Medication Management of Pain

Medication Management of Pain:

Medication management should only be carried out by appropriately trained and experienced physicians, observing all safety, efficacy, and prescribing guidelines noted in the package inserts of these or other utilized medications.  Care should be consistent with accepted NSAID, opiod and neuropathic pain prescribing guidelines. [1-9] Clinical judgment should be used to appropriately individualize each patient’s medication regimen to maximize safety and efficacy.  The following represents a brief outline of options.  Please refer to the referenced articles for further guidance.

Approved Risk Evaluation and Management Strategies (REMS) certification options, helpful in the management of narcotic and other medications, can be found at:

http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm111350.htm

Colorado DORA Controlled Substances Guide:

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Washington State Agency Directors Opioid Policy:

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CDC Opioid Guidelines 2016:

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Medications

Suggested:

  1. Trial of oral NSAIDS, in therapeutic doses, for at least one week prior to change to “as needed” use unless contraindicated.
  2. Acetaminophen, aspirin, or other OTC analgesics

Optional:

  1. Oral corticosteroids (methylprednisolone dose pack or dexamethasone 4mg t.i.d. x 6 doses) – p.r.n. max. of 2 total courses
  2. Calcium channel modulator (gabapentin, pregabalin)
  3. Muscle relaxant trial(s): cyclobenzaprine, metaxalone, other
  4. Secondary amine TCA (nortriptyline, desipramine), or SNRI (duloxetine, venlafaxine, others)

Additional:

  1. Clonazepam, baclofen used judiciously
  2. Alpha-2 adrenergic agonist trial (e.g. tizanadine, clonidine)
  3. Other anticonvulsants (e.g. topiramate, lamotrigine, carbamazepine)
  4. Opiates – short or long acting
  5. NMDA receptor antagonists (e.g. dextromethorphan, methadone)
  6. Topical mono or poly-pharmaceutical preparations

1.            Dworkin, R.H., et al., Recommendations for the pharmacological management of neuropathic pain: an overview and literature update. Mayo Clin Proc, 2010. 85(3 Suppl): p. S3-14.

2.            Chou, R., Pharmacological management of low back pain. Drugs, 2010. 70(4): p. 387-402.

3.            Barkin, R.L., Nonopioid analgesics for osteoarthritis: availability of topical NSAIDs. J Pain Palliat Care Pharmacother, 2010. 24(2): p. 180-1.

4.            Barkin, R.L., et al., Should Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) be Prescribed to the Older Adult? Drugs Aging, 2010. 27(10): p. 775-89.

5.            Attal, N., et al., EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol, 2010. 17(9): p. 1113-e88.

6.            Tan, T., et al., Pharmacological management of neuropathic pain in non-specialist settings: summary of NICE guidance. BMJ, 2010. 340: p. c1079.

7.            Saarto, T. and P.J. Wiffen, Antidepressants for neuropathic pain: a Cochrane review. J Neurol Neurosurg Psychiatry, 2010.

8.            Fick, D.M., et al., Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med, 2003. 163(22): p. 2716-24.

9.            Argoff, C.E., et al., Multimodal analgesia for chronic pain: rationale and future directions. Pain Med, 2009. 10 Suppl 2: p. S53-66.

NASAL NALOXONE (NARCAN) FDA INFORMATION:

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