Effective pain management includes

Know Your Pain Treatment Options

Whether your pain is from arthritis, cancer treatments, fibromyalgia, or an old injury, you need to find a way to get your pain under control. What’s the best approach to do that?

The first step in pain management is scheduling an appointment with your doctor to determine the cause of your pain and learn which pain management approach is often the most effective for it. There are many different pain management options available: You can find the right treatment combination to get the relief you need.

Before you try to treat your pain, it’s important to understand how pain is defined.

“The International Association for the Study of Pain came up with a consensus statement,” says Judith Scheman, PhD, program director of the Chronic Pain Rehabilitation Program at the Cleveland Clinic in Ohio. “Pain is an unpleasant sensory and emotional experience. I think that’s extraordinarily important. When we focus only on the sensory aspect, we fail to appreciate the suffering component of the pain, which is important to recognize because pain is not what occurs at the periphery.”

Why Do People Experience Pain Differently?

Pain is real and it’s physical — there’s no mistaking that. But pain is measured and specific to one person based on that person’s perception of the pain, and that’s why everyone’s pain is different.

“What the brain perceives is indisputably modifiable by emotions,” notes Scheman. That means that people who are fearful of pain, depressed, or anxious may experience pain differently, and perhaps more severely, than someone who has pain but isn’t experiencing those other emotions.

Pain Management: Treating Mind and Body

Scheman stresses the importance of approaching pain both physically and emotionally and addressing “people as entire human beings.” So while chronic pain medication can be effective and important for pain management for many people, it isn’t the only tool available when it comes to pain treatment, and it shouldn’t be the only tool that’s used.

Medications. “There are a lot of medications that are prescribed for pain,” says Scheman, although she notes that opioids (narcotics) and benzodiazepines may not be the best options. Those treatments “have their own problems, and there are no good studies on using opioids for long periods of time for the treatment of chronic pain.”

Types of chronic pain medication used include:

  • NSAIDs (non-steroidal anti-inflammatory drugs), including ibuprofen, naproxen, and aspirin
  • Acetaminophen (Tylenol)
  • Antidepressants, which can improve sleep and alleviate pain
  • Anti-seizure medications, which can be effective in treating pain related to nerve damage or injury
  • Steroids, like dexamethasone and prednisone, to alleviate inflammation and pain

Therapy. Therapy can be aimed at both the mind and the body. Says Scheman, “I try to look at any of these therapies as not being purely physical or purely psychological — we are always a mixture of both of those things.”

  • Physical therapy is a very important part of any pain management program. Pain can be worsened by exercise that isn’t done correctly (or interpreted incorrectly as pain rather than overuse), and a physical therapist can tailor the right exercise regimen for you. Proper exercise slowly builds your tolerance and reduces your pain — you won’t end up overdoing it and giving up because it hurts.
  • Cognitive-behavioral therapy allows people to “learn and have a better understanding of what the pain is from, and what they can do about it,” says Scheman. This therapy is really about understanding the role of pain in your life and what it actually means for you, add Scheman.

Other pain management options. A variety of approaches and modalities can help you deal with both the physical and emotional parts of pain:

  • TENS (transcutaneous electrical nerve stimulation) therapy
  • Meditation
  • Relaxation techniques
  • Visual imagery, as simple as picturing a peaceful scene, for example
  • Biofeedback, which teaches control over muscle tension, temperature, heart rate and more
  • Heat and cold therapy
  • Manipulation and massage

The bottom line: Seek help for your pain as soon as it becomes a problem in your life. “We aren’t guaranteed lives without pain,” says Scheman. But when chronic pain starts to destroy your ability to function in the world, then it’s a problem that needs to be addressed.

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Pain Management

In both acute and chronic health conditions, pain is top on the list of concerns for patients, caregivers and physicians. Effective pain control improves the individual’s state of mind and ability to move through the healing process. There are a variety of options for pain control, and doctors work toward addressing side effects that can occur with pain medications.

Coming to terms with being in pain, acute or chronic, is a hurdle for many folks who grew up learning to “put aside” pain. Individuals who have been vocal about pain levels and received negative responses may feel angry, refusing treatment as an expression of emotional pain.

Fortunately, pain control centers, physicians and other healthcare personnel have become more aware over the years. Asking about pain levels during office visits is as common as checking vital signs.

TYPES OF PAIN

Acute pain can occur at the same time chronic pain is experienced. The euphemism “breakthrough pain” is one type of acute pain an individual can undergo. This pain can occur because of movement or activity, but it can also happen when the body has involuntary movements, such as expelling gas or muscle twitches. Medication can be prescribed for the “break” in pain that around the clock medicating provides.

Breakthrough pain may occur in the same area as the chronic pain, but not always. Noting the events leading up to the episode of breakthrough pain can help caregivers adjust activity levels if needed. In some cases, the area in pain and/or the event that contributes to it cannot be pinned down. Recording episodes, including seemingly random incidents, will still help when pain management is reviewed.

When pain resurfaces before the next scheduled dose of medication and isn’t associated with a voluntary or involuntary action, the physician can be notified to examine the timing and amount of around the clock medication. Noticing the time of pain onset and keeping a record can help the doctor make a decision about keeping pain relief consistent. Caregivers will find their loved one complains at or about the same interval of time prior to their next dosage.

Chronic pain is consistent and “stable.” While there may be some fluctuating of intensity, it is “reliable” in its characteristics. Medication for this type of pain is generally around the clock to provide continuity of relief. Over time, medications are adjusted to account for changes in the pain cycle, including a patient’s tolerance to a given dosage.

AGE DOESN’T MATTER

Children and adolescents with cancer experience pain just as deeply as an adult. They may be better equipped to admit to pain and track where they are hurting, as opposed to adults who may have dementia as a hindrance to assessment.

Physicians have a specific protocol, or pathway, to follow when managing pain for adults and children. When dealing with “pain psychology,” caregivers will learn to watch facial expressions, body positions and other gestures to determine if their loved one is understating their pain level. Kids may not want to worry their parents, or be afraid of a visit to the doctor or hospital. As the healthcare experience continues, parents become more attuned to what their child is feeling, and may find that personnel involved in their child’s care are able to help them understand what is typical at different stages of treatment.

While the same is true for caregivers of adults, the adult-to-adult psychology can have a wider range of variation. Children helping their parents through a health crisis may take time to relate to them on an adult-to-adult level, and parents may attempt to mask their fear and pain by amplifying “Parent Mode.” When possible, ask the doctor to allow for some time alone with the parent, to allow them to express their needs without feeling “weak.”

