AUTHOR: Marc Mitnick DPM
REVIEWED BY: Podiatric Medical Review Board
TREATMENT OF PAIN
The treatment of this subjective sensation is directed at symptomatic relief and is guided by the classification of pain and patient specific factors. Acute pain is managed differently than chronic and patient allergy history, co-morbidities, medical profile contraindications and body weight/age are all factors involved in the health care provider’s decision making process.
Acute pain can be generally managed with acetaminophen (APAP, Tylenol), non-steroidal anti-inflammatory (NSAIDs), steroids (catabolic-resembling those produced by the body during physical/emotional stressors), and opioids/narcotics. By definition, usage for acute pain is of short duration and their intermittent dosage in most patients is of little risk. Chronic pain, due to the less than optimal response to analgesics (pain relievers), is different and prolonged use carries a greater patient risk of adverse reactions. Improvement or pain reduction is possible but is not always possible and patient with diagnosed chronic pain must be made aware and fully understand the outcome expectation. To reduce toxicity (adverse effect of medication) often combination of drug and non-drug treatment is utilized to increase relief of pain and lessens the possible toxicity. An example being a modality such as ice or heat and one or more analgesic with different modes of action (poly-pharmacy) in lessened dosages.
Though therapy should be regulated in a step-wise progression as individual responses vary and the efficacy of analgesics do change over time, a generalized schematic approach can be attempted for nociceptive (pain receptor stimulated) pain. For acute, non inflammatory pain, acetaminophen may be the first step, followed by low doses (i.e. OTC –over the counter) NSAIDs.. For those patients with gastric (stomach) problems the prescription medicine, Celebrex- a specific NSAID with reduced gastric complications (known as a COX-2 inhibitor) may be substituted. If no relief is experienced, a second line agent such as Tramadol may be used. The regiment is different for inflammatory acute pain; in step one low dose OTC NSAID with/without ice is indicated. In cases of chronic pain, non-drug therapy with physical therapy, heat or ice pending the problem, glucosamine for arthritic pain, and acetaminophen with a possible topicals such as capsaicin(a pepper extract) is the first step. Tramadol, then prescription strength NSAIDs with an opioid/narcotic along with patient education may be necessary.
Since analgesic efficacy may vary with prolonged treatment, patients require periodic evaluations. Though acetaminophen is indicated as mentioned for the initial treatment of osteoarthritis, patients may only experience a short period of response of relief and then will require a change in medication. Another reason for change may be poor tolerance, for example codeine which may cause constipation or too much sedation. Laboratory and other diagnostic tests may be indicated with untoward reaction to prolonged usage of NSAIDs. Renal (kidney), gastrointestinal (GI) bleeding in 1% of patients, with increases to 4% in patients over 60 years of age, necessitate examination as deemed necessary by the health care provider. Patient self medication with the increasing OTC products along with patient co-morbidities can cause deleterious reactions Goals then are a thorough understanding of the underlying pain etiology, patient’s total health and past psychological responses to pain so that therapy can be properly individualized for maximum relief with minimal risks.
References
RX Consultant, Vol IX, #5, May 2000
RX Consultant, Vol XI #5, May 2002
