www.nhs.uk/conditions/acupuncture/

I take a turmeric and black pepper supplement already which I think is the sake thing?

Yes, I've tried the eccentric exercises but perhaps I needed to do them for longer. They did not help in the month or so episodes I've given then a proper go. I am perimenopausal and have been on HRT for nearly 3 years. I'm on Evorel 225, Utro 100, Testogel 1/8 and Mirena. But I wonder if just the background process beyond the symptoms relief of HRT still impacts healing ability. And maybe just being older. I'm healthy otherwise.

Hypermobility will make a difference for sure. I have some resources if helpful:

1. Jeanie Di Bon- she has EDS but more than that she is great at explaining how to look after your joints and move well with hypermobility. She has a section specifically for elbows here

2. when trying the eccentric loading, the choice is weight is really important, too much and will flare, too little and it won’t make a change. A part filled water bottle is really handy to adjust the weight as you can easily add/remove the water. I usually recommend 12 x 3 with at least two minute rest inbetween sets. Adjust the weight so it’s sore (no more than 4-5/10) by the 10-12th rep. Any additional discomfort should settle within the hour. If the pain is worse that evening and night after the exercises the weight is too high and needs reducing. This is every other day max, maybe everything third day initially. .

3. for 1 month, try to decrease as many overloading factors as possible. Anything that brings your pain above a 7 (on a scale out of 10) try to find another way of doing the task if st all possible. I know this will be tricky with both arms impacted, but if the tendon is constantly overwhelmed it can’t heal.

4. if work aggravates the pain talk to occupational health. If desk based check your workstation set up. If gripping activities as needed get these risk assessed with your line manager.

It just seems to work better in some conditions (kidney stones being the obvious). All csections get a dose on finishing

Diclofenac is a stronger nsaid than the equivalent dose of ibuprofen so will have more anti-inflammatory effect

Some nsaids work on some people and not others though, I find diclofenac does nothing but ibuprofen and naproxen both work well (latter is prescription only).

We give it in paeds anaesthetics as know they've got the full dose and not spat some of it and if it's given at the start of the op it'll be at peak hit for wake-up. Similarly better absorption in someone that's vomiting from whatever is wrong with them

Are you regularly committing to the gel? So many people just try once or twice and stop bothering

Codeine causes constipation and sometimes nausea but not the pain u get with ibuprofen

All nsaids should be eaten with a decent meal to protect the stomach. I give ppis to anyone over 60

Ask for a pain referral but it's many months to get to us in clinic. Stick with the physio the benefits are longer term even if u don't think are getting immediate benefit

Could you take omeprazole for your stomach alongside dihydrocodeine and paracetamol?
Do you use ibuprofen gel?

You will need a PPI (e.g. lansoprazole) with any longer term NSAID you take, including ibuprofen, because you also take sertraline. Sertraline raises the risk of gastric bleeding on it’s own, but with an NSAID in the mix even more so.

as a physio ( also in the throws of perimenopausal exacerbated pain issues!) it’s a shame your physio hasn’t been able to support you in introducing what you need to do in a slow way without exacerbating your pain. There’s a real balance that’s needed when you have significant pain …I echo other comments about perhaps needing to get to the bottom of why you are getting bilateral pain. Sometimes it’s worth changing practitioner to someone who perhaps specialises in people more like you. I also highly recommend acupuncture to try and get on top of the pain relief…. but it’s also very good when they may be something more systemic/ multi-joint going on.

This is great advice @DottyMilkshake and sounds much more nuanced than the physio I was given. I was handed a print out and ushered out of the door. I'm good a sticking to plan if I understand it and feel it's working. I'll watch that you tuber you linked to as well. Thanks for taking the time to reply, I appreciate it.

Thanks, this is all really helpful to know.

So I tried the gel for a couple of week although I probably didn't always use it twice daily as directed. It sounds like from what you're saying the effect can build with regular, proper use? I'm wondering if my stomach isn't tolerating painkillers as well as I used to because I'm on 50mg Sertraline. I will retry the physio but with some modifications as suggested by DottyMilkshake. I'm getting bloods taken and xrays so I will mention pain clinic when I go to follow up on results of these. Thanks again, really helpful information.

I have ketoprofen gel which I didn't find very helpful but will try again with it. The GP was very steer clear of NSAIDS because I'd had a side stomach with ibuprofen and didn't think addition of PPI was a good idea either.

Thanks, wondering if the Sertraline is contributing to my stomach issues with both ibuprofen and cocodamol.

Thanks and sorry you're struggling with peri pain. I have had this too but now that things have quietened on the cyclical front with my HRT thankfully this has gone for the most part. I agree, a slightly more nuanced support would be better but this physio at my practice seems quite patch and despatch, obv under the pressure everyone in the NHS is under I guess. I think there is only her at my practice so no other option than to pay which I want to avoid (already had a few private appointments and spent £2K on private meno care a couple of years ago and I'm unable/unwilling to keep paying for care which should be available on NHS). I'm reluctant with acupuncture too because the evidence around it isn't strong (unless I'm wrong about this?) and it's more money. Thanks, I hope you can access HRT and it helps with your own pain.

Yes, on HRT. Good regime that works well for me. It toom 8 months for it to work so I'd say stick with it if you can.

If I could get it via NHS I would certainly try it. Thanks for this.

I've been reading some of your updates OP,
I was the one who recommended the pain clinic.
I see you are suffering from nerve pain.
I have complex nerve issues.
I have ulnar nerve entrapment and also a brachial plexus injury and severe ICU related peripheral neuropathy and I'm only 31. They also had to take major nerves out of my leg when I had necrotising faschitis. I was diagnosed via physiotherapy and nerve conduction studies so it's with pushing for that as well.
I'm on a buponorphrine patch (20mcg) and amitriptyline at night and paracetamol PRN.
I've been on gabepentin, pregablin, duloxetine. I also must note, even with the strongest pain killers it won't rid chronic pain completely - I accept my pain is on the upper spectrum but nerve pain is complex and awful to live with so don't accept shoddy care.