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 valtrex (valacyclovir), 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.
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Nancy Reyes is a retired physician living in the rural Philippines.
She writes medical essays at HeyDoc Xanga Blog.
5 users commented in " Shingles Pain: Back to using narcotics? "
Follow-up comment rss or Leave a TrackbackTo be effective usage of the Rx oral med, Valtrex (Rx oral med) must begin during the initial 48 hours of onset. Tramadol proved to be helpful in controlling the neuralgia but I was fortunate to have located information on using the Lidocaine patch in controlling surface pain. I found the information on Lidocaine through surfing the web. To those who have not experienced the pain of shingles, it is quite different from any other type pain I had ever felt. It is an extremely deep pain, i.e. not entirely an external pain amenable to topical solutions. As in my particular case, relatively mild, the PHN lasted for several months after visible signs had disappeared. *Dr. Reyes – Does the shingles vaccine protect one from ever getting shingles? If it does, then anyone susceptible to contracting shingles should certainly receive the shot.
the chicken pox vaccine does lower the rate of shingles, and those who do get shingles get a milder case with a lot less post herpetic neuralgia.
Lidocaine patches work for some people, but a lot of people become allergic, and they are very expensive.
Tramadol is an excellent alternative to narcotics and I’ve prescribed it many times. It is similar to narcotics, but less addictive.
Hello, do you have personal experience with this?. This article was extremely interesting, especially since I was searching for thoughts on this subject last Thursday.
Thanks to Nancy for helping to get the word out that the “grit your teeth and bare it” method of enduring shingles pain greatly increases the risk of post herpetic neuralgia. PHN so often follows shingles because the intense, prolonged pain of shingles overstimulates the pain-processing mechanism at the dorsal nerve root. The nerve’s interpretation of pain is affected, so that even minor stimulus to the nerve, such as the touch of clothing or a slight breeze, is interpreted as severe pain. In my work as a shingles pain consultant, I talk daily with people who suffer with shingles and with PHN. Those with PHN would do anything to be able to go back and take dramatic measures to prevent and treat their shingles pain. I urgently recommend getting the vaccine to try to prevent shingles, even though it is only about 50% effective. If you do get shingles, definitely take oral anti-viral meds if your doctor will prescribe them. Definitely use a topical shingles treatment (there is one that reduces pain and speeds healing for 79% of users), and definitely take pain medicine if needed in addition to all these.
I BROKE OUT WITH A SEVERE CASE OF SHINHLES NOV 14 2009 I STILL BEAK OUT EVERY FEW WEEKS TO MONTHS MY WHOLE LEFT SIDE BACK AND BREAT WERE COVERED WITH BLISTERS I HAVE BEEN ON EVERY THING YOU MENTIONED PLUS LIRICA AND NUROTIN THE PAIN WAS SO BAD I THOUGHT OF SUISIDE I WOULD SCREEM AND BITE THE PILLOW OTHER MEDICALS PROBLEMS HAVE POPED UP AND I HAVE NOT FELT GOOD FOR OVER 14 MONTHS I NOW HAVE BEEN ON TRAMADOL AND IT TAKES THE EDGE OFF I DO NOT ALLOW MORE THAN3 PILLS A DAY I JUST SUFFER I HAVE LOST OVER 25 LB I BEG PEOPLE TO GET THE VACINE
ICALLED FDA AND CDA NEITHER COULD GIVE ME A POSITVE RESPONSE IAM NOW TAKINGA POSITIVE SAVELLA WITH THE TRAMADOL DONT LIKE SIDE AFFECTS
PLEASE CANE SOMEONE HELP DR REALLY NO VERY LITTLE ABOUT THIS HORRIFIC ILLNESS
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