Pain Management

Pain is the most common reason for seeking medical attention in primary health care, most of the diseases described on this site cause pain, and the best management of this symptom is often poorly achieved. While pain relief in hospices and some specialist units is good, and the majority of cases, in part due to lack of understanding of both the pharmacology and cause of the pain by health practitioners, many patients suffer unnecessarily. There are a number of approaches to treating pain, and in most cases for significant discomfort, a number of these should be used together.
Reassurance or creating contentment can make you major difference to the need for the more powerful analgesic drugs. For this reason it is important for the health practitioner to spend time talking about the pain, the condition causing the pain and the patient's expectations, and provide as much support and reassurance as possible.

Drugs:

  • Non-opioid analgesics – aspirin, paracetamol (acetaminophen), non-steroidal anti-inflammatory drugs (NSAIDs).
  • Narcotics and opioids (tramadol, morphine, fentanyl, dihydrocodeine, oxycodone.
  • Antidepressants – tricyclic (amitriptyline, doxepin, imipramine, nortriptyline, desipramine and serotonin nor epinephrine reuptake inhibitors (SNRIS) [ venlafaxine, desvenlafaxine, duloxetine, and milnacipran.] – These drugs appear to have pain relieving properties as well as antidepressant actions.
  • Antiepileptic drugs – gabapentin and pregabalin – these are especially effective in nerve related pain.
  • Muscle relaxants – tight muscles especially run joints can increase inflammation and make pain worse.
  • Topical analgesic agents. – lidocaine is sometimes helpful in nerve pain (e.g. after shingles), capsaicin cream is derived from chili peppers does appear to have some week pain relieving effect in nerve pain. Topical NSAIDs provides modest relief for musculoskeletal pain.
  • Opioids – ideally these should be kept only for patients with severe pain, usually associated with cancer. Sometimes however they are used in other situations such as diabetic neuropathy, low back pain, chronic pancreatitis and severe fibromyalgia – when these conditions are unresponsive to other pain relief therapies. They are divided into immediate action preparation (morphine, oxycodone, tramadol), and long acting preparations (fentanyl patch, dihydrocodeine ER, morphine sulphate ER, oxycodone ER, tramadol ER).
    Because of the dangers of addiction, tolerance (requiring higher doses), and adverse effects the opioid should only be used (other than in cancer patients) when other treatments have failed, and should also be used in conjunction with other drugs so lower doses of the opioid is necessary.

Other drugs which are frequently used include antispasmodic drugs to reduce muscle spasm (baclofen), Botox – by poisoning nerves can help some nerve pain is especially postherpetic neuralgia; benzodiazepines (Librium and Valium) to reduce anxiety but their efficacy is uncertain.

Other pain controlling therapies – because pain is a combination of both physical and psychological derangements, then many therapies that do not necessarily have a physical or pharmacological action are also very effective. These include:

  • Cannabis and cannabinoids – their uses controversial, even though a number of trials have shown significant benefit. Most trials confirm it is very likely that these are helpful in chronic pain and neuropathic pain.
  • Acupuncture – many studies this treatment has shown a significant reduction in pain, it is poorly understood by modern medicine but when one sees people having open heart surgery with purely acupuncture for pain relief, (click here) it is obvious this ancient treatment is effective.  Acupressure which doesn't require needles is also effective.  (We have recently found an acupressure mat (Shakti mat, which one lies on,  is very effective in reducing muscle and other pains without requiring a specialist practitioner)
  • Massage therapy – a review of many trials (click here ) show that massage has a weak anti-pain effect, but is additive to other treatments. It also makes pain and life more tolerable.
  • Exercise – particularly in people with low back pain, exercise, aerobics, flexibility training, stretching, yoga, have all been shown to be beneficial in reducing pain, and preventing relapse.
  • Tumeric – this commonly used spice, contains curcumin which has properties very similar to the Cox2 inhibiting NSAIDs it has been shown to be very effective in treating pain, particularly muscular and joint pain (click here).
  • Essential oils such as lavender, marjoram, chamomile, sandalwood, wintergreen, clove, fennel, frankincense, ginger can be used as aromatherapy, massage over a painful area or included in a bath tub.
  • Homeopathy – while this treatment is pooh-poohed by the conventional medical pundits, there have been trials  which show that is can be effective particularly with low back pain.

 

With the large number of therapies all working in different ways, affecting different forms of pain, it is understandable why health practitioners are often confused as to the best form of treatment to offer a patient with pain.

Some general guidelines:

  • Multiple approaches are more effective than just a single form of therapy, including both drugs, physical medicine, behavioral medicine and other therapies.
  • The type of pain is important in choosing the most appropriate drug - nerve pain (antidepressants, gabapentin, and sometimes opioids are required), musculoskeletal pain response best to non-steroidal drugs, and for many intestine pains, antispasm therapies can also be effective.
  • It is of an effective to have a base line analgesic therapy (e.g. paracetamol 500 – 1000 mg 4 times a day) and then either give a short-acting more powerful analgesic on top, when there is breakthrough pain. This often means that a lower dose of the more powerful agent is necessary.
  • The use of opioids in noncancer pain is fraught with difficulty, and should be avoided if possible. (Pain relief in cancer patients is discussed in the cancer segment).