Pain medicine is a part of medicine aimed to ease the suffering and improve the general quality of life of those people experiencing pain. Pain sometimes resolves straightaway once the underlying trauma or pathology has healed, and could be threaten by one practitioner, with drugs such as analgesics and occasionally anxiolytics. Effective management of continuous pain, however, often requires the corresponding efforts of the team of several doctors.
The World Health Organization define a term ‘pain ladder’ when dealing with analgesia for any type of pain. In the treatment of chronic pain, whether due to malignant or benign processes, this three-step WHO Analgesic Ladder provides guidelines for selecting the kind and quantity of the amount of analgesia. The exact medications recommended will vary from country to country and upon individual circumstances, but the following gives an example of the general approach to treating chronic pain with medications. If, at any point, treatment fails to provide adequate pain relief, then the doctor and patient move onto the next step.
Mild pain
Paracetamol (acetaminophen), or a non-steroidal anti-inflammatory drug such as ibuprofen
Mild to moderate pain
Paracetamol, an NSAID and/or paracetamol in a combination with a weak opioid such as Hydrocodone used in combination, may provide greater relief than if taken separately.
Moderate to severe pain
When treating moderate to severe pain, the type of the pain needs to be considered, whether it acute or chronic. Different types of pain require prescription of different medications. Certain medications may work better for acute pain, others for chronic pain, and some may work equally well on both. Chronic pain medication is for alleviating long-lasting, ongoing pain. Acute pain medication is for rapid beginnings of pain such as from an imposed damage or to treat post-operative pain.
Main types of pain relieving medications:
Opioids
Opioid medications can be used as a short, intermediate or long acting analgesics depending upon the specific properties of the medication and whether it is formulated as an extended release drug. Opioid medications may be used orally, by injection, via nasal or oral mucosa, rectally, transdermal, epidurally or intravenously. In case of chronic pain that is opioid responsive a combination of short acting medication for breakthrough pain in conjunction with a long acting (extended release) medication is often prescribed.
Whilst suppositories and skin patches can be prescribed, most opioid treatments are managed orally as tablets, capsules or liquids. Chronic pain patients do rarely need an opioid injection.
Although opioids are strong analgesics, they do not provide complete analgesia regardless of origin of pain (acute or chronic). Opioids are effective analgesics in chronic malignant pain and modestly effective in nonmalignant pain management. However, there are related adverse effects, especially during the beginning or change in dose. In case of use opioids for a long periods of time, chemical dependency, addiction and diversion may occur.
Non-steroidal anti-inflammatory drugs
The other major group of analgesics are non-steroidal anti-inflammatory drugs (NSAID). This class of medications does not include acetaminophen. Though acetaminophen may be received as a single medication or in combination with other analgesics both NSAIDs and opioids. The alternatively prescribed NSAIDs such as ketoprofen and piroxicam, have limited benefit in chronic pain disorders and with long term use is associated with significant adverse effects. The use of selective NSAIDs designated as selective COX-2 inhibitors is limited due to significant rising of cardiovascular and cerebrovascular risks.
Antidepressants and antiepileptic drugs
Some of antiepileptic and antidepressant drugs are used in chronic pain management and act mainly within the pain pathways of the central nervous system, however peripheral mechanisms could be attributed as well. These mechanisms are vary and in common are more effective in neuropathic pain conditions as well as complex regional pain disorders. The complete list of side effects for these classes of drugs are typically much lengthier comparing to one related to opiate or NSAID treatments for chronic pain, and moreover many antiepileptic medications cannot be promptly stopped without the risk of seizure.
Other analgesics
Other drugs are frequently used to support analgesics resist various types of pain or specific parts of the overall pain encounter. This is drugs like orphenadrine, cyclobenzaprine, trazadone and other drugs with anticholinergic capabilities which could be used together with opioids for reducing neuropathic pain. In case of painful musculoskeletal disorders again orphenadrine and cyclobenzaprine can be used as a muscle relaxants. Also, clonidine used as an analgesic for similar purpose and all of the mentioned drugs enhance the effects of opioids overall.