Relationships of every kind are challenged when there is a health problem, and relationship dynamics should be evaluated at the time of diagnosis by loved one and caregiver. Understanding that there will be changes in any relationship is a first step toward coping with those changes, and making them positive ones.

PAIN MANAGEMENT IS A SCIENCE

Over the decades, the perspective on managing pain has widened. Healthcare practitioners and patients have a closer relationship in deciding pain management routes, incorporating “natural” and prescribed medications and “alternative” methods of pain relief.

Pain management was once considered “doping up” the patient in some circles. Today’s viewpoint incorporates consistent pain relief with keeping the patient alert and functioning.

The variety of conditions that require pain management has created a demand for an accurate “science” to provide help based on condition and individual need. The World Health Organization has a “ladder” for managing cancer pain. Level One uses non-steroidal anti-inflammatory medications (such as aspirin) and “adjuvant,” or supplementary medications that have a secondary effect of controlling pain by eliminating a side effect. As pain increases with cancer progression and/or treatment, professional caregivers step to the next level of pain management. By Level Three, opiates are incorporated and the adjuvant medications are there to assist with opiate side effects.

OPIATES AND PAIN CONTROL

In the classic film “The Wizard of Oz,” the Wicked Witch deters Dorothy and her friends by creating a field of poppies they must walk through before reaching the Emerald Castle. Dorothy and the Lion fall asleep until the Good Witch intervenes with snowflakes to wake them up, and the crew moves toward their destination.The poppy plant is used to create opiates such as morphine and codeine, which relieve pain, but also make the individual sleepy or lethargic. The effects of “Opiates from Oz” are shorter lasting than those administered for those in chronic pain. Since alertness is a factor in complying with pain medications, patients may be unwilling to try them, looking to “natural” remedies instead.

The brain has receptors that recognize both opiates and endorphins. Endorphins are “feel good” chemicals produced naturally in the brain, and have an analgesic effect. While they are preferable to medications, both acute and chronic pain sufferers may not produce sufficient quantities of endorphins to dull or eradicate pain. Even simple pain relievers like acetaminophen or aspirin may not do the trick, and pain control must include opiates.

Morphine and its opiate cousins can be given by mouth or intravenously. In some cases, morphine can be delivered by a nebulizer, dispersing the drug into an aerosol that can be inhaled. The lungs also contain receptors for opioids, absorbing and processing the medication.

Caregivers should be aware that any medication delivered by nebulizer can disperse through the room. Taking precautions when it comes to room ventilation and proximity to the patient will help the caregiver with unwanted exposure to medication. The concern for precautions has less to do with a “secondary high” for the caregiver than with residuals of the medicine showing up in their urine if drug tested.

The type of morphine nebulized is the intravenous type without preservatives. When given by aerosol, morphine can activate histamines and constrict breathing passages. The goal of morphine by aerosol is to alleviate difficult, painful breathing rather than bring it on, so doctors may order an aerosol treatment with medication to keep the airways open prior to nebulized morphine. There is a specialized, single dose nebulizer that delivers morphine to the lungs. The medication “strips” look very similar to the ones used to test blood sugar, but contain the correct medication dosage. Aerosol particles do not “fly” around because of the design.

TOLERANCE IS NOT ADDICTION

Caregivers and loved ones may worry that tolerance means addiction, but they are not the same. Over extended periods of time, the dosage of the medication may need to be increased because the individual has developed a tolerance to the medication, or there has been a rise in pain levels. Doctors work to use the lowest effective dosage to keep the patient alert and pain free.

Medication dependence occurs when there is a physical reliance on the medication and withdrawal symptoms (that are specific to the drug class) occur. There may be tolerance present, but the withdrawal symptoms are noted if the medication is suddenly removed and/or levels of the medicine in the bloodstream decrease.When addiction is present, caregivers and medical personnel notice that the patient may “lose” prescriptions, and/or take their medications at inappropriate times. A number of other behaviors may be present, including behavioral changes that include isolation from family members.

Rather than diagnose your family member, bring concerns to the family physician to evaluate the situation. What seems like dependence or addiction may be the response to changes in pain level, tolerance or other factors that the doctor must evaluate. Behavioral responses such as anger or depression may be due to poorly controlled pain, especially if the pain control journey is just beginning.

CONTROLLING PAIN IN CANCER

The National Cancer Institute offers an information to assist cancer patients and their caregivers with pain management. Cancer pain may arise from chemotherapy or radiation, creating nerve damage or phantom pain from body parts that have been removed. Radiation can cause painful “sunburn” during treatment.

Whenever there is surgery performed, temporary pain may be experienced because skin and organs are cut and maneuvered around. Post-surgical pain fades with time and appropriate management, which may include physical therapy and resuming daily activities.

The growth of cancer within the body contributes to pain, also. As cancer is being treated, therapeutic levels of controlling the growth are sought; but patients may still experience pain while waiting for the abnormal cells to be eradicated. This is where pain control offers a great deal to assist in stress reduction and continuing patient compliance with therapy. It’s difficult to ask a loved one to continue with treatment when pain makes them feel they aren’t getting better, and the goal is to quickly assess the level of pain to begin pain control. It makes the treatment much easier to cope with, for caregiver and loved one.

Differential pain assessment in cancer is important also, to help the treatment team to discern if new pain is from cancer that has moved to a new area, or if there is an acute condition that must be addressed (such as appendicitis or gall bladder stones). It may seem unlikely that cancer patients may experience an acute episode of pain unrelated to their cancerous process, but it is possible. It may help to keep a written record of pain to offer feedback to the physician during visits, or if a call must be placed after hours.

Swelling, itching and rashes cause pain, and while minor when compared to pain from cancer, they can actually make it harder to tolerate pain levels if the minor pain is left unaddressed.

COMPLEMENTARY PAIN TREATMENTS

Biofeedback has been around for some time, and there are competent technicians able to instruct patients in controlling their breathing and heart rate. The technique has worked well for persons who have an ability to focus on these measurable parameters, which can help reduce pain and the anxiety that comes from being in pain.

Massage therapy can work in almost any case to reduce pain and improve the relaxation effect. It is not necessary to “work” the area where pain is felt to provide comfort and a sense of healing.

Patients with swelling from radiation or surgery (such as removal of lymph nodes) can look for a lymphedema therapist, who is trained in proper technique for massaging swollen areas as well as the rest of the body.

Reflexology can be performed on the hands or feet to help release tense areas which may be related to painful spots. The body in pain will tense itself in a variety of ways in response to pain, and by relaxing one part of the body by massage, the rest of it can follow.

