Clinicians should ask about the nature, severity,

timing, location, quality, and aggravating and

relieving factors of the pain.
Distinguishing between somatic, visceral, and
neuropathic pain is essential to proper tailoring
of pain treatments.
 The goal of pain management is properly
decided by the patient.
While some patients may :
o wish to be completely free of pain even at the
cost of significant sedation
o most will wish to control pain at a level that still
allows maximal functioning
 Chronic severe pain should be treated continuously.
For ongoing pain, one can give a long-acting analgesic
around the clock plus a short-acting drug as needed for
"breakthrough" pain.
 The oral route of administration is preferred because it
is easier to administer at home, is not painful, and
imposes no risk from needle exposure.
 Rectal, transdermal, and subcutaneous administration
are also frequently used, as is intravenous
administration when necessary.
 Patient-controlled analgesia (PCA) of intravenous
medications is appreciated b} patients, may lead to less
medication use, and has been adapted for use with oral
administration.
When possible, the cause of pain should be
diagnosed and created, assuming that the burden
of these efforts does not increase the patient's
suffering.
Removing the underlying cause of pain can
preempt the need for ongoing treatment with
analgesic medications along with their side
effects.
Regardless of decisions about seeking and
treating the underlying cause of pain, however,
prompt symptomatic relief of pain should be
offered to every patient.
Typically, pain can be well controlled with
analgesic medications, both opioid and
nonopioid.
 For mild to moderate pain, acetaminophen,
aspirin, and nonsteroidal antiinflammatory drugs
(NSAIDs) may be sufficient.
 For moderate to severe pain, analgesics that
include those agents combined with opioids may
be helpful.
Severe pain typically requires pure opioid
agonists.
 Appropriate doses of acetaminophen may be just as
effective as an analgesic and antipyretic as NSAIDs, but
without anti-inflammatory effects and without the risk of
gastrointestinal bleeding or ulceration.
 Acetaminophen can be given at a dosage of 500-1000 mg
orally every 6 hours, though it can be taken every 4 hours
as long as the risk of hepatotoxicity is kept in mind.
Hepatotoxicity is a concern at doses greater than 4 g/d
chronically, and doses for elderly patients and those with
liver disease generally should not exceed 2 g/d.
 Aspirin (325-650 mg orally every 4 hours) is an effective
analgesic, antipyretic, and anti-inflammatory medication.
Gastrointestinal irritation and bleeding, bleeding from
other sources, allergy, and an association with Reye's
syndrome in children and teenagers limit its use.
 Like aspirin, the NSAIDs are antipyretic, analgesic, and anti-
inflammatory.
 NSAIDs inhibit prostaglandin synthesis, inhibiting platelet
aggregation and consequently increasing the risk of
gastrointestinal bleeding by 1.5 times normal. The risks of
bleeding and nephrotoxiciry from NSAIDs are both
increased in the elderly. Gastrointestinal bleeding and
ulceration may be decreased with the concurrent use of
proton pump inhibitors (eg, omeprazole, 20-40 mg orally
daily) or with the new class of NSAIDs that inhibit only
cyclooxygenase-2.
 COX-2 inhibitors include celecoxib (100 mg/d to 200 mg
twice daily orally), rofecoxib (12.5-50 mg/d orally), and
valdecoxib (10 mg/d orally).
 The NSAIDs, including COX-2 inhibitors, can lead to
exacerbations of congestive heart failure and should be
used with caution in patients with that disorder.
 Opioids are appropriate for severe pain due to any cause.
 Full opioid agonists such as morphine, hydromorphone,
oxycodone, methadone, fentanyl, hydrocodone, and
codeine are used most commonly. Hydrocodone and
codeine are typically combined with acetaminophen or an
NSAID.
 Short-acting formulations of oral morphine sulfate (starting
dosage 4 mg orally every 3-4 hours), hydromorphone (1 mg
orally every 3-4 hours), or oxycodone (5 mg orally every 3-4
hours) are useful for acute pain and as rescue treatment for
patients experiencing pain that breaks through long-acting
medications.
 For chronic stable pain, one should give sustained-release
morphine (two or three times a day), oxycodone (two or
three times a day), methadone (three or four times a day),
or transdermal fentanyl (starting dose 25 gg every 3 days,
with 24-40 hours required to achieve full analgesia).
Meperidine is not useful for chronic pain because
it has a short half-life and a toxic metabolite that
can cause irritability and seizures.
The dosages of any full opioid agonists used to
control pain can be translated into an equivalent
dose of any other opioid. In this way, 24-hour
opioid requirements and dosing regimens
established initially using shorter-acting opioid
medications can be translated into equivalent
dosages of longer-acting medications or
formulations.
 Some clinicians and patients inexperienced with the
management of severe chronic pain may feel more
comfortable with combined nonopioid-opioid agents,
because of the toxicities of acetaminophen and NSAIDs
at higher doses, full agonist opioids provide more
flexibility in dosing and the dose may be increased as
required for more effective analgesia.
 While physiologic tolerance is possible with opioids,
failure of a previously effective opioid dose to
adequately relieve pain is usually due to an increase in
the underlying pain. In this case, for moderate pain,
the dosage of opioid can be increased by 25-50%. For
severe pain, a dosage increase of 50-100% may be
appropriate.
 In addition, chronic dosing may be adjusted by adding
the amount of short-acting opioid necessary for
breakthrough pain over the long-acting medication
dose
 In establishing or reestablishing adequate dosing,
frequent reassessment of the patients pain and
medication side effects is necessary
 As dosages of opioids are increased, increasing
difficulty with the side effects of opioid is to be
expected.
