Pain Management

Oral Analgesics

There are three main classes of oral analgesic. These are NSAIDs, Acetaminophen, and Opioid Analgesics.

NSAIDs drugs such as Ibuprofen and Naproxen  function by inhibiting an enzyme needed to produce inflammatory messengers. NSAIDs generally aren’t used for a week prior to a procedure as they increase the risk of bleeding although the benefit of this precaution is debatable in something as minor as placement of a magnet. NSAIDs do little to control pain during a procedure; however, they do play an important role after a procedure due to their anti-inflammatory properties. This role will be discussed further in aftercare. NSAIDs are generally safe if taken according to the label.

Acetaminophen functions through enzyme inhibition as well as by modulating the endocannabinoid system. Although it lacks the anti-inflammatory properties of NSAIDs, Acetaminophen is generally superior for acute pain. It can be taken before and during procedures without any effect on bleeding. Attention should be paid as to dose and frequency as large amounts of acetaminophen are toxic to the liver. Acetaminophen is appropriate prior to a procedure if a person chooses to use the ice method of analgesia but isn’t necessary if infiltrative anesthesia is used.

Opioid Analgesics act directly on opioid receptors resulting in euphoria and a decrease in pain. These are only legally available through a physician. Some people have reported using opioid analgesics prior to a procedure in order to remain relaxed and calm. Opioids aren’t recommended for this procedure. If a person is working on themselves it’s important to be clear headed and no one should ever perform body mod procedures on a person who is under the influence of a drug.

Topical Analgesics

There are a number of topically applied analgesics. These are generally creams or ointments containing either prilocaine, lidocaine, or a combination of both. Although these can be effective they are less dependable than infiltrative anesthetics and require an extended period of contact time. EMLA cream contains 2.5% lidocaine and 2.5% prilocaine. It’s applied to the area of skin on which a procedure will be performed and then covered with an occlusive dressing for two to three hours. The analgesia persists for one to two hours following removal of the dressing.

Infiltrative Anesthesia and Peripheral Nerve Blocks

Fingers are particularly rich with nerves and injuries can be excruciating. Anesthesia crucial prior to suturing and repair. There are two options: Infiltration anesthesia or peripheral nerve blocks.

A peripheral nerve block is the injection of an anesthetic onto a nerve to block the transmission of sensation. The site of injection is often quite distant from the region where anesthesia is required. A few quick injections can completely eliminate the pain of broken ribs, migraines, and even herniated discs for up to twelve hours. It’s an underused modality despite that nerve blocks are in many cases more effective and safer than systemic anesthetics. Many physicians prefer pain management that they themselves aren’t required to administer and unfortunately it’s a task that can’t be delegated to nurses. An exception to this is the digital nerve block which is easily achieved and distant enough from high risk areas that they’re routinely performed by even the most tremulous of general practitioners.

Infriltration anesthesia is the administration of anesthetic by injection directly into the tissue to be anesthetized. There are a number of advantage to a nerve block over a topical; however, topical anesthesia require no finesse at all. The following information such as onset and duration are specific to use in peripheral nerve blocks but can still serve as a method to compare the actions of each anesthetic if one does decide to use a topical.

Cocaine

The use of Coca leaves in Mesoamerica has been dated to the eve of the holocene. Even without being processed into cocaine, it is a powerful anesthetic making elective surgery possible. It was introduced to Europe in the 16th century. It was mostly a novelty drug until the isolation of cocaine in 1859. Freud wasn’t a mere junky. He reported, “among the persons to whom I have given coca, three reported violent sexual excitement which they unhesitatingly attributed to the coca.” God damn the pusher man, eh? Cocaine was marketed and sold by the Parke-Davis company in forms ranging from saturated cigarette wrappers to elaborate cocaine injection sets until a number of events tarnished its reputation. Foremost amongst these was a doctor who botched a surgery under its influence. By the turn of the century cocaine was only being dispensed under order of a physician. Cocaine is still used medicinally but has become exceedingly rare.

Cocaine occurs naturally in the leaves of the coca shrub and is an ester of benzoic acid. The clinically desired actions of cocaine are blockade of nerve impulses and local vasoconstriction secondary to inhibition of local norepinephrine reuptake. However, its toxicity and the potential for abuse have precluded wider clinical use of cocaine in modern practice. Its euphoric properties are due primarily to inhibition of catecholamine uptake, particularly dopamine, at CNS synapses. Other LAs do not block the uptake of norepinephrine and do not produce the sensitization to catecholamines, vasoconstriction, or mydriasis characteristics of cocaine. Currently, cocaine is used primarily to provide topical anesthesia of the upper respiratory tract, where its combined vasoconstrictor and LA properties provide anesthesia and shrinking of the mucosa with a single agent.

It remains the anesthetic of choice for eye and nasal surgeries but has otherwise been superseded. It could be used as a local anaesthetic but there are far safer alternatives. Cocaine is being included in this list not because it’s appropriate, but rather because it’s often mentioned as a potential option. Medical grade cocaine is most commonly distributed as Cocaine Hcl as an aqueous solution in 4% or 10% strengths. These are meant for use as a topical agent and are usually applied to mucous membranes with a swab. In theory it could be used as an infiltrate but one would need to dilute the solution to 2% first using sterile water. The source more often discussed is from a local sidewalk pharmacist or the dark web. This is ill advised for a number of reasons such as a lack of sterility, the impossibility of determining the percentage of cocaine present, and the possibility of fillers incompatible with injection. It would be far better to go with an ice bath alone than to use recreational cocaine.