Massage can be combined with biofeedback, imagery or other alternative therapies (such as aromatherapy) to diminish stress response.

WORKING WITH OPIATE SIDE EFFECTS

Constipation arising from opiate medications is a frustrating consequence for caregiver and loved one. A common misconception is that fiber and exercise will address all types of constipation. When opiates are given, the bowels are slowed down; the result is constipation, which occurs in many people who take opioid/opiates.

The buildup of waste in the intestines creates discomfort in all people. In general, suggestions to alleviate and control constipation include increasing water intake to soften food passing through the digestive tract, and exercise, which helps muscles “massage” the internal organs. The intestines made “sleepy” by opiods can be helped by these two suggestions, but more help may be needed; especially when pain hinders the ability to move.

Fiber is an excellent “homespun” cure to deal with constipation, and as long as the individual has a somewhat hearty appetite, salads and vegetables can be given as snacks and meals. When appetites are poor or finicky, fiber bought at the health food store can be sprinkled on easy-to-consume foods (like pudding or baby food). Fiber is helped by fluid intake, and those who are having trouble keeping up with their liquids may prefer “fun fluids,” such as snow cones and popsicles.

Caregivers and loved ones may be reluctant to continue pain medication when constipation is the result. The key to working with this side effect is to allow for the body’s changing ability to pass waste as usual. Constipation may also be a result of compressed nerves or other factors that are at work in a health challenge. Continuing medications is important, but advise the doctor about constipation and the success of any home remedies. Combining simple fixes like diet and exercise with physician-prescribed solutions may be what is needed. Laxatives and slow-release magnesium are over the counter remedies that are helpful, but should not be used without speaking to the doctor. Overuse of laxatives can create or increase constipation in the long run.

There are prescribed medications which work to counteract the effects of various drugs. “Antagonist” medications are given at the doctor’s discretion. Discussion of possible medications to counteract medication effects can be done when there are problems noted, but as always, caregivers must give as much information possible to the doctor so he can be guided.

PAIN CAN HAVE POSITIVE EFFECTS

If an area is completely numb from treatment, pain may be an indicator that the area is “coming back to life,” however uncomfortably. When pain is addressed within a reasonable time, corrective measures can be taken to alleviate it. This assists the body in healing, and helps loved one and caregiver enjoy their time together as they move toward the next step in recovery.

Pain Management 101: Types of Pain and Treatment Options

Medically reviewed by Carmen Fookes, BPharm Last updated on Nov 26, 2019.

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Assessing | Types | What is Pain | Identifying | Management | Medications

We have all experienced pain. But despite it being one of the most common symptoms people seek medical help for, it is also one of the most misunderstood and ineffectively treated.

Part of the reason is that one person’s experience of the same painful event can be significantly different from another’s. In this article, we identify the most common types of pain and offer some suggestions on the best type of treatment. Because there is no one-size-fits-all approach.

Types of Pain

Pain is a general term that describes any kind of unpleasant or uncomfortable sensation in the body.

There are many different types and causes of pain, and these can be grouped into eight different categories to help with pain management:

  • Acute pain
  • Chronic pain
  • Breakthrough pain
  • Bone pain
  • Nerve pain
  • Phantom pain
  • Soft tissue pain
  • Referred pain.

Acute pain

This starts suddenly and only lasts for a short period (ie, minutes, hours, a couple of days, occasionally a month or two).

It is usually caused by a specific event or injury, such as:

  • A broken bone
  • A car crash or other type of accident
  • A fall
  • Burns or cuts
  • Dental work
  • Labor and childbirth
  • Surgery.

Chronic Pain

Chronic pain is pain that has persisted for longer than six months and is experienced most days. It may have originally started as acute pain, but the pain has continued long after the original injury or event has healed or resolved. Chronic pain can range from mild to severe and is associated with conditions such as:

  • Arthritis
  • Back pain
  • Cancer
  • Circulation problems
  • Diabetes
  • Fibromyalgia
  • Headache.

Chronic pain can severely affect a person’s quality of life and prevent them from returning to work or participating in physical activity. In some people, it may lead to depression or social isolation.

Breakthrough Pain

Breakthrough pain is a sudden, short, sharp increase in pain that occurs in people who are already taking medications to relieve chronic pain caused by conditions such as arthritis, cancer, or fibromyalgia.

Breakthrough pain may also be called a pain flare and it may occur with exercise or physical activity, coughing, illness, stress, or during the period between pain medication doses. The pain level is often severe, but the location of the pain is usually the same as the person’s chronic pain.

Bone Pain

This is a tenderness, aching or discomfort in one or more bones that is present during both exercise and rest.

Bone pain is commonly associated with conditions or diseases that affect the structure or function of bone, such as cancer, a fracture (broken bone), infection, leukemia, mineral deficiency, sickle cell anemia, or osteoporosis. Many pregnant women experience pelvic girdle pain.

Nerve Pain

Nerve pain is caused by nerve damage or inflammation. It is usually described as a sharp, shooting, burning or stabbing pain and may also be called neuralgia or neuropathic pain. Some people describe it as being like an electric shock and it is often worse at night.

Nerve pain can severely interfere with a person’s life and affect their sleep, work, and physical activity levels. They are often very sensitive to cold and may experience pain with even the slightest touch. Many people with chronic nerve pain also develop anxiety or depression.

People with neuropathic pain are often very sensitive to touch or cold and can experience pain as a result of stimuli that would not normally be painful, such as brushing the skin.

Common causes of nerve pain include:

  • Alcoholism
  • An injury to the brain, a nerve, or the spinal cord
  • Cancer
  • Circulation problems
  • Diabetes
  • Herpes zoster (shingles)
  • Limb amputation
  • Multiple sclerosis
  • Stroke
  • Vitamin B12 deficiency.

Phantom Pain

Phantom pain is pain that feels like it is coming from a body part that is no longer there. It is common in people who have had a limb amputated, but is different from phantom limb sensation, which is usually painless.

Historically, Doctors believed phantom pain was a psychological problem but they now realize these are real pain sensations that originate in the spinal cord and brain. It often gets better with time, but managing phantom pain can be challenging in some people.

Soft Tissue Pain

This is pain or discomfort that results from damage or inflammation of the muscles, tissues, or ligaments. It may be associated with swelling or bruising and common causes include:

  • Back or neck pain
  • Bursitis
  • Fibromyalgia
  • Rotator cuff injury
  • Sciatic pain
  • Sports injuries, such as sprains or strains
  • Temporomandibular joint (TMJ) syndrome.

