Helping the hurt, without hurting the patient:

safe and effective pain management.

•  116 million Americans have chronic pain;
• 50% of these are undertreated;
• of these, 25% receive no treatment.^1,2

Pain management principles

Acetaminophen

•  good first-line "foundational" treatment for most patients.³
• do not exceed 3 g/day for age >65 (4 g/d for others);
• caution patients about acetaminophen in OTC and combination products;
• 650 mg dose is as effective as 1000 mg, with less risk.³

NSAIDs

• All NSAIDs have similar analgesic efficacy;⁴
• to minimize cardiac risk, prescribe naproxen;
• to minimize GI bleed risk, add a PPI or H2 blocker;
• celecoxib (Celebrex) has a higher cardiac risk than other NSAIDs; its lower GI risk is negated by aspirin use.

Opiates

• can be useful when more analgesia is required;
• sometimes underused;
• addiction is rare with appropriate use and monitoring.

Drugs for neuropathic pain can be helpful in appropriately selected patients.

Non-pharmacologic therapies, including exercise and weight loss, can reduce the burden of pain.

Non-steroidal anti-inflammatory drugs (NSAIDs)

All provide equal pain relief,⁴ but have different cardiac and GI risk based on degree of COX-1 versus COX-2 inhibition.

Minimizing cardiac risk:

Naproxen (Naprosyn, Aleve, and generics) has the lowest risk of cardiac side effects.

Managing GI toxicity

For patients at increased risk of GI toxicity, add a proton pump inhibitor (PPI) such as omeprazole (Prilosec and generics) or an H2 blocker to the NSAID.⁶ For those at highest risk of GI side effects, if an NSAID must be used, celecoxib can be combined with a PPI.⁷

NSAIDs and cardioprotective doses of aspirin

Any dose of aspirin will reverse the GI protective effects of celecoxib. For patients who need both a cardioprotective aspirin and an NSAID, prescribe naproxen (with an H2 blocker or PPI to minimize GI risk if needed). Any NSAID should be taken at least 8 hours before or 30 minutes after aspirin to prevent the NSAID from interfering with aspirin’s cardiac benefit.⁷

Sometimes, an opiate is needed

Most opiates have equal analgesic efficacy, adjusting for dose.

• However, pharmacogenic and other differences among patients can cause different degrees of pain relief and adverse reactions. Of these, differences in codeine metabolism are the most common.

Opiates are very effective in pain relief, but come with important risks.

• sedation,
• constipation,
• confusion,
• falls and fractures, and
• addition potential.

Addiction, dependence, and accidental overdose are all potential problems with chronic opiate use.

• As needed dosing (versus scheduled dosing) and higher doses increase the risk of accidental overdose.⁸

Reduce risk of opiate misuse with specific prevention measures.⁹

When starting:

• Reserve opiates for patients with moderate to severe pain who do not respond to other agents.
• When considering long-term opiate use, screen for risk of addiction and misuse. This risk is often over-estimated.¹⁰
• Using a medication agreement can help establish a shared understanding of treatment goals and expectations.

During treatment:

• Regularly reassess pain, adverse effects, and risk of misuse.
• Use the lowest dose of opiate possible.⁸
• Refer to a pain specialist if a patient is not improving or shows evidence of misuse.
• Use caution when switching between opiate classes; dose conversion charts do not always reflect how variable patient responses will be.

Get ahead of bowel problems. Start a bowel regimen proactively when initiating an opiate.

• Ask about constipation at follow-up visits.

Opiate-like agents

• tramadol (ultram): short- and long-acting; generics available
• tapentadol (Nucynta): only short-acting; no generics available (a Schedule II agent)

Both are as effective as other low-potency opiates (e.g. Schedule III agents).^11,12

Neuropathic pain (e.g. diabetic neuropathy, post-herpetic neuralgia, fibromyalgia)

Some anti-convulsants and antidepressants are effective in treating the neuropathic component of pain, though their use is often limited by adverse effects.

• most common side effects are somnolence, dizziness, and nausea.
• triyclic antidepressants should be used very carefully and at low dose in the elderly, with regular
  assessments of anti-cholinergic side effects.

Comparative efficacy of selected antidepressants and anti-convulsants in the treatment of diabetic neuropathy.¹³

Combining an opiate with a neuropathic agent in diabetic neuropathy can reduce pain levels better than either drug alone, at low doses.¹⁴

Other treatments

Other approaches can have modest effects in reducing pain.

For many patients with severe degenerative joint disease, replacing a hip or knee can provide substantial relief and end the need for dependence on pain medications. Consider referral to a specialist for worsening DJD.

Non-pharmacologic interventions can also be useful in controlling pain, improving function, or both in osteoarthritis, fibromyalgia, and chronic low back pain.

Cost

• Acetaminophen and most NSAIDs are available OTC or as easily affordable generics.
• Most long-acting opioids are costly, while many short-acting opiates are available as easily affordable generics.
• Within agents for neuropathic pain, tricyclic antidepressants are available as affordable generics, but some SNRIs and anti-convulsants are costly.