img2 Chronic pain is typically managed using multiple modalities at RELIV Pain Center for Chronic Pain Management

Acetaminophen

This is the most commonly used first line medication for pain management. Acetaminophen is also combined with opioid drugs as it works synergistically with the opioids. It is very effective in managing any type of pain including headaches at beginning stages when the condition is of mild severity. When taken on a chronic basis at high doses it may cause liver failure.


Non Steroidal Anti Inflammatory Drugs (NSAID)

Examples of these drugs include, ibuprofen, naproxen, diclofenac sodium, celecoxib, etc. NSAIDs are normally used for treating acute inflammation, arthritis, acute exacerbations of chronic pain, headache and so on. Typically we reserve the use of NSAIDs for short courses of treatment to manage acute exacerbations as chronic continuous use may lead to peptic ulcers, kidney damage and even cardiovascular complications.

Antidepressants

Antidepressants have been known for a long time to be effective in managing chronic pain. Amitriptyline is one of the first antidepressants to be used for chronic pain at much lower doses than what is used for management of depression. Venlafaxine, duloxetine and milnacipran are the latest antidepressants used extensively for management of chronic pain. These medications are effective in managing fibromyalgia, chronic arthritis related pain and neuropathic pain as in diabetic peripheral neuropathy or radiculopathy from irritated spinal nerves. Generally these medications need to be taken in gradually escalating doses for a few weeks before relief can be noticed. One of the adverse effects unique to this class of medications is serotonin syndrome that presents with symptoms of severe hot flashes, irritability, palpitations, etc.

Anticonvulsants

Anticonvulsants are extremely effective in the management of neuropathic pain. Pain arising from diabetic peripheral neuropathy, irritation of spinal nerves or damage to peripheral nerves can be managed using this class of drugs. Gabapentin and pregabalin are the most commonly used anticonvulsants in the management of chronic pain. Topiramate and carbamazepine are used in cases of chronic migraine headaches and trigeminal neuralgia respectively. Common side effects from these drugs include drowsiness, lack of appetite, swelling of the feet, weight gain and others

Muscle relaxants

Muscle spasm is a common sign of underlying joint or spinal degeneration and can cause severe pain, discomfort, stiffness and lack of mobility. Muscle relaxants are very useful in managing these spasms on an as needed basis. Most of the muscle relaxants act centrally and cause drowsiness, decrease in blood pressure, etc. Long term continuous use of this class of medications has not been found by research to be useful in treating chronic conditions leading to pain. However widespread use of these agents is common while treating severe painful disorders.

Opioid medications

Opioids like tramadol, hydrocodone, oxycodone, morphine and others are extremely potent medications very effective in the management of chronic intractable pain. These medications are typically used to manage severe degenerative conditions or during and after surgeries. Management of chronic pain using opioids is indicated when the condition is severe as documented by imaging studies and other investigations after having tried and failed less potent medications listed above. These medications can suppress breathing, decrease blood pressure and can be fatal if not used strictly as prescribed under close supervision. Patients prescribed opioids are monitored closely to detect tolerance, dependence, addiction, likelihood of accidental or intentional overdose, abuse and diversion. Monitoring involves periodic follow up visits to the physician, urine drug testing, extensive history taking and keeping track of the overall health status of the individual.

Topical medications

Examples of this include local anesthetics (lidocaine) and NSAIDs like diclofenac sodium, capsaicin, menthol and camphor. The last three are available over the counter. Topical application of lidocaine or NSAIDs as a cream, gel or a patch can be very effective when treating localized areas of pain like arthritis of a single joint. When used as prescribed the systemic uptake of these drugs is limited and side effects, minimal and rare. Of late most of the other classes of drugs listed above except opioids are being compounded by specialist pharmacies in to creams that have been found to be effective in carefully selected patients.

Ketamine

Ketamine is a drug in a class of its own and was widely used a few decades ago as a general anesthetic. Ketamine is an excellent pain reliever and muscle relaxant and unlike opioids does not suppress breathing. However it is a hallucinogenic and not ideal for the management of chronic pain and no ideal route of administration has yet been established. Certain compounding pharmacies are using this medication in creams in combination with other medications for use on localized but intractable neuropathic pain. Certain pain centers are using this medication as infusions in small doses to manage severe generalized body pains, extremely severe, unrelenting migraines lasting several days and reflex sympathetic dystrophy as a last resort when all else have failed. Ketamine induced coma is also being tried in some premier medical institutions.


  • Non-opioids - Acetaminophen

  • Non-steroidal - NSAIDS & COX-2 Inhibitors

  • Opioids - Codeine, Tramadol, Morphine, Pethidine, Fentanyl, Buprenorphine, Tapentedol

  • NMDA antagonists - Ketamine

  • Antidepressants - Tricyclic's, SSRI's

  • Antineuropathic agents - Gabapentin, Pregabalin, Carbamazepine etc.

  • Muscle Relaxants - Baclofen, Diazepam, Methocarbamol

  • Alpha Agonists - Clonidine

Patches

  • Lignocaine 5% patch

  • Local Application Capsaicin 8% (Qutenza) patches Tropical Medications

  • EMLA, Lignocaine, Capsaicin 0.025 % & 0.075%, NSIADS, Gabapentin

  • In-patient Ketamine Trials

  • In-patient IV Lignocaine treatment

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DateSeptember 7, 2014
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