Referred pain

This is pain that feels like it is coming from one particular location, but is the result of an injury or inflammation in another structure or organ. For example, during a heart attack, pain is often felt in the neck, left shoulder, and down the right arm. An injury or inflammation of the pancreas is often felt as constant pain in the upper stomach area that radiates to the back. A ruptured spleen can cause pain in the shoulder blade.

Referred pain happens because there is a network of interconnecting sensory nerves, that supply many different tissues. An injury in one area of the network can be mistakenly interpreted by the brain as being in a different part of the network.

What Type of Pain do I Have?

Sometimes it can be hard to identify exactly what type of pain you are experiencing. The checklist below can help you to identify your pain type and other contributing factors. Fill it in before you see your doctor.

If you have a child that is experiencing pain, The Faces Pain Scale may help. This uses a series of diagrams depicting a face with no pain (0) to intense pain (10).

How Do I Manage My Pain?

There are many different types of pain-relieving medications and each class works in a slightly different way. Most medications can be grouped under one of the following:

  • Nonopioids: a medicine that is not similar to morphine (an opioid) but is not addictive (eg, acetaminophen, aspirin, NSAIDs)
  • Weak opioids: a medicine that is similar to morphine (an opioid) but not considered as strong (eg, codeine, tramadol)
  • Combination opioids: these contain a nonopioid and either a weak opioid or a strong opioid (eg, acetaminophen and hydrocodone)
  • Strong opioids: a medicine such as morphine or similar to morphine that has the potential to cause addiction (eg, fentanyl, morphine, oxycodone)
  • Other (eg, ketamine)
  • Adjuvant treatments: a medicine that can help relieve pain by relieving inflammation or by improving the functioning of other systems (eg, cannabidiol, capsaicin cream, gabapentin)
  • Nonpharmacological treatments (drug-free treatments), such as psychotherapy or counseling.

The choice of pain-relieving medication comes down to how effective it is for that type of pain and the likelihood of side effects in that particular person.

  • Once a pain medication is started, it should be monitored for effectiveness and side effects and the dosage or choice of treatment modified if the pain changes or the choice is deemed unsuitable or ineffective.
  • Some types of pain (such as cancer-related pain) have an unpredictable course that can vary dramatically in severity and duration, depending on the type of treatment and disease progression. Pain management needs to have some flexibility to account for this.
  • Some people will have more than one type of pain.
  • Changing the method of delivery of pain medication may improve its effectiveness; for example, changing from an oral treatment to a patch or a subcutaneous pain pump.

Traditionally, most experts have recommended a stepwise approach to pain management, starting with acetaminophen or NSAIDs, then progressing to a weak opioid (such as codeine, dihydrocodeine, or tramadol), before changing to a strong opioid (such as fentanyl, morphine, oxycodone).

However, this “Pain Ladder” was developed in 1986, and other medications that are not analgesics can also be effective at relieving pain. In addition, opioids should only be used for certain types of pain, because of their risk of addiction. Nowadays, a modified three-step pain management ladder may be used, which should always take into account the type of pain.

Pain Management for Specific Types of Pain

Some medications are considered better for some types of pain compared with others, although factors such as the cause of the pain, genetics, interacting medications or supplements, as well as coexisting conditions, can all impact on how effective a medicine is. Possible treatment options for different types of pain are:

  • Acute pain: nonopioids, weak opioids, opioids, nonpharmacological treatments such as ice or bioelectric therapy
  • Chronic pain: nonopioids, weak opioids, opioids, antidepressants, capsaicin cream, nonpharmacological treatments such as bioelectric therapy, radiation therapy
  • Breakthrough pain: short-acting opioid, nonpharmacological treatments such as acupuncture or relaxation techniques
  • Bone pain: nonopioids, bisphosphonates, opioids, nutritional supplements, surgery
  • Nerve pain: antidepressants, anticonvulsants, capsaicin cream, nonpharmacological treatments such as cognitive-behavioral therapy
  • Phantom pain: nonopioids, antidepressants, anticonvulsants, ketamine, nonpharmacological treatments such as acupuncture or repetitive transcranial magnetic stimulation (rTMS)
  • Soft tissue pain: nonopioids, corticosteroids, nonpharmacological treatments such as ice, physiotherapy, or ultrasonography
  • Referred pain: nonopioids, cold/warm compresses, nonpharmacological treatments such as massage or transcutaneous electrical nerve stimulation (TENS).

Always talk to your doctor about which pain medication is right for you.

Below is a summary of all the different types of pain medications available as well as a list of nonpharmacological treatments.

Nonopioids

  • Acetaminophen
  • Ibuprofen
  • Naproxen
  • Diclofenac

Weak opioids

  • Codeine
  • Tramadol

Combination opioids

  • Acetaminophen + codeine
  • Acetaminophen + hydrocodone
  • Acetaminophen + oxycodone
  • Acetaminophen + tramadol
  • Codeine + acetaminophen + butalbital + caffeine
  • Codeine + aspirin + butalbital + caffeine
  • Dihydrocodeine + acetaminophen + caffeine
  • Hydrocodone + ibuprofen

Strong Opioids

  • Alfentanil
  • Fentanyl
  • Hydrocodone
  • Hydromorphone
  • Methadone
  • Morphine
  • Oxycodone
  • Oxymorphone
  • Sufentanil

Other

  • Ketamine

Adjuvant treatments

Anxiety

  • Diazepam
  • Lorazepam

Bone pain

  • Bisphosphonates
  • Calcitonin
  • Denosumab

Bowel-related pain

  • Glycopyrrolate
  • Octreotide

Muscle or joint pain/spasm

  • Baclofen
  • Capsaicin cream
  • Cyclobenzaprine
  • Diazepam
  • Lorazepam
  • Methocarbamol
  • Tizanidine

Nerve Pain

  • Antidepressants (eg, duloxetine, TCAs, SSRIs)
  • Anticonvulsants (eg, gabapentin, lamotrigine, pregabalin)
  • Cannabidiol
  • Capsaicin cream
  • Mexiletine

Widespread pain

  • Cannabidiol
  • Corticosteroids
  • Lidocaine/prilocaine
  • CNS stimulants

Nonpharmacological treatments

  • Acupressure
  • Acupuncture
  • Alexander technique
  • Bioelectric therapy
  • Biofeedback
  • Braces and supports
  • Chiropractic therapy
  • Cognitive-behavioral therapy
  • Comfort therapy
  • Diathermy
  • Distraction
  • Electromuscular stimulation
  • Functional restoration training
  • Guided imagery
  • Hot/cold packs
  • Hypnosis
  • Interferential therapy
  • Low-level laser therapy
  • Magnetic therapy
  • Massage
  • Mindfulness
  • Mirror box
  • Multidisciplinary rehabilitation
  • Osteopathy
  • Physical and occupational therapy
  • Psychosocial therapy/counseling
  • Qigong
  • Radiofrequency ablation
  • Repetitive transcranial magnetic stimulation (rTMS)
  • Relaxation techniques
  • Spinal cord stimulation
  • Surgery
  • Tai Chi
  • Transcutaneous electrical nerve stimulation (TENS)
  • Ultrasound
  • Yoga

See Also

  • Understanding Opioid (Narcotic) Pain Medications

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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What are other causes of pain?

