Pain type guides medication prescribed

Somatic (nociceptive) pain: Acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs caution in older adults) and opioids (long-acting preferred); trial of adjuvants (see Table 2) for refractory symptoms.

Neuropathic pain: Serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), anticonvulsants, lidocaine patch, tramadol and opioids. (SSRIs and NSAIDs often ineffective.)

Centralized pain/Fibromyalgia: TCAs (amitriptyiline, cyclobenzaprine), SNRIs (duloxetine) and alpha-2-delta ligands (pregabalin and gabapentin) are effective for conditions such as fibromyalgia. Serotonin-selective reuptake inhibitors (SSRIs) can also be useful. (Opioids are not indicated.)

The Opioid Dilemma


Recent studies indicate a dramatic increase in accidental deaths associated with the use of prescription opioids and an increasing average daily morphine equivalent dose (MED) of the most potent opioids since 19991-3. Between 1999–2006, people aged 35–54 years had higher poisoning death rates involving opioid analgesics than those in any other age group4.
In response to the increasing morbidity and mortality associated with the increasing use of opioids, the Centers for Disease Control and Prevention5 has
1 The AMDG consists of the medical directors from these WA State Agencies: Corrections, Social and Health Services (Medicaid), Labor and Industries, and the Health Care Authority
released several recommendations for how health care providers can help. The recommendations include:
 
  • Use opioid medications for acute or chronic pain only after determining that alternative therapies do not deliver adequate pain relief. The lowest effective dose of opioids should be used
  • In addition to behavioral screening and use of patient agreements, consider random, periodic, targeted urine testing for opioids and other drugs for any patient less than 65 years old with noncancer pain who has been treated with opioids for more than six week
  • If a patient’s dosage has increased to 120 mg MED per day or more without substantial improvement in function and pain, seek a consult from a pain specialist.
  • Do not prescribe long-acting or controlled- release opioids (e.g., OxyContin®, fentanyl patches, and methadone) for acute pain.