Summary: Injectables always work better than oral painkillers. It is because injectables do not undergo first-pass metabolism in the liver. However, injectables may not be the right option when living with chronic or intractable pain. Fortunately, in many cases, troches, which are a kind of lozenges, work better. Troches often act faster and have higher bioavailability.
People living with chronic pain or intractable pain often complain that their medications do not help them sufficiently. Medications often fail to provide sufficient relief when living with conditions like Adhesive Arachnoiditis (AA) and related diseases. However, it has nothing to do with medications. Painkillers often fail to help due to different reasons. In most such instances, injectables work quite well. However, for those living with chronic pain, daily injection of painkillers is not an option.
Well, the reason is simple, in many cases, medications just fail to absorb sufficiently. It is especially true for those living with chronic gastrointestinal health issues. However, even if medications are absorbed well, they are often metabolized by the liver. Thus, in many cases, 30-50% of the drugs are lost during the so-called first-pass metabolism.
When people take oral drugs, they are absorbed via the intestine. From the intestine, they reach the liver via the portal vein. However, when they reach the liver, a significant amount of these drugs is destroyed by the liver since the liver is an organ responsible for detoxification. It happens because the liver considers medications as foreign material. It means that in most cases, less than half of the medicines reach the bloodstream.
The less medication reaches the bloodstream, the lesser the probability it will help with the pain. How much any medication would reach the bloodstream depends on many factors. Some drugs are absorbed well and are not readily metabolized by the liver. However, other drugs are more readily metabolized by the liver.
So, as one can guess, when one injects medications, the liver is bypassed, and medications directly enter the bloodstream. That is why injectables are so good at providing relief. However, apart from injectables, there are other ways of bypassing the so-called first-pass metabolism in the liver. Just think of sublingual drugs. They are kept just below the tongue, and their medications are absorbed into the bloodstream. However, not all drugs are fit for sublingual use.
It seems that ancient Greeks knew how to bypass first-pass metabolism in the liver. They noticed that if drugs are kept between the tongue and cheeks for a long, it results in better benefits. They called such medication forms troches (the Greek pronunciation is “tro-key”). These days troches are more commonly called lozenges.
Of course, not all drugs are good to be taken as lozenges or troches, but some are quite helpful. These days, many medications are available in this form, like hormones and painkillers. There are some distinct benefits of troches:
There are some other benefits of troches. In many cases, it also results in a better safety profile. Since the drug is not injected, but rather absorbed via the mucous membrane of the mouth, thus troches are less likely to cause gastrointestinal disturbances. As a result, such medications are often better tolerated.
Additionally, troches are easier to use as all one needs to do put medication in the mouth. One can carry them and also use them when and as required. Hence, if you think that your medications or oral pills are not providing sufficient pain relief, it would be a good idea to check with your doctor if it is possible to prescribe troches. Only remember that not all drugs are available in this drug form.
By Gurpreet Singh Padda, MD, MBA, MHP