Other causes of pain include:

  • headaches,
  • facial pain,
  • peripheral nerve pain,
  • coccydynia,
  • compression fractures,
  • post-herpetic neuralgia,
  • myofasciitis,
  • torticollis,
  • piriformis syndrome,
  • plantar fasciitis,
  • lateral epicondylitis, and
  • cancer pain .

Headaches and facial pain, including atypical facial pain and trigeminal neuralgia.

Headaches are a major source of discomfort and lost productivity in the workplace. Many effective treatments exist for persisting headaches, including medication, biofeedback, injections and implants, depending upon the precise type of headache. Botox also provides a useful means of effectively and safely treating headaches.

Atypical facial pain can be debilitating. Often times it can be treated by injections into local nerve tissue (such as the sphenopalatine ganglion).

Trigeminal neuralgia, also called tic douloureux, is a condition that most commonly causes very intense intermittent shooting pain in the face.

Peripheral nerve pain

Peripheral nerve pain, or neuropathy, can be debilitating. It can respond well to simple treatments such a trigger point injections with anesthetic medicines and cryoablation (an office based procedure which involves freezing the nerves). Examples of peripheral nerve pain include intercostal neuralgia, ilioinguinal neuroma, hypogastric neuroma, lateral femoral cutaneous nerve entrapment, interdigital neuroma and related nerve entrapments.

Coccydynia

Coccydynia is simply pain in the region on the tailbone, or coccyx. It can result from trauma or arise without apparent cause. The initial treatment is conservative, with oral pain relief medicines (analgesics). Oftentimes, the pain originates in the portion of the nervous system that we have no control of (involuntary or autonomic nervous system) and can respond to either a local anesthetic injection of the head of a nerve called Ganglion Impar, which is located below the coccyx or by medically destroying (ablating) the Ganglion Impar, usually using radiofrequency.

Compression fractures

Compression fractures of the bony building blocks (vertebral bodies) are common in the elderly as a result of osteoporosis, or loss of calcium in the bone. With less calcium, the bone becomes weak and can break. Like any fracture, compression fractures hurt. Like any fracture, they are treated by stabilization, in this case, by injecting cement into the bone in a procedure known as a vertebroplasty or kyphoplasty. Vertebroplasty is an effective way to treat the pain of compression fractures. Kyphoplasty uses a balloon to restore height to the compressed vertebral body.

Post-herpetic neuralgia

Post herpetic neuralgia (PHN) is a painful condition occurring after a bout of shingles. When we are young, we are almost all exposed to chickenpox, caused by the Herpes Zoster virus. Our immune system controls the virus, but it lives in a dormant state in the spinal cord. When we age, or become ill or stressed, the virus can reactivate and attack the infected nerve and adjacent skin. However, in this second attack, the body usually recognizes the Herpes Zoster virus and contains the pain to a localized area, along the course of one nerve. A patient may have the characteristic blisters, which normally heal. Sometimes, however, the Herpes Zoster virus damages the nerve, causing ongoing nerve pain that persists after the skin blisters from the shingles have healed.

The ideal way to treat the post herpetic neuralgia is to treat it before it sets in. Medications, such as acyclovir (Zovirax), steroids and injections such as sympathetic injections can help prevent the onset of PHN. After the pain is present, injections, local anesthetics, medications and pain medications or topical patches can be useful.

Myofasciitis and Torticollis

Myofasciitis (pain in the muscles, whether in the neck or back) often responds to conservative physical therapy treatments (for example, massage and exercise). If the pain persists, trigger point injections can be used. If the trigger point injections provide temporary relief, sometimes Botox injections can help. Botox, which is botulinum toxin, can relax the muscles for six or more months, with long-term relief of pain. It provides a safe, effective treatment for what can otherwise be a difficult, ongoing problem.

Torticollis is spasm of the muscles in the neck, forcing the sufferer to hold his or her neck tilted or rotated to the side. Botox is approved for treatment of this problem.

Piriformis Syndrome

The piriformis muscle goes from the hip to sacrum (tailbone). It is important in that the sciatic nerve passes through it. Piriformis syndrome is a spasm of the piriformis muscle. When the muscle goes into spasm, it can squeeze the sciatic nerve, causing pain going down the leg. Piriformis syndrome will usually respond to physical therapy. When pain persists, local anesthetic and/or steroid injection can help. If the pain persists, injecting Botox or Myobloc, which are both botulinum toxins, into the muscle can provide effective, safe treatment.

Plantar fasciitis and lateral epicondylitis

Plantar fasciitis (heel pain) and lateral epicondylitis (tennis elbow) are two common pain problems. Treatment starts with conservative options, such as rest, non-steroidal anti-inflammatory medications, steroid injections, over-the counter pain medications, physical therapy and, for heel pain, shoe inserts.

If the pain lasts for more than six months, Extracorporeal Shockwave Treatment is an effective, FDA approved treatment. Extracorporeal shockwave treatment is not recommended for pregnant women, children, anyone with a pacemaker, anyone on anti-coagulant therapy or anyone with a history of bleeding problems.

Cancer pain

Cancer pain can arise from many different causes, including the cancer itself, compression of a nerve or other body part, fractures or treatment of the cancer. There are many techniques to assist with treating the various pains from cancer, including medications and injections. In particular, medical destruction of nerve tissue (ablative therapies) and the use of pumps surgically placed into the body to deliver pain medication into the subarachnoid space can be used. Pain pumps deliver medication that is targeted to pain receptors on the spinal cord. The advantage to the cancer patient is chronic pain control with decreased side effects.

What is pain, and how do you treat it?

Doctors will treat different types of pain in different ways. A treatment that is effective against one type of pain may not relieve another.

Acute pain treatment

Treating acute pain often involves taking medication.

