Sean Mackey, M.D., Ph.D.
speaker
373 appearances
1 recordings
1 series
first heard Apr 2025
last heard Apr 2025
Sean Mackey, M.D., Ph.D.’s voice in public audio — every appearance, attributed to the second.
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Minimally, more information. And I haven't, in full disclosure, I haven't read up on it a lot. I know it has some cyclooxygenase I impact. A lot of it is thought to be central. I haven't tracked it much beyond that. I saw some interesting side studies where it seems to have some impact in the brain around emotional modulation. And so there's a degree of emotional blunting on acetaminophen.
Now, whether it translates into a real world or if it's just an experimental manipulation, I don't know.
I think you just said it, Peter. You said it beautifully. I use those in combination. to get the twofer, to get that synergy. The one plus one is not two, but three. So you can take Tylenol. Historically, we would say up to four grams a day. More recently, there's been some push to try to reduce that to two grams a day.
Clearly, if you've got liver dysfunction, if you are drinking large amounts of alcohol, less.
Now let me ask you, does ibuprofen work better for you than naproxen?
Yeah.
The reason I ask is I find huge individual variability in responses to NSAIDs.
Naproxen works beautifully for me at 500 twice a day. Ibuprofen, not so good. At what dose? 800 three times a day. Wow. Yeah. With food and water.
I don't find it as effective in neuropathic pain. It might take a little bit of the edge off. Nociceptive pain typically is your go-to. You're kind of your nociceptive or... You're nociceptive inflammatory pain, the kind of pain you'd see in a joint. Those are your typical go-to forms of back pain, particularly in acute situations, but also somewhat in chronic.
And I get a lot of patients that say, yeah, that didn't do it for me. But if you inquire and ask questions, you find maybe it knocked it off a little. Because in our game, we're trying to knock off pieces and pieces and pieces of their pain experience. The issues with the different responses are very individually based.
And I think in part, it has to do with a little bit of what we call pharmacokinetics or where the drug is getting. And different NSAIDs can permeate different tissues at different rates.
Obviously, don't take them together, but your take-home message is spot on.
I just said a conserver, listen, don't do more than like a drink a day. Is that the right amount? I don't know. But if I tell them one drink a day, they'll go do two. They're probably still okay with that. And then I am looking in their chart just to make sure they're not drinking four or eight and there's liver issues. What do you do?
Beautiful case example, by the way, for yourself of how we would use those. Baclofen is one of the safest to use. It is not habit forming like the Soma's. and others that can be like a barbiturate, can act, and people can get highly psychologically dependent on them.
The flexorils have a tricyclic antidepressant property about them that may sometimes be helpful for people in various mixed pain states, but also can cause sedation. The baclofen seems to be pretty benign. We don't typically use muscle relaxants for long-term chronic conditions. The data hasn't borne out.
Oh, I'm comfortable with a person being on Baclofen all their life. It's just, forgive me if I'm preaching to the choir here. Everything I'm doing is taken in the context of the person in front of me and the cost and benefit of the treatments I'm providing them. Meaning there are costs with Baclofen. I don't mean monetary cost. It can cost sedation.
I think it's individual, and obviously it is dose-dependent. The higher dose is more sedation. We can use baclofen intrathecally. We put in intrathecal pumps for baclofen. This is a beautiful, life-saving, minimal surgery that we do for people with a spinal cord injury and tractable spasticity, because to get the spasms under control with oral doses, you just can't get there.
So we thread a little catheter into the CSF and we deliver baclofen that way. Now, it, again, is a clean, relatively safe medication, but I'm always evaluating long-term, is this person getting benefit from this? Should we be talking about dialing it back and trying to wean? And if they're not getting benefit, then why should they stay on the medication?
I know you do the same types of things in your practice. We use it. We can use it in acute, subacute. We'll use it in some chronic conditions as a trial. What's a trial? Month, two months. And then we monitor data on every single person.
Yeah, up to 80 milligrams, I believe, is the upper end. I don't usually get there.
Showing 161–180 of 373 · page 9 of 19
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