Anesthetic Onset Duration Dose
Cocaine 15-30 minutes 90 Minutes Not advised for infiltration

Procaine

Procaine was developed as a replacement. It isn’t addictive or euphoric, but was categorized a drug of abuse in the nineteen seventies. A number of physicians had reported that patients receiving procaine experienced a regrowth of hair and the return of hair color. Patients described feeling younger, stronger, and pain free even in arthritic joints nowhere near the site of injection. A study published in 1956 by Romanian Gerontologist Ana Aslan discussed the effects of ten years of procaine therapy on 189 elderly subjects. Aslan later created a procaine preparation called Gerovital H3 with claims it slows many aging phenomena and increases intelligence. The Romanian Government was enthusiastic about these findings. It funded volumes of further research and founded clinics across the country. Aslan was recipient of the German “Order of Merit,” the Italian “Cavalier de la Nouvelle Europe,” french “Les Palmes Academiques” and even today is celebrated by the World Health Organization as a Pioneer in the field of gerontology.

This is where the strange begins. The US National Institute of Health was apparently outraged by these claims regarding procaine. The NIH begrudged the influx of procaine products from Eastern Europe and called for the formation of a new council to investigate these claims called the National Institute of Aging. The NIA conducted what they deemed a thorough evaluation of the claims. They concluded that Gerovital was an unsafe state funded product from a Communist Regime and that no evidence exists for any benefit beyond mild MAO inhibition. Seriously, this was the type of language used. Procaine became a serious crime in the United States and new a black market arose that persists even today on sketchy websites and craigslist offerings. Romania and other European countries maintain that Gerovital is a valuable treatment for the aged. Romania is to Gerovital H3 what Amsterdam is to Marijuana with a number of large resorts catering to those seeking to extend their life and expand their consciousness. The Hurculane Resort has caught my eye with thermal springs once used by emperors, massage, and Gerovital H3 infusions provided under strict medical supervision. It remains arguable whether procaine has anti-aging properties. As a local anesthetic it’s safe and effective; however, weird politics has made it harder to acquire than cocaine. Procaine is safe for use in peripheral nerve blocks and a good choice if one is able to acquire it.

Anesthetic Onset Duration Maximum Dose
Procaine 10-15 Minutes 45 Minutes 8mg/kg

Lidocaine

Lidocaine is the most widely used anesthetic today. It outperforms both cocaine and procaine and it’s free of the undesirable anti-aging and pleasure inducing side effects. Lidocaine is mundane enough to be sold over the counter in topical products to numb the burn of hemorrhoids and prevents premature ejaculation. These OTC formulations also contain various substances to modify viscosity and stability making them unsuitable for injection. The appropriate form for our purposes is a sterile 1% or 2% solution.

 

 Anesthetic Onset Duration Dose
Lidocaine 2% 10-20 minutes 120 Minutes 4.5 mg/kg

Mepivacaine

Another rather unexceptional anesthetic appropriate for our use is Mepivicaine. Mepivacaine is less likely to cause adverse effects at higher doses than lidocaine and has a slightly longer duration at comparable doses. Mepivacaine is the anesthetic of choice by the New York School of Regional Anesthesia and is optimal for use during a magnet implant. It isn’t as versatile and common as lidocaine however, so it’s more difficult to obtain.

Anesthetic Onset Duration Maximum Dose
Mepivacaine 1.5% 10-20 minutes 180 Minutes 5 mg/kg

Syringes, Needles, and Miscellaneous Precautions

Nerve blocks or infiltrative anesthesia requires a 3ml syringe and an appropriate needle. A 25 gauge 5/8 inch needle is preferable. Pretty much any gauge of needle higher than a 22 can be used. With needle size it’s ok to make due with what you can easily get. This pliant attitude doesn’t extend to anesthetic agents. Many are available in formulations containing epinephrine. Epinephrine should never be used in extremities such the ears, nose, penis, toes, or fingers. It’s a powerful vasoconstrictor intended to keep an anesthetic in the desired area longer. This vasoconstriction can cut off blood flow entirely to peripheral tissue resulting in tissue necrosis. Some plastic surgeons who specialize in surgery of the hand forgo this warning and one can find discussions amongst such professionals arguing the advantages and disadvantages of epinephrine. Allow me to remind you that you are not a peer to these surgeons and the best course of action is the most conservative one. Avoid the use of epinephrine for this procedure as one certainly doesn’t require the additional duration that it provides.

It’s important to remember that these anesthetics are not harmless. There’s a reason they aren’t available without order of a physician: if improperly administered they can kill you. Accidental intravenous injection can cause cardiac toxicity and death. The procedures for nerve blocks and topical anesthetics will be discussed in a further post; however, take heed that there exists virtually no way to monitor for systemic toxicity. Even physicians experienced and educated in the fine points of regional anesthesia have negative outcomes. They take this risk in stride because these blocks occur in settings capable of cardiac resuscitation: something I’ve never seen in body mod parlor or grinder garage.

An alternative method that yields anesthesia without use of infiltration is ice immersion. Immersion of the distal half of the hand for 10 minutes will generally provide five to ten minutes of working time without the risk of toxicity or any additional expense.