Pain Treatment Selection: Which Is Best?

Finding the right therapeutic approach for a patient does not have to be a challenging task for clinicians specializing in the treatment and management of pain. More often than not, pain management specialists are required to use more than one approach for patients with painful conditions. At the end of the day, it is up to the expert to make the final decision on the most effective treatments for his or her own patient.

Classifying the type of pain a patient is experiencing—sympathetic, neuropathic, visceral, somatic, or nociceptive—is where treatment begins.

“It is important to have an understanding of the mechanism of drug binding in order to apply this to drug therapeutics,” said Tanya J. Uritsky, PharmD, BCPS, a clinical pharmacy specialist at the Hospital of the University of Pennsylvania. “A common misconception is that if a drug in a particular class does not work, that an alternative within the same class is not an option—but this is not true.”

If an agent within a drug class does not work, an alternative within the same class may still yield results, Dr. Uritsky told conference attendees. She also reminded the audience that  patients typically will not immediately feel any pain relief.

“Many of these drugs take time to work. Often painful conditions do not occur overnight; therefore, careful drug selection, dose titration, and a variety of modalities may need to be employed to successfully achieve an acceptable level of pain control,” she said. “Additionally, patients may expect to experience no pain at all, which is often not achievable with available medication therapies.”

Selecting the right medication also depends on how it can complement nonpharmacologic modalities. Even within the same class, there are a variety of agents available for a pain management specialist to choose among.

“Agent selection should be based on patients and drug-related variables that may provide compelling indications,” Dr. Uritsky said. “Also, remember that there are evidence-based guidelines to help guide practitioners in making good therapeutic decisions.”

Opioid analgesics can be an appropriate modality for patients with painful conditions; there are several classes and multiple routes of administration to consider.  Guidelines are also available to instruct clinicians on appropriate dosing. Opioid-related adverse effects are myriad and can involve the central nervous system, as well as gastrointestinal, genitourinary, integumentary, metabolic, cardiovascular, hepatic, renal, ocular, and immune function.

Dosing of opioids can be particularly challenging in individuals with renal or hepatic compromise and warrants special consideration, Dr. Uritsky cautioned.  In addition, special consideration should be made to opioid administration in both very young and very old individuals.

Non-opioid options for pain include nonsteroidal anti-inflammatory drugs (NSAIDs) such as celecoxib, diclofenac, ibuprofen, and naproxen. As with opioids, NSAIDs are associated with adverse effects impacting the gastrointestinal, cardiovascular, and renal systems, among others.  Other adjuvant treatment options for pain include antidepressants, anticonvulsants, anesthetics (eg, lidocaine), capsaicin, and muscle relaxants.

There are a variety of ways healthcare professionals can stay up to date on the latest happenings in the pain management field: attending conferences (such as PAINWeek) is one of the best ways to gain insight, discuss treatments, and partake in insightful and meaningful conversations.

“It creates an opportunity to get updated on the literature and new evidence and modalities, and it provides an opportunity to interact with colleagues in the same field or with the same interests,” Dr. Uritsky said. “Receiving journal updates and bulletins can also help as new information becomes available. Refreshing oneself on therapeutics as often as new things come out is ideal.”

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