Nonsteroidal anti-inflammatories (NSAIDs)

These are a type of analgesic, or pain reliever, that can reduce pain and help a person regain daily function. They are available over the counter (OTC) or on prescription at a range of strengths. They are suitable for minor acute pains, such as headaches, light sprains, and backaches.

NSAIDs can relieve localized inflammation and pain that is due to swelling. These drugs may have side effects relating to the digestive system, including bleeding. Therefore, a doctor will monitor a person taking a high dosage.

It is always important to read the packaging to find out what is in an analgesic before using it and to check the maximum dosage. People should never exceed the recommended dosage.

Opioids

Doctors prescribe these drugs for the most extreme acute pains, such as those that result from surgery, burns, cancer, and bone fractures. Opioids are highly addictive, cause withdrawal symptoms, and lose effectiveness over time. They require a prescription.

In situations involving severe trauma and pain, the doctor will carefully manage and administer the dosage, gradually reducing the amount to minimize withdrawal symptoms.

People should discuss all medication options carefully with a doctor and disclose any health conditions and current medications. Opioids may significantly affect the progression of several chronic diseases, including:

  • chronic obstructive pulmonary disorder (COPD)
  • kidney disease
  • liver problems
  • previous drug use disorder
  • dementia

A doctor can often identify and treat an underlying disorder. For example, if an infection is causing a sore throat, antibiotics will remove the infection, and the pain will disappear.

Chronic pain treatment

A range of nondrug therapies can help relieve pain. These alternatives to medication may be more suitable for people experiencing chronic pain.

These therapies include:

  • Acupuncture: Inserting very fine needles at specific pressure points may reduce pain.
  • Nerve blocks: These injections can numb a group of nerves that act as a source of pain for a specific limb or body part.
  • Psychotherapy: This type of therapy can help with the emotional side of ongoing pain. Chronic pain can often affect a person’s enjoyment of everyday activities and reduce their ability to work. A psychotherapist can help a person enhance their understanding of pain and implement lifestyle changes to minimize the intensity of the pain and build coping skills.
  • Transcutaneous electrical nerve stimulation (TENS): TENS aims to stimulate the brain’s opioid and pain gate systems and thus provide relief.
  • Surgery: Various surgeries on the nerves, brain, and spine are possible for treating chronic pain. These include rhizotomy, decompression, and electrical deep brain and spinal cord stimulation procedures.
  • Biofeedback: Through this mind-body technique, a person can learn to control their organs and automatic processes, such as their heart rate, with their thoughts more effectively. Virtual reality may now play a role in the use of biofeedback in pain management, according to 2019 research.
  • Relaxation therapies: These include a wide range of controlled relaxation techniques and exercises, mostly in the realm of alternative and complementary medicine. A person can try hypnosis, yoga, meditation, massage therapy, distraction techniques, tai chi, or a combination of these practices.
  • Physical manipulation: A physiotherapist or chiropractor can sometimes help relieve pain by manipulating the tension from a person’s back.
  • Heat and cold: Using hot and cold packs can help. People can alternate these or select them according to the type of injury or pain. Some topical medications have a warming effect when a person applies them to the affected area.
  • Rest: If pain occurs due to an injury or overworking a part of the body, rest may be the best option.

With adequate pain management, it is possible to maintain daily activities, social engagement, and an active quality of life.

Discover how yoga can help people who have fibromyalgia.

Q:

Is there any research on what the most painful type of injury is?

A:

There is a lot of research on pain and varying reports on what is the most painful. Nerve pain — for example, cluster headaches, shingles, or a pinched spinal nerve from a herniated disc — often tops the charts.

Deep visceral pain, such as the pain that occurs with peritonitis, childbirth, or kidney stones, ranks high on the worst pain scale. Burns are especially painful, depending on the severity.

However, many factors affect the severity of pain, including the subjective tolerance of the individual.

Deborah Weatherspoon, Ph.D., R.N., CRNA Answers represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.

Management of Pain Without Medications

What is non-pharmacological pain management?

Non-pharmacological pain management is the management of pain without medications. This method utilizes ways to alter thoughts and focus concentration to better manage and reduce pain. Methods of non-pharmacological pain include:

Education and psychological conditioning

Not knowing what to expect with cancer treatment is very stressful. However, if you are prepared and can anticipate what will happen, your stress level will be much lower.

To decrease your anxiety about cancer treatment, consider the following:

  • Ask for an explanation of each step of a procedure in detail, utilizing simple pictures or diagrams when available.
  • Meet with the person who will be performing the procedure and write down answers to questions.
  • Tour the room where the procedure will take place.
  • Ask what you can expect as an outcome of the treatment.

Hypnosis

With hypnosis, a psychologist or doctor guides you into an altered state of consciousness. This helps you to focus or narrow your attention to reduce discomfort.

Methods for hypnosis include:

  • Imagery: Guiding you through imaginary mental images of sights, sounds, tastes, smells, and feelings can help shift attention away from the pain.
  • Distraction: Distraction is usually used to help children, especially babies. Using colorful, moving objects or singing songs, telling stories, or looking at books or videos can distract preschoolers. Older children and adults find watching TV or listening to music helpful. Use distraction appropriately, and not in place of an explanation of what to expect.
  • Relaxation/guided imagery: Guiding you through relaxation exercises such as deep breathing and stretching can often reduce discomfort

Other non-pharmacological pain management may utilize alternative therapies such as comfort therapy, physical and occupational therapy, psychosocial therapy/counseling, and neurostimulation to better manage and reduce pain. Examples of these non-pharmacological pain management techniques include the following:

Comfort therapy

Comfort therapy may involve the following:

  • Companionship
  • Exercise
  • Heat/cold application
  • Lotions/massage therapy
  • Meditation
  • Music, art, or drama therapy
  • Pastoral counseling
  • Positioning

Physical and occupational therapy

Physical and occupational therapy may involve the following:

  • Aquatherapy
  • Tone and strengthening
  • Desensitization

Psychosocial therapy/counseling

Psychosocial therapy/counseling may involve the following:

  • Individual counseling
  • Family counseling
  • Group counseling

Neurostimulation

Neurostimulation may involve the following:

  • Transcutaneous electrical nerve stimulation (TENS)
  • Acupuncture
  • Acupressure

Non-opioid options for managing chronic pain

Published: September, 2016

If you started taking prescription opioids to manage chronic pain, then you will need new pain relief options when you cut back or stop taking opioid drugs. Following are options that alone, or in combination, may help.

Cold and heat. Cold can be useful soon after an injury to relieve pain, decrease inflammation and muscle spasms, and help speed recovery. Heat raises your pain threshold and relaxes muscles.

