Mount Carmel Health Partners Clinical Guidelines Chronic Pain Management

Pharmacologic Treatment Neuropathic pain: Initial treatment usually includes antidepressants or calcium channel alpha2-delta ligands with adjunctive topical therapy (lidocaine). Opioids are second-line treatment. Nociceptive pain: Treatment includes non-narcotic and opioid analgesia, first-line therapy include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) Acetaminophen • Recommended for management of hip or knee osteoarthritis • Commonly combined with opioid medications to reduce amount of opioid needed • Overdose can lead to severe hepatotoxicity Nonsteroidal anti-inflammatory drugs (NSAIDs) • Indicated for mild or moderate pain of somatic origin, i.e., soft tissue injury, sprains, headaches, arthritis • Adverse effects: inhibition of platelets, interactions with antihypertension drugs, warfarin and low-dose aspirin, dyspepsia, gastric ulceration, nephrotoxicity, fluid retention, and hepatic toxicity Opioids • Reserved for patients with moderate to severe chronic pain that adversely impacts function or quality of life • Patients should be assessed for the risk of substance abuse, misuse, and addiction • Meperidine should not be used for chronic pain because of CNS toxicity and availability of less toxic and more effective alternatives • Selection of opioid regimen should be individualized and dose titrated until the goal for pain is achieved or side effects limit further dose escalation • Opioid agreements and/or contracts and informed consent regarding risks and benefits of treatment foster adherence to the treatment program, limit potential for opioid abuse, and improve efficiency of the pain treatment program • Monitoring should take place at each visit (at least every 1 to 3 months) and include documentation of pain intensity, functional status, progress toward goals, adverse effects, and adherence to the treatment • Periodic urine drug screens are recommended for patients who are at high risk for aberrant drug related behaviors • To discontinue therapy, a slow taper of a 10 percent dose reduction per week will minimize withdrawal symptoms • Side effects include: nausea, vomiting, constipation, opioid-induced hyperalgesia, narcotic bowel syndrome, and somnolence Anticonvulsants • Gabapentin: effective treatment for postherpetic neuralgia and painful diabetic neuropathy • Pregabalin: effective treatment for postherpetic neuralgia, painful diabetic neuropathy, central neuropathic pain and fibromyalgia; can cause euphoria and is a Schedule V controlled substance Antidepressants • Tricyclic antidepressants: believed to have independent analgesic effects as well as ability to relieve depressive symptoms; adverse effects include anticholinergic and antihistamine effects; side effects include: sedation, constipation, mental clouding, orthostatic hypotension, urinary retention and dry mouth. • Serotonin norepinephrine reuptake inhibitors: - Venlafaxine: effective in painful diabetic peripheral neuropathy and polyneuropathies of different origins; use with caution in patients with cardiac disease due to possibility of cardiac conduction abnormalities and increase blood pressure; taper when discontinuing due to withdrawal symptoms. - Duloxetine: effective treatment of painful diabetic neuropathy, fibromyalgia, chronic low back pain, and osteoarthritis; side effects include nausea, dry mouth, insomnia, drowsiness, constipation, fatigue, and dizziness. - Milnacipran: FDA-approved for treatment of fibromyalgia but not depression Adjuvant Medications Used to treat side effects of pain medication and/or potentiate analgesia. • Benzodiazepines: may be utilized in patients with anxiety disorder; disadvantages: addictive potential, sedative effects, and respiratory depression in patients who currently use opioids • Antispasmodics: may cause CNS depression • Topical agents: 1) Lidocaine for neuropathic pain 2) Capsaicin cream for post herpetic neuralgia, HIV neuropathy, and diabetic neuropathy 3) Topical nonsteroidal anti-inflammatory drug chronic low back pain, widespread musculoskeletal pain and peripheral neuropathic pain Ziconotide • Intrathecal analgesic therapy should be reserved for intractable severe pain with significant impact on quality of life that is refractory to all other treatments • Patients with preexisting history of psychosis should not be treated with ziconotide • Should only be used in patients with no other reasonable options for pain control Chronic Non-Cancer Pain Management - 3

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