United States Schedule 3 Pain Relievers

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Figure 6.3 Devil's claw is found primarily in the African deserts. The dried root is said to reduce the pain of osteoarthritis, although researchers are not sure how the herb works.

Oenothera biennis, whose flowers open in the evening. The plant is native to North America, Europe, and Asia. Evening primrose oil contains essential fatty acids called linolenic acids, such as gamma-linolenic acid (GLA). GLA is involved in the formation of prostaglandins. Some scientists believe taking evening primrose oil balances the production of "good" prostaglandins (which maintain a healthy stomach lining and blood clotting) with the production of "bad" prostaglandins (which cause pain and inflammation). Evening primrose oil can be used to relieve menstrual cramps, reduce arthritis-related joint pain and swelling, and relieve pain from neuropathies (pain from damaged nerves). It can be taken in pure oil form or in oil-filled softgels or capsules. Side effects of this oil are rare and are usually experienced as an upset stomach or bloating. However, evening primrose oil may cause seizures in people with schizophrenia who are taking certain types of psychiatric medications.

• Feverfew. The feverfew plant (Tanacetum parthenium) grows wild throughout Europe and South America. The leaves of the plant are dried and chopped or ground into a powder, which can then be made into pills and capsules. Some people even chew the dried leaves, but this can irritate the mouth. Feverfew has gained recent attention for its ability to reduce the frequency and severity of migraine headaches and some of the associated symptoms, such as nausea. However, feverfew does not reduce the intensity of a migraine once it has already started. The plant has also been reported to relieve menstrual cramps. The main ingredient in feverfew was originally thought to be a substance called parthenolide, but more recently numerous active ingredients were discovered in this herb. These ingredients can inhibit the release of serotonin from blood and nerve cells and can also inhibit the synthesis of prostaglandins. Feverfew is considered a blood thinner and should not be taken with other blood thinners such as aspirin or other NSAIDs. People who are allergic to various plants, such as daisies, marigolds, or chrysanthemums, may experience an allergic reaction to this herb. Feverfew must be taken for several weeks before it becomes effective, and if a person suddenly stops taking it, he or she may suffer withdrawal symptoms and a recurrence of severe headaches.

• Ginger. The ginger plant (Zingiber officinale) is a natural spice with a pungent taste whose use in cooking and medicine can be traced back to ancient times. Early physicians found it effective in treating upset stomachs, and even today ginger, taken in the form of ginger ale, is used to ease indigestion and nausea. Ginger is primarily cultivated in tropical and semitropical areas such as Southeast Asia and Jamaica. Aside from its ability to quell an upset stomach, it is an anti-inflammatory agent that reduces the formation of prostaglandins. Ginger is mildly effective in treating various forms of arthritis. It can be taken in the form of a pill, powder, whole ginger root, tea, and—an American favorite—ginger ale. Very few people report side effects from taking ginger, and, aside from other blood thinners such as aspirin and other NSAIDs, few other drugs interact negatively with the herb.

• Kava. Also called kava-kava, this herb is derived from the root of the plant Piper methysticum, which is grown primarily in the islands of the South Pacific. Kava powder is often mixed into drinks to produce a significant sense of well-being and relaxation. Kava leaves can be chewed for a mild euphoric effect, and other forms of kava include tablets and capsules. In addition to its reported ability to reduce tension and anxiety, kava has muscle relaxant properties that relieve muscle aches. Kava may even possess local anesthetic properties similar to those of drugs like benzocaine (see Chapter 5). However, sporadic reports of kava-induced liver toxicity have caused many government agencies to keep kava on its watchlist of dangerous natural products, although no restriction against the drug has officially been legislated in the United States. Because too much acetaminophen can also cause liver damage, experts warn against taking kava with products such as Tylenol. Kava has potent effects on the brain and should not be taken in combination with alcohol, sedatives, antidepressants, or other psychiatric medications. Kava can also cause a mild upset stomach and can worsen the symptoms of Parkinson's disease.

• Lavender. The lavender plant (Lavandula angustifolia) is native to the Mediterranean region and has an intense pleasant aroma often used in soaps, perfumes, fragrances, potpourri, and air fresheners. Various lavender oils, flowers, and leaves can be applied topically to the skin for the relief of pain from sunburn and minor cuts and scrapes. Although the main active ingredient of lavender is not yet known, it can also be mildly sedating and can help treat insomnia and anxiety. However, because of this, lavender can interact with prescription sedatives, sleep aids, and opiate narcotic pain relievers. In some people, topical application of lavender can cause an allergic skin reaction.

• St. John's wort. The St. John's wort plant (Hypericum perforatum; Figure 6.4) is an increasingly popular herbal supplement that proponents claim has the ability to cure a vast array of ailments. St. John's wort appears to boost the release of the neurotransmitter serotonin in the brain, which may be the reason it is able to treat anxiety and depression. The herb contains numerous substances, two of which, hypericin and hyperforin, may be key active ingredients. St. John's wort appears to be effective in relieving the muscle pain associated with fibromyalgia and the tissue pain associated with hemorrhoids. The herb comes in tablet, capsule, cream, and ointment forms and must be taken for several weeks before it takes full effect. St. John's wort should not be taken with antidepressants such as

Figure 6.4 The St. John's wort plant, pictured here, is a popular herbal supplement. In some people, it relieves the symptoms of anxiety and depression, as well as muscle pain attributed to fibromyalgia.