Exercise. Staying physically active, despite some pain, can play a helpful role for people with some of the more common pain conditions, including low back pain, arthritis, and fibromyalgia.

Weight loss. Many painful health conditions are worsened by excess weight. It makes sense, then, that losing weight can help to relieve some kinds of pain.

Physical therapy (PT) and occupational therapy (OT). PT helps to restore or maintain your ability to move and walk. OT helps improve your ability to perform activities of daily living, such as dressing, bathing, and eating.

Transcutaneous electrical nerve stimulation (TENS). This technique employs a very mild electrical current to block pain signals going from the body to the brain.

Iontophoresis. This form of electrical stimulation is used to drive medications into areas of pain and reduce inflammation.

Ultrasound. This therapy directs sound waves into tissue. It is sometimes used to improve blood circulation, decrease inflammation, and promote healing.

Cold laser therapy. Cold laser therapy, also called low-level laser therapy, is FDA-approved to treat pain conditions. The cold laser emits pure light of a single wavelength that is absorbed into an injured area and may reduce inflammation and stimulate tissue repair.

Mind-body techniques. Mind-body relaxation techniques are commonly used at hospital-based pain clinics. They include:

  • Meditation
  • Mindfulness
  • Progressive muscle relaxation
  • Breathing exercises
  • Hypnosis therapy

Yoga and tai chi. These mind-body and exercise practices incorporate breath control, meditation, and movements to stretch and strengthen muscles. They may help with chronic pain conditions such as fibromyalgia, low back pain, arthritis, or headaches.

Biofeedback. This machine-assisted technique helps people take control of their own body responses, including pain.

Therapeutic massage. Therapeutic massage may relieve pain by relaxing painful muscles, tendons, and joints; relieving stress and anxiety; and possibly impeding pain messages to and from the brain.

Chiropractic. Chiropractors try to correct the body’s alignment to relieve pain and improve function and to help the body heal itself.

Acupuncture. Acupuncture involves inserting extremely fine needles into the skin at specific points on the body. This action may relieve pain by releasing endorphins, the body’s natural painkilling chemicals. It may also influence levels of serotonin, the brain transmitter involved with mood.

Psychotherapy. These professionals can offer many avenues for pain relief and management. For example, they can help you reframe negative thinking patterns about your pain that may be interfering with your ability to function well in life, work, and relationships. Seeing a mental health professional does not mean the pain is “all in your head.”

Pain-relieving devices. A range of assistive devices can help support painful joints, relieve the pressure on irritated nerves, and soothe aches and pains. They include splints, braces, canes, crutches, walkers, and shoe orthotics.

Topical pain relievers. These medication-containing creams and ointments are applied to the skin. They may be used instead of or in addition to other treatments.

Over-the-counter medications. Pain relievers that you can buy without a prescription, such as acetaminophen (Tylenol) or nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn) can help to relieve mild to moderate pain.

Herbal or nutritional pain relievers. Scientific evidence supporting their effectiveness for pain relief is scant.

Non-opioid prescription drugs. Certain medications can be very effective for treating condition-specific pain. Examples include triptans for migraine headaches and gabapentin (Neurontin) or pregabalin (Lyrica) for nerve pain.

Corticosteroid injections. Used occasionally, corticosteroid injections can relieve pain and inflammation caused by arthritis, sciatica, and other conditions.

Disclaimer:
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Pain Relievers

Pain relievers are medicines that reduce or relieve headaches, sore muscles, arthritis, or other aches and pains. There are many different pain medicines, and each one has advantages and risks. Some types of pain respond better to certain medicines than others. Each person may also have a slightly different response to a pain reliever.

Over-the-counter (OTC) medicines are good for many types of pain. There are two main types of OTC pain medicines: acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs). Aspirin, naproxen (Aleve), and ibuprofen (Advil, Motrin) are examples of OTC NSAIDs.

If OTC medicines don’t relieve your pain, your doctor may prescribe something stronger. Many NSAIDs are also available at higher prescription doses. The most powerful pain relievers are opioids. They are very effective, but they can sometimes have serious side effects. There is also a risk of addiction. Because of the risks, you must use them only under a doctor’s supervision.

There are many things you can do to help ease pain. Pain relievers are just one part of a pain treatment plan.

