Hepatitis C or no hepatitis C, everyone experiences
pain from time to time. However, if you have chronic hepatitis C virus
(HCV) infection, you are likely to have pain. The Institute of
Medicine (IOM) estimates that around 100 million Americans have pain.
Compare this to the 3 million Americans living with HCV, how do you
know if HCV or something else is causing your pain? This two-part
series will explore hepatitis C and pain.
Hepatitis C is called the
“silent killer,” because the liver is a non-complaining organ. Liver
cells don’t have nerves, so there can be serious tissue damage, but no
pain. However, lack of nerve cells doesn’t mean there can’t be liver
pain (hepatalgia or hepatodynia). Located in the right upper part of
the abdomen, hepatalgia is usually caused by stretching of the capsule
surrounding the liver, as well as by complaints from nearby organs.
Liver pain does not mean that hepatitis C is worsening. The discomfort
may be dull, sharp, mild, severe, constant or intermittent. For me it
felt like my liver was fluttering. The only way I can describe it was
it felt like when I was pregnant and the baby moved.
Even if there isn’t discomfort in the area of the liver, HCV may cause pain in other parts of the body. These are known as extrahepatic manifestations, and the complaints most associated with pain other than hepatalgia are:
Since pain is a common symptom
of many medical conditions, the first order of business is to get a
medical diagnosis to determine the cause of your discomfort. Is HCV the
cause, or is there something else? It doesn’t have to be either/or, as
some people have more than one cause of pain. If HCV is the cause, the
next order of business is to find out if the pain is a direct result
of the virus, or has HCV caused a secondary problem, such as
cryoglobulinemia or an autoimmune disorder.
In the case of cryoglobulinemia, hepatitis C causes the body to produce proteins called cryoglobulins
Cryoglobulins clump together in the blood when they are cold; this
causes joint pain. Various studies have shown that successful HCV
treatment also improves cryoglobulinemia. The American Association for
the Study of Liver Diseases (AASLD) and the Infectious Diseases Society
of America (IDSA) HCV Guidelines
highly recommend HCV treatment for people with cryoglobulinemia.
Treatment may also help
HCV-positive people with autoimmune disorders such as lupus and
rheumatoid arthritis. If the pain is primarily from HCV, then
eradicating the virus usually eliminates the aches and pains that are
caused by the virus.
Acute pain, meaning that it is short-lived, is the
easiest to manage. There is a wide selection of pain medications or
analgesics, ranging from over-the-counter (OTC) aspirin to prescription
narcotics. These drugs generally work well for acute pain because
patients don’t take them for long periods of time, since the problem
that caused the pain usually heals.
That is not to say that there
aren’t risks and downsides to taking painkillers—there are, especially
from a liver standpoint. This risk increases if the liver is severely
damaged by HCV. However, if someone with hepatitis C has a
well-functioning liver, most physicians are comfortable prescribing a
short-course of narcotics for conditions that warrant it, such as
injuries or surgery. The risk to the liver is low, and it’s inhumane
and medically unwise to withhold pain relief.
A much bigger problem is
chronic pain, or pain that lasts for more than three months (some
experts say six months). Chronic pain affects body, mind, and spirit,
and it can change your life. The more severe the pain, the greater the
transformation. Not the good transformation, like from a caterpillar to
a butterfly; more like from a butterfly to an ogre.
People with hepatitis C who are
in pain, are confronted with the issue of finding pain relief that
doesn’t further damage the liver. Fortunately, there is a wide
selection of medications and pain management tools. Let’s explore pain
medication this month; next month I’ll delve into medication-free pain
Anti-inflammatory Drugs (NSAIDs)
(Tylenol) is one of the most commonly used non-prescription analgesics.
Known as paracetamol in Europe, acetaminophen is great for headaches,
fever and mild pain. Technically, acetaminophen is an NSAID, but it’s
anti-inflammatory effects are not as good as drugs such as ibuprofen.
cetaminophen is one of the
safest drugs there is, even if you have liver disease. It is harmless
at low doses. However, acetaminophen can cause acute liver injury and
death from acute liver failure at amounts just twice the maximum
recommended dose of acetaminophen. The big problem with acetaminophen
is that it is added to many medications. Remedies for colds, headaches,
pain, sleep, sinus problems, cough and PMS often contain
acetaminophen. Lose track of this fact, and you may take toxic amounts.
For more information, read Acetaminophen: Safe or Harmless?
In the U.S., approximately 50
million people take acetaminophen every week, and more than 25 billion
doses are sold yearly. Slightly more than 300 people die annually from
it. Nearly all of these are from overdose; half are from intentional
overdose (suicide attempts). Acetaminophen hepatotoxicity most commonly
arises after a suicide attempt using more than 7.5 grams, but more
often at more than 15 grams as a single overdose.
perhaps the most commonly used analgesic and fever-reducing medication
in the world. At low daily doses (81 mg), aspirin is used to decrease
the risk of stroke, and may prevent a second heart attack. Daily
aspirin is no longer recommended to prevent heart disease unless there
is a pre-existing condition.
At high doses, aspirin can
injure the liver. However, this damage is not from toxicity, such as
what may occur with high doses of acetaminophen. The biggest risk with
aspirin is a gastrointestinal (GI) bleed. Far more people are injured
every year from aspirin use than from acetaminophen. Mortality and
morbidity studies are scant, but it appears that there are 10 times
more deaths and hospitalizations from NSAID use than from
acetaminophen. Complications may occur even at low doses, and the risk
increases with age.
Rounding out OTC NSAIDs are
drugs such as ibuprofen (Advil, Motrin) and naproxen (Alleve). These
drugs are used for mild-to-moderate pain and inflammation. Around 30
million Americans take NSAIDs every year. These drugs rarely cause
liver problems, but have other risks, such as injury to the kidneys and
GI tract. In addition to OTC NSAIDs, there are many prescription
Opioids are medications related in structure to the
natural plant alkaloids found in opium. There are natural and
synthetic opioids, and many medications in this category. The most
commonly prescribed opioids for pain are codeine, hydrocodone
(Vicodin), and oxycodone (Oxycontin). Unlike NSAIDs, opioids have a
high potential for dependency and abuse.
According to the CDC, more than
16,000 people in the United States die every year from overdose of
prescription painkillers. This is approximately 44 people every day. On
their own, opioids rarely injury the liver. However, opioids are
sometimes formulated with acetaminophen, and excessive amounts can
injure the liver. The FDA has recommended that physicians not use
opioid combinations in which the dose of acetaminophen is greater than
325 mg per dose.
Opioid use is making the news
these days. Hepatitis C infections rates are increasing at alarming
rates in young people, most notably in Kentucky, Tennessee, Virginia
and West Virginia. Sharing needles through opioid abuse is fueling this
Another reason that opioids are
making the news has to do with how it is prescribed. In some cases,
opioids are over-prescribed. Just as bad, is that in some cases opioids
are under-prescribed, leaving patients in misery. I am not going to
dive in to this debate, but for those looking for well-written
information on this, I highly recommend Judy Foreman’s book, “A Nation
When it comes to managing pain, there are more
choices than just prescription and OTC medications. Next month, I will
present information on effective alternatives, such as medical
marijuana and drug-free pain management techniques including an
effective technique that may surprise you.
Lucinda K. Porter, RN, is a long-time contributor to the HCV Advocate and author of Free from Hepatitis C and Hepatitis C One Step at a Time. Her blog is www.LucindaPorterRN.com