 Constipation is common and should be anticipated and
prevented in all patients.
Sedation can expected with opioids, though
tolerance to this effect typically develops within
24-72 hours at a stable dose.
Sedation typically appears well before significant
respiratory depression.
If treatment for sedation is desired,
dextroamphetamine (2.5-7.5 mg orally at 8 AM
and noon)may be helpful.
Some patients even use caffeinated beverages to
help manage minor opioid sedation
Although sedation is more common, patients may
experience euphoria when first taking opioids or
when the dosage is increased.
However, patients generally develop tolerance to
this effect after a few days at a stable dose.
At higher doses of opioids, patients may develop
multifocal myoclonus.
This symptom will typically resolve after lowering
the dose or switching opioids.
While waiting for the level of the offending
medication to fall, low doses of clonazepam or
dantrolene may be helpful for treating myoclonus
Nausea due to opioids may occur with inittiation
of therapy and resolve after a few days.
If it is severe or persistent, it can be treated with
prochlorperazine, 10 mg orally or intravenously
every 8 hours or 25 mg rectally every 6 hours
Although clinicians may worry about respiratory
depression with opioids, that effect is uncommon
when a low dose is given initially and titrated
upward slowly.
 Even patients with pulmonary disease can tolerate low-
dose opioids, though they should be monitored
carefully.
 Clinicians should not allow concerns about respiratory
depression to prevent them from treating pain
adequately
 True allergy (with urticaria) to opioids is rare.
 More commonly, patients will describe an intolerance
due to side effects such as nausea, pruritus, or urinary
retention in response to particular opioid.
 If such symptoms develop, they can usually be relieved
by lowering the dose or switching to another opioid.
 Although many types of pain will respond to opioids, neuropathic
pain-which patients typically describe as burning, shooting, “pins
and needles,” or electricity and which is commonly associated with
numbness may respond better to antidepressants (tricyclic anti
depressants [TCAs] in particular) and anticonvulsants like
gabapentin, clonazepam, and carbamazepine, It is therefore
essential when taking the history to listen for words that suggest
neuropathic pain.
 The TCAs are a good First choice and usually have an effect within
days and at lower doses than are needed for an antidepressant
effect. Desipramine, 25-150 mg/d orally, and nortriptyline, 25-150
mg/d orally, are good first choices as they cause less ortho- static
hypotension and have fewer anticholinergic effects than
amitriptyline.
 One can start with a low dosage (25 ing orally daily) and titrate
upward every 4 or 5 days.
 Other antidepressant medications such as sustained-
release bupropion may also be effective for neuropathic
pain; however, the selective serotonin reuptake inhibitors
(SSRIs) are not.
 The anticonvulsants can be used in the same dosages as are
used to prevent seizures.
 Because car bamazepine can cause bone marrow
suppression, a complete blood count is obtained
periodically in patients taking this drug.
 Gabapentin can cause sedation, dizziness, ataxia, and
gastrointestinal side effects and therefore should be started
at low dosages of 100-300 mg orally three times a day.
 Gabapentin is relatively save in accidental overdosage and
may be preffered over TCAs for a patient with a history of
congestive heart failure or arrhythmia or if there is a risk of
suicide.
 The lidocaine patch is effective is postherpetic
neuralgia and may be effective in other types of
neurophatic pain also.
 A new patch is applied to the painful region daily.
 Mexiletine at a starting dosage of 150 mg orally once
or twice a day can also be used for treating
neurophatic pain but should be avoided in patients
with arrhythmias.
 The dosage can be increased slowly to a maximum of
300 mg orally three times daily if side effects such as
nausea, vomiting, tremor, dizziness, unsteadiness, and
paresthesias do not limit dosing.
Baclofen can be helpful for treating lancinating or
paroxysmal neuropathic pain.
Side effects including dizziness, somnolence, and
gastrointestinal distress can be mitigated by
starting at a low dosage (5 mg orally two or three
times daily) and titrating slowly upward to a
dosage of 30-90 mg/d.
Because abrupt withdrawal from baclofen can
cause syndrome that includes delirium and
seizures, the drug should be tapered slowly
before being discontinued
 If pain cannot be controlled without uncomfortable
medication side effects, clinicians should consider
using lower doses of multiple medications rather than
larger doses of one or two medications.
 This may be particularly true for neurophatic pain.
 For bone pain, the anti-inflammatory effect of NSAIDs
can be particularly helpful.
 Radiation therapy and bisphosphonates may also
relieve bone pain.
 For same patients, such as those with pain from
pancreatic cancer, a nerve block-in this case, block of
the celiac plexus-can provide dramatic relief.
Intrathecal pumps may be useful for patients with
severe pain responsive to opioids but who
require such large doses that systemic side effect
such as sedation and constipation become
limiting.
Neurolysis, rhizotomy, or ablative surgery and
neurosurgery may be tried in selected patients
Cannabinoids have not been proven to work as
analgesics.
Chemotherapeutic agents are sometimes used
for symptom management with palliative intent.
Carticosteroids such as dexamethasone or
prednisone can be helpful for patients with
headache due to increased intracranial
pressure, pain from spinal cord compression,
metastatic bone pain, and neuropathic pain
due to infiltration of nerves by tumor.
Because of the side effects or long-term
corticosteroid administration, they are most
appopriate in patients with end-stage disease.