Shingles Pain: Back to using narcotics?

Shingles is when the long latent chickenpox virus sitting around in a nerve root decides to break out again.

Often we see these people for “pain”, and can’t find much on the examination, until two days later they complain of a rash. Then, lo and behold, you see the flat red rash with tiny waterblisters. The clue is that the rash tends to be on one side of the body, and follows the map of a single nerve root–usually a “band” around the trunk, but it can also be on the face or in the genital region. PHOTOLINK

No one knows why the virus decides to break out, but in some cases a lowering of immunity is suspected: often we see it in pregnant women, or in people who have various myelodysplastic syndromes (we used to call some of these “pre leukemia” but a lot of them go on for years and never get leukemia, so they changed the name).

But it is most common in the elderly.

Shingles is also called “Herpes Zoster” (not related to Herpes the sexually transmitted disease–there are dozens of Herpes viruses). Usually the disease is not “serious” (unless it involves the eye), but it is painful…or should I say PAINFUL. The Wikipedia page describes it as “..stinging, tingling, aching, numbing or throbbing, and can be interspersed with quick stabs of agonizing pain.”

The main treatment in the good old days for the acute pain of shingles was painkillers, usually with codeine, and high dose prednisone .

More recently, anti viral medicines are being used to shorten the course of illness, along with newer medicines such as gabapentin type medicines and anti depressants. Analgesic patches are used, but the high rate of allergy to these have made them less popular than we had hoped.

The acute stage of Shingles only lasts a few days or a few weeks, but despite the pain a lot of our older patients refuse to take pain medicine: some for fear of “addiction” and others because they grew up in a “Stiff upper lip” culture where pain medicine isn’t used.

The problem? Post Herpetic Neuralgia. The more pain you have in the “acute” phase, the higher the chance you will continue to have a painful, sensitive area after the rash disappears.

So how is best to treat the “acute” phase of shingles?

Well, a recent study comparing all these medicines showed that narcotics are best. The narcotic they used was Oxycodone.(in many medicines, including Oxycontin) Often patients with mild cases take Tylenol/acetaminophen/paracetamol or Ibuprofen/Advil/Motrin, but they don’t give sufficient pain relief.

“Oftentimes patients are told that the rash will heal in two or three weeks anyway, and the pain will go away, so they’re not given something for the pain unless it’s excruciating,” said Robert Dworkin, Ph.D., the University of Rochester Medical Center pain expert who led the study. “But moderate pain can stop people from working, or enjoying their hobbies, and it can also make some people depressed or anxious. So there’s good reason to treat all pain from the infection.”

Similarly, Gabapentin (which is very valuable in post herpetic neuralgia pain) has to be slowly increased to limit the sleepiness side effects, so you just can’t use a high enough dosage in the acute stage.

So if you get a case of shingles, go to your health care provider to get a course of anti viral medicine.

And don’t have a stiff upper lip: Take enough pain killer to feel comfortable, even if it means taking narcotics.

But the sedative and severe constipation side effects of narcotics limit their use in many older patients, especially constipation side effects when used for a longer period of time.

So if you are the small percentage (up to 30%) that do develop the Post Herpetic Neuralgia syndrome, your doctor will probably treat you with old fashioned tri cyclic antidepressants and Gabapentin or a similar seizure medicine. Both of these work for nerve pain, and are non addicting. Sometimes we just have to use narcotics for this type of pain too, but it’s more controversial: most of my patients thought the Gabapentin worked better, but sometimes needed a narcotic analgesic to supplement the other medicines, especially at night.

If you do not get enough pain relief to function normally, or if the medicines make you sleepy, ask for a referral to a pain specialist.

But in the acute phase, if you need narcotics, you probably should use them to prevent this complication.

Most people wait until they can’t stand the pain, and then end up taking a higher dose to get relief. Wrong. The trick is to figure out a dose that works but doesn’t make you sleepy or confused, and then figure out how long that dose lasts, and then take the next dose shortly before the pain would usually return. Pain specialists usually figure out the dosage for their chronic pain patients, and switch to long acting narcotics, but for acute shingles pain, usually we stick with the short acting medicines, which usually are a mixture of tylenol or advil with a weaker medicine like codiene or low dose oxycodone.

And now for the good news: Some studies suggest that if you give a shot of Chickenpox vaccine to older people, you see fewer cases of Shingles, and the cases you see are less severe, with fewer problems. Not a cure-all, but with the increase in the aging population, a vaccination that might become routine in the near future.

Finally, please don’t use this essay as a way to treat yourself. See your physician. Often certain medicines interfere with the other medicines you take, and of course, even common medicines (including herbal medicines) can result in problems.

Nancy Reyes is a retired physician living in the rural Philippines.

She writes medical essays at HeyDoc Xanga Blog.

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