Prozac and Zoloft. It may also reduce the effectiveness of some HIV medications. Mild side effects of St. John's wort include fatigue, dry mouth, increased sensitivity to the sun, and gastrointestinal problems.

Turmeric. Turmeric (Curcuma longa) is a member of the ginger family and has traditionally been used as a spice that adds flavor and color to mustard and curry powder. It comes from India and southern Asia, where the stalk of the plant is scalded, dried, and made into a powder, tablet, capsule, ointment, cream, lotion, or tea. The best-characterized ingredient of turmeric is a substance called curcumin. Curcumin is an antioxidant that also causes certain cells in the body to release steroids such as cortisol, which help fight inflammation

(see Chapter 5). Turmeric is used to treat arthritis, carpal tunnel syndrome, and other joint inflammations. It can cause mild side effects such as upset stomach or ulcers when used for prolonged periods of time. Turmeric is also a blood thinner and should not be taken in combination with NSAIDs such as aspirin.

• Willow bark. The bark of the white willow tree (Salix alba) has been used as a pain and fever reducer for centuries. The main active ingredient in willow bark is salicin, which the body converts to salicylic acid, a substance that acts like aspirin. In fact, the first stable form of aspirin (acetylsalicylic acid) was made from a related herb called meadowsweet. Salicylic acid inhibits

MARIJUANA—THE FORBIDDEN HERBAL PAIN RELIEVER

In recent years, a furious debate has erupted over the legality and ethical use of "medical marijuana"—that is, the use of marijuana to ease medical problems such as glaucoma, nausea associated with cancer chemotherapy, and chronic pain. It has been known for centuries that marijuana and related substances (termed cannabinoids [can-ah'-bih-noydz] after the botanical name of the marijuana plant, Cannabis sativa) are extremely effective in reducing pain. As early as 2600 B.C., the Chinese emperor Huang Ti advocated the use of marijuana for the relief of cramps and menstrual pain. In the early 1990s, scientists discovered that the body has its own cannabinoid-like pain reliever called anandamide. Cannabinoids, whether from marijuana or from the body's own pain-relieving system, act within the central nervous system to inhibit the transmission of pain signals.

But there is one major problem—marijuana is illegal in the United States and most other countries because of its intoxicating the formation of prostaglandins in the body, which results in reduced stimulation of nociceptors and reduced perception of pain. The salicin in willow bark may take longer than aspirin to take effect, but it may actually provide longer-lasting pain relief. In addition, willow bark does not cause the upset stomach and ulcers that aspirin can. Willow bark comes in liquid, capsule, tablet, and powder forms and is primarily taken to relieve mild-to-moderate back or muscle pain or menstrual cramps and to control the discomfort associated with arthritis. To avoid the risk of gastrointestinal side effects, ringing in the ears, and blood thinning, willow bark should not be taken with aspirin or other NSAIDs.

and potentially addictive properties. Nonetheless, in rare instances, doctors still prescribe marijuana cigarettes or capsules containing synthetic cannabinoids to people who desperately need it for the relief of pain that doesn't respond to NSAIDs, opiates, or traditional pain relievers. Medical marijuana use has created a storm of controversy among medical professionals, marijuana legalization activists and prohibitionists, and local, state, and federal governments, with patients seeking relief from chronic pain caught in the middle.

Today, scientists continue to try to unravel the biological mechanisms by which cannabinoids relieve pain, with hopes that one day a synthetic cannabinoid drug will be produced that can be legally prescribed to alleviate pain and suffering in people with AIDS, cancer, and other illnesses that cause chronic pain. At the same time, scientists hope that this new cannabinoid pain reliever will be free of the negative effects of marijuana, which include intoxication and addiction.

DEA Classification of Pain Relievers

In 1970, the U.S. government passed the Controlled Substances Act, which classified all drugs into one of five categories, or "schedules." In effect, this law classified drugs according to how medically useful, safe, and potentially addictive they are. These schedules are defined as follows:

SCHEDULE I The drug or other substance has:

> A high potential for abuse.

> No currently accepted medical use in treatment in the United States.

> A lack of accepted safety for use of the drug or other substance under medical supervision.

SCHEDULE II The drug or other substance has:

> A high potential for abuse.

> A currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions.

> Abuse of the drug or other substances may lead to severe psychological or physical dependence.

SCHEDULE III The drug or other substance has:

> A potential for abuse less than the drugs or other substances in Schedules I and II.

> A currently accepted medical use in treatment in the United States.

> Abuse of the drug or other substance may lead to moderate or low physical dependence or high psychological dependence.

SCHEDULE IV The drug or other substance has:

> A low potential for abuse relative to the drugs or other substances in Schedule III.

> A currently accepted medical use in treatment in the United States.

> Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in Schedule III.

SCHEDULE V The drug or other substance has:

> A low potential for abuse relative to the drugs or other substances in Schedule IV.

> A currently accepted medical use in treatment in the United States.

> Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in Schedule IV.

Common Pain Relieving Drugs and Their Schedule Designation

Many of the pain relievers described in this book are currently classified into these schedules, as listed in the table below. However, scheduling of individual drugs can change over time as trends in abuse potential and addiction to a particular drug change. Thus, the classification of drugs is continuously updated by the Drug Enforcement Administration (DEA).

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