Acute pain, treatment

In the initial stages of acute pain treatment, analgesics should be given around the clock. As the painful state subsides, as-needed schedules can be used. Around-the-clock administration is also useful for management of chronic pain. 

Opioids are used for the treatment of moderate to severe or very severe pain of acute or chronic type (Stein, 1999). Nearly all forms of pain are sensitive to opioid treatment and in contrast to traditional opinions even neuropathic pain is reasonably sensitive to higher doses of opioids. This was clearly shown in well-controlled clinical studies (Watson, 2000). The most important use of opioids in acute pain treatment is postoperative pain, whereas treatment of cancer pain, often accompanied by a neuropathic pain component, is the classical domain of chronic opioid treatment. 

Educating the Patient and Famiiy The nurse instructs patients under treatment for narcotic addiction to wear or carry identification indicating that they are receiving naltrexone If the patient is taking naltrexone and requires hospitalization, it is important that all medical personnel be aware of therapy with this drug. Narcotics administered to these patients have no effect and therefore do not relieve pain. Fhtients receiving naltrexone may pose a problem if they experience acute pain. The primary health care provider must decide what methods must be used to control pain in these patients. 

Promoting an Optimal Response to Therapy The patient with a musculoskeletal disorder may be in acute pain or have longstanding mild to moderate pain, which can be just as difficult to tolerate as severe pain. Along with pain, there may be skeletal deformities, such as the joint deformities seen with advanced rheumatoid arthritis. For many musculoskeletal conditions, drug therapy is a major treatment modality. Therapy with these drugs may keep the disorder under control (eg, therapy for gout), improve the patient s ability to carry out the activities of daily living, or make the pain and discomfort tolerable. 

Opioid dependence rarely results ftom the prescribing of opioids temporarily for treatment of acute pain or pain of terminal illness. Even use in chronic... 

Opioids are considered the agents of choice for the treatment of severe acute pain and moderate to severe pain associated... 

American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 5th ed. Glenview, IL American Pain Society, 2003 13MT. 

Owing to the lag time between initiation and effect, capsaicin is not used for treatment of acute pain from injury. Instead, topical capsaicin is used for chronic pain from musculoskeletal and neuropathic disorders. Capsaicin preparations have been studied in the treatment of pain from diabetic neuropathy, osteoarthritis, rheumatoid arthritis, postherpetic neuralgia, and other disorders.48 It is often used as an adjuvant to systemic analgesics in these chronic pain conditions. 

Patients with acute gout should be monitored for symptomatic relief of joint pain as well as potential adverse effects and drug interactions related to drug therapy. The acute pain of an initial attack of gouty arthritis should begin to ease within about 8 hours of treatment initiation. Complete resolution of pain, erythema, and inflammation usually occurs within 48 to 72 hours. 

In acute pain, comorbid conditions are usually not present, and outcomes of treatment are generally predictable. In chronic pain, comorbid conditions are often present, and outcomes of treatment are often unpredictable. 

Data from American Pain Society. Prinaples of Analgesic Use in the Treatment of Acute Pain and Chronic Cancer Pan, 5th ed. Glenview, IL American Pain Society, 2003 Anonymous. American Hospital Formulary Service. In Mc/oyGK, ed. Drug Information. Bethesda, MD American Society of Hospital Pharmacists, 1987, 1991, 1994, 1997, 1999,2001,2003,2004,2005,2006,2007 Anonymous. Facts and Comparisons. Philadelphia Lippincott, 1986, 1991, 1994, 1997,2000,2003,2004,2006,20Q7 and Watkins PB, Kaplowitz N, Slattery TJ, et al. Aminotransferase elevations in healthy adults receiving 4 grams of acetaminophen daily A randomized controlled trial. JAMA 2006 296 87-93. 

Patients tolerant to or physically dependent on op/o/c/s. Nalmefene may cause acute withdrawal symptoms in individuals who have some degree of tolerance to and dependence on opioids. Closely observe these patients for symptoms of withdrawal. Administer subsequent doses with intervals of at least 2 to 5 minutes between doses to allow the full effect of each incremental dose of nalmefene to be reached. Reversal of postoperative opioid depression Use 100 mcg/mL dosage strength (blue label) refer to the following table for initial doses. The goal of treatment with nalmefene in the postoperative setting is to achieve reversal of excessive opioid effects without inducing a complete reversal and acute pain. This is best accomplished with an initial dose of 0.25 mcg/kg followed by 0.25 mcg/kg... 

Acute pain is a warning signal and it is necessary to take a medical history and make the appropriate investigations to make a diagnosis and to give causal treatment. In pain of a more chronic nature an analysis of the origin of the pain and its character must be made in order to give the correct treatment (Table 1). 

Celecoxib has been approved for the treatment of osteoarthritis and rheumatoid arthritis, and rofecoxib has been approved for the treatment of osteoarthritis, acute pain and primary dysmenorrhea. Celecoxib and rofecoxib do not appear to differ in efficacy for the treatment of osteoarthritis. However, neither drug has efficacy greater than that of the non-selective NSAIDs. Since the COX-2 enzyme appears to play an important role in colon cancer the COX-2 inhibitors may find future uses in the treatment or prevention of colorectal cancer. 

