NSAIDs Opioids

Superficial and deep heat Decreased muscle/joint pain and stiffness NSAIDs opioid analgesics local anesthetics - -... 

Chronic Pain Recurring pain for 6 months or more treated with combinations of NSAIDs, opioid analgesics, antianxiety, and medications to reduce swelling... 

The drugs dealt with in this section include aspirin and other salicylates, NSAIDs, opioid analgesics, and the miscellaneous analgesics, such as nefopam and paracetamol. Table 6.1 , (p.l34) contains a listing, with a further classification of the NSAIDs. 

The second group of non-opioid analgesics, which are not classified as NSAIDs, consists of substances that lack anti-inflammatory properties, such as phenazones, metamizole (dipyrone) and paracetamol. Their molecules are neutral or weakly basic, have no hydrophilic... 

Pharmacological intervention NSAIDs, local anesthetics, opioid analgesics, sodium-channel blockers Opioid analgesics, NSAIDs, calcium-channel blockers ... 

The mechanisms of pain and the ability to control pain may vary in different pain states. This is of particular importance in consideration of a rational basis for the treatment of both inflammatory and neuropathic pain where the damage to tissue and nerve leads to alterations in both the peripheral and central mechanisms of pain signalling. In respect of existing drug therapies, this plasticity, the ability of the system to change in the face of a particular pain syndrome, explains the effectiveness of NSAIDs in inflammatory conditions and yet is also responsible for some of the limitations in the effectiveness of opioids in neuropathic pain. 

The role of NSAIDs and opioids in chronic non-malignant pain has been discussed however, a review of adjuvant agents... 

Low-dose opioid analgesics (e.g., oxycodone) may be useful for patients who experience no relief with acetaminophen, NSAIDs, intraarticular injections, or topical therapy. 

Tramadol with or without acetaminophen has modest analgesic effects in patients with OA. It may also be effective as add-on therapy in patients taking concomitant NSAIDs or COX-2 selective inhibitors. As with opioids, tramadol may be helpful for patients who cannot take NSAIDs or COX-2 selective inhibitors. 

The nonopioids are preferred over the opioids for mild to moderate pain (see Table 54-1). The salicylates and nonsteroidal antiinflammatory drugs (NSAIDs) reduce prostaglandins produced by the arachidonic acid cascade, thereby decreasing the number of pain impulses received by the CNS. 

Agents Acetaminophen or NSAID combinations with opioids Adjuncts Tricyclic antidepressants Anticonvulsants Radiopharmaceuticals (Bone pain) Acetamnophen (See above) Opioids Titrate Amitriptyline 10-50 mg Imipramine 10-50 mg NSAIDs (See above) Gabapentin (Neurontin) 3.6 g... 

Whenever bone pain is present, consideration of an NSAID with opioid should be routine. 

The combination of an opioid and nonopioid oral analgesic often results in analgesia superior to monotherapy and may allow for lower doses of each agent. An NSAID with a scheduled opioid dose is often effective for painful bone metastases. 

Voltarol is a brand-name preparation for diclofenac (NSAID) and modified-release tablets are available in 75 mg and 100 mg strength. Nu-seals is a proprietary preparation of enteric-coated aspirin 75 mg. Fentanyl, co-codamol and Suboxone (buprenorphine and naloxone) consist of opioid drugs. 

Alternative products to diclofenac include naproxen and mefenamic acid, both of which are non-steroidal anti-inflammatory drugs. Co-codamol is a mixture of the opioid analgesic codeine and paracetamol and it does not possess the anti-inflammatory component. It may be used in pain management either where NSAIDs are contraindicated or in patients who are intolerant to the effects of NSAIDs. 

Analgesics are divided into two groups opioids (morphine-like substances), which predominantly influence the central nervous system (CNS) and nonopioids (nonsteroidal antiinflammatory or fever-reducing drugs—NSAID), which act predominantly on the peripheral nervous system. 

NSAIDs, radiocontrast agents, aminoglycosides Anticholinergics, opioids... 

Apart from their anti-inflammatory activity the NSAIDs also show, dependent on the condition and the type of pain, considerable analgesic efficacy. In some forms of postoperative pain the NSAID s can be as efficacious as opioids, especially when prostaglandins, bradykinin and histamine, which are released by inflammation, have caused sensitization of pain receptors to normally painless stimuli. In Table 4 some advantages and disadvantages of NSAID s and opioids are compared. Although analgesic effects at peripheral or central neurons cannot be excluded completely, most studies indicate that... 

Table 4. Comparison of some advantages and disadvantages of NSAIDs and opioids...

Ziconotide is a non-opioid, non-NSAID, non-local anesthetic used for the amelioration of chronic pain. In December 2004 the FDA approved ziconotide for intrathecal administration. The drug is derived from a marine snail toxin. Its mechanism of action has not yet been elucidated. Due to serious side effects or lack of efficacy when delivered through more conventional routes ziconotide must be administered in-trathecally. It s use is considered appropriate only for management of severe chronic pain in patients for whom intrathecal therapy is indicated. 

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