The management of acute and chronic pain often includes opioid therapy. In both the acute and chronic pain settings, however, opioids have several disadvantages including risk of nausea and vomiting, somnolence, constipation, respiratory depression, androgen deficiency, physical dependence, and tolerance. Opioid medications also carry a risk of abuse or addiction by either the patient or non-medical users. For these reasons, consideration of non-opioid strategies for pain management is beneficial. While opioids will certainly continue to have a place in pain management despite their disadvantages, the use of non-opioid medication options may limit the amount of opioid necessary or even result in improved pain control. In fact, given that the majority of both acute and chronic pain is thought to be complex and multifactorial, a multimodal analgesic approach is ideal for management. The purpose of this article is to review selected non-opioid medications used in either acute or chronic pain management.
Acute Pain Management
IV Acetaminophen (Ofirmev)
While oral and rectal acetaminophen have been available for quite some time, in 2010 an intravenous (IV) formulation was approved by the FDA. IV acetaminophen (Ofirmev) is indicated for use in management of mild to moderate pain and moderate to severe pain with adjunctive opioid analgesics.1 When studied as an adjunct to opioids following major surgery, IV acetaminophen demonstrated superiority over placebo in decreasing pain scores.2,3 IV acetaminophen has also been shown to decrease opioid consumption in major surgery by nearly one-third compared with placebo.2 The most common adverse effects seen with IV acetaminophen were constipation, nausea, injection site pain, pruritus, and vomiting.2 For adults and adolescents weighing greater than 50 kg, the recommended dosage of IV acetaminophen is 1000 mg every 6 hours or 650 mg every 4 hours, with a maximum single dose of 1000 mg.1 For adults and adolescents weighing under 50 kg as well as children ≥2 to 12 years old, the recommended dosing is 15 mg/kg every 6 hours or 12.5 mg/kg every 4 hours to a maximum of 75 mg/kg per day.1 As with other acetaminophen formulations, caution should be given to avoid exceeding the recommended maximum dose of 4000 mg per day to prevent potentially fatal hepatic injury. No benefit over oral or rectal acetaminophen has been demonstrated at this time; therefore use of IV acetaminophen would most likely be reserved for those patients who are unable to tolerate oral medications.
IV Ibuprofen (Caldolor)
With ongoing drug shortage concerns with ketorolac,4 IV ibuprofen (Caldolor) may begin to see increased usage. Approved in 2009, IV ibuprofen is approved for management of mild to moderate pain and moderate to severe pain as an adjunct to opioid analgesics in adult patients.5 Similar to IV acetaminophen, IV ibuprofen has been shown to decrease pain scores and opioid usage in studies evaluating postoperative pain.6,7 The dosing for IV ibuprofen is 400 mg to 800 mg every 6 hours as necessary with a maximum of 3200 mg per day.5 The product must be diluted prior to administration and then infused over a period of 30 minutes, which is a disadvantage compared with ketorolac, which is available in prefilled syringes and single-dose vials for IV push or IM administration. Like all other non-steroidal anti-inflammatory drugs (NSAIDs), caution should be used when considering use of IV ibuprofen in patients with heart failure, kidney impairment, and those with a history of gastrointestinal bleeding, due to risk of serious cardiovascular and gastrointestinal events. Of note, IV ibuprofen is contraindicated for the treatment of perioperative pain in the setting of coronary artery bypass graft surgery.5 Compares with ketorolac, which is limited to a usage of 5 days, IV ibuprofen does not have a limit on duration of use, although one would expect this formulation to be limited to time periods when patients are unable to tolerate oral medications. An important medication safety consideration is the availability of another ibuprofen formulation for injection, ibuprofen lysine, for use in the closure of patent ductus arteriosus in premature infants. Given the differing indications and dosing between these 2 IV formulations of ibuprofen, inadvertent substitution of these products could result in patient harm. Another important safety concern to note is that in September 2012, Cumberland Pharmaceuticals, the manufacturer of IV ibuprofen, issued a statement recommending that only Baxter Viaflex and Hospira 250 mL bags be used when diluting the product due to reports received indicating possible incompatibility with B Braun PAB, Hospira VisIV , and Baxter AVIVA bags.8
Chronic Pain Management
As noted above, a multimodal approach to pain management is often considered ideal, especially in the setting of chronic pain, where use of long-term opioids can increase the risk of many medication-related problems. Below, several non-opioid medication options for use in both nociceptive and neuropathic pain are reviewed.
Anticonvulsants
Gabapentin and pregabalin (Lyrica) have established efficacy and are typically considered first-line medications in various types of neuropathic pain.9 Gabapentin is initially started at a lower dose (300 to 600 mg per day) to limit side effects such as drowsiness and dizziness and titrated as tolerated to an effective dosage typically considered to be between 1800 and 3600 mg per day. In 2011 a once-daily gabapentin formulation (Gralise) was approved.10 This product was intended to overcome the dose-limiting side effects of drowsiness and dizziness often seen with regular-release gabapentin by allowing for plasma levels to peak overnight. Currently the once-daily gabapentin formulation is approved for the management of postherpetic neuralgia and has a recommended dose titration to reach a daily dose of 1800 mg within 2 weeks.10 There is no evidence that the once-daily gabapentin formulation confers better tolerability compared with regular-release gabapentin; however, it may be a reasonable option in patients who are unable to reach effective doses of regular-release gabapentin due to side effects. Other anticonvulsants such as lamotrigine, lacosamide, topiramate, carbamazepine, oxcarbazepine, and valproic acid have been studied in the setting of neuropathic pain but are typically considered only when patients have failed multiple other agents due to their limited evidence.9
Serotonin and norepinephrine reuptake inhibitors
Duloxetine (Cymbalta) is FDA approved for management of diabetic peripheral neuropathy, fibromyalgia, and chronic musculoskeletal pain.11 A desirable effect of duloxetine in the setting of chronic pain is thought to be improvement in depression. Duloxetine is typically dosed for painful conditions as 30 mg once daily and then titrated to 60 mg once daily after 1 week if tolerated.9 The most common adverse effect seen with duloxetine is nausea.11 Due to reported cases of hepatic failure with use of duloxetine, its use in patients with hepatic impairment or alcohol abuse is not recommended.11 Venlafaxine has also demonstrated efficacy in the setting of diabetic peripheral neuropathy9 and is available generically, whereas duloxetine is still available only as a brand-name medication.
Tricyclic antidepressants
Tricyclic antidepressants such as amitriptyline, desipramine, and nortriptyline have shown benefit in the setting of postherpetic neuralgia, diabetic peripheral neuropathy, post-stroke pain, and polyneuropathy.12 These agents are often preferred due to low cost; however, their use may be limited by their anticholineric side effects (xerostomia, constipation, urinary retention) and potential for cardiac toxicity. Because of these potential side effects, caution is advised for use in elderly patients. A desirable effect of these agents is improvement in depression and sleep disruption, common problems among chronic pain patients. Amitriptyline, desipramine, and nortriptyline are all initially dosed as 25 mg at bedtime and increased by 25 mg every 3 to 7 days as tolerated to a maximum of 150 mg at bedtime.9 TCAs used in the setting of chronic pain are typically increased until pain is adequately controlled or side effects occur. As with many agents used in chronic pain, an adequate trial with TCAs is considered to be several weeks.
Topical NSAIDs
Various formulations of topical diclofenac are available, including Voltaren gel, Pennsaid solution, and Flector patch, and are used in the setting of osteoarthritis or musculoskeletal pain. In clinical practice, these agents are often considered when there is a contraindication to oral NSAID therapy, such as cardiovascular disease, kidney impairment, or history of gastrointestinal bleed, as the systemic absorption of diclofenac with these formulations is low. For example, the amount of diclofenac that is systemically absorbed from Voltaren gel is on average 6% of the systemic exposure from an oral form of diclofenac.13 Voltaren gel is approved for the relief of the pain of osteoarthritis of joints such as the knees and those of the hands but was not evaluated for use on joints of the spine, hip, or shoulder.13 Recommended dosing for Voltaren gel is 4 grams to the affected area 4 times daily on joints of the lower extremities and 2 grams to the affected area 4 times daily to joints of the upper extremities.13 Pennsaid is indicated for management of osteoarthritis of the knees only and its recommended dose is 40 drops on each painful knee 4 times a day.14 Flector patch is dosed as 1 patch to painful area twice daily and is indicated for acute pain due to minor strains, sprains, and contusions.15 No direct comparison between the various topical diclofenac formulations has been performed and in clinical practice choice of an agent is often left to patient preference of a particular dosage formulation: gel, solution, or patch.

Dr. McKnight is a clinical pharmacist at the University of North Carolina Hospitals Pain Management Center in Chapel Hill, North Carolina
References

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