Etodolac (Lodine) is indicated for the treatment of osteoarthritis, rheumatoid arthritis, and acute pain. It inhibits COX-2 with slightly more selectivity than COX-1 and therefore produces less GI toxicity than many other NSAIDs. Common adverse effects include skin rashes and CNS effects. 

Rofecoxib is approved for the treatment of osteoarthritis, dysmenorrhea, and acute pain. The most common adverse reactions to rofecoxib are mUd to moderate GI irritation (diarrhea, nausea, vomiting, dyspepsia, abdominal pain). Lower extremity edema and hypertension occur relatively frequently (about 3.5%). It is not metabohzed by CYP2C9, so rofecoxib should not be subject to some of the interactions seen with celecoxib. However, its metabolism is increased by the coadministration of rifampin, which acts as a nonspecific inducer of hepatic metabolism. 

Psychostimulant medication can be useful in the treatment of severe, acute pain, such as that seen during a sickle cell crisis (Yaster et al., 2000). Dextroamphetamine and methylphenidate are also effective as adjuvants, as they have independent analgesic effects, and potentiate the effects of opioid analgesics. The increase in alertness afforded by the use of psychostimulants can also allow the use of larger doses of opioids (Yaster et al., 2000). Methylphenidate and dextroamphetamine have been used to diminish the sedative effects of opioid analgesic medication (Yee and Berde, 1991) in adolescent patients with malignancies or sickle crisis, and may also potentiate the effects of analgesics. Doses used by Yee and Berde (1991) were 2.5 to 10 mg bid of methylphenidate, or 2.5 to 5 mg bid of dextroamphetamine. 

The FDA approves Vioxx, an anti-inflammation drug for treatment of osteoarthritis and some other conditions that cause acute pain. 

Dosages and routes of administration For acute (postoperative) pain and for anesthesia, fentanyl is given by the intravenous route. For pre-medication in anesthesia and for break-through pain the compound can also been given as an oral-transmucosal formulation (Ashburn and Streisand, 1994). A transdermal patch has been developed for chronic pain treatment (Jeal and Benfield, 1997 O Siordin, 1998). The intravenous doses for premedication are 50-100 pg, oral-transmucosal systems contain 200-400 pg and patch formulations have a delivery rate of 25-100 pg/h. 

Analgesic efficacy and clinical use Morphine (Benyhe, 1994) is a very potent analgesic and is used for the treatment of moderate to severe acute and chronic pain of various origins. It is more active in nociceptive and in inflammatory as compared to neuropathic pain and is regarded as the gold standard for pain treatment (Coluzzi,1998). 

In preclinical tests, antidepressants can also be effective in acute pain models, but in humans the acute analgesic effects are rather small and of no therapeutic relevance. When used as adjunctive treatment, usually doses lower than those required for the treatment of depression are sufficient for improvement of pain, reducing the side-effects arising from this adjunctive treatment. However, antidepressant treatment has clear beneficial effects only in a proportion of patients (McQuay and Moore, 1997) and may not be equally effective in all chronic pain states (Onghena and van Houdenhove, 1992). 

Assuming that we can apply these results to the human situation, CGRP1 antagonists may also be effective for treatment of chronic inflammatory and visceral pain but not for acute pain. A thorough evaluation of this receptor in neuropathic pain is still missing. 

Meperidine is occasionally used in outpatients for the treatment of acute pain, especially if other opioids prove ineffective. Its use for chronic pain is less accepted. Meperidine is eliminated from the body more quickly than other opioids, which means it must be taken more frequently, and its analgesic effects fluctuate more rapidly. 

Rofecoxib is approved for the treatment of acute pain and dysmenorrhea at a dose of 50 mg for up to 5 days. The clinical studies indicate that rofecoxib shows efficacy similar to that produced by the maximum analgesic doses of naproxen and ibuprofen (Ehrich et al., 1999). The pain settings in which rofecoxib has been tested include acute postoperative dental pain, the pain of dysmenorrhea for up to 3 days, and postoperative pain for 5 days following surgical replacement of the knee or hip. In contrast, celecoxib is not approved in the United States for the treatment of acute pain, and it appears to be less effective when given acutely than rofecoxib, ibuprofen, or naproxen. The explanation for the differences between rofecoxib and celecoxib in acute pain is not known. 

Fortunately, acute pain goes away relatively quickly, either on its own or with medication or other medical treatment. However, millions of people suffer from some form of pain that is chronic (i.e., it lasts for years, sometimes for most of the person s life). Chronic pain causes not only terrible suffering to the individual, but also severe economic and social consequences, such as the inability to work or spend time with family. Chronic pain often results in depression, addiction to pain medications, and, in rare instances, suicide. Below are some medical conditions that are characterized by chronic pain ... 

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