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office_hours:pain:start [2026/02/14 17:15] – [Pharm Reference: Pain Drug Reference (Mechanism → Best Use)] andrew2393cnsoffice_hours:pain:start [2026/02/15 03:28] (current) – andrew2393cns
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-====== Pain Management Series ====== +{{ :office_hours:series:pain.png?400 |}}
- +
-{{:pharmatlas:pain_management_banner.jpg?nolink&1200x250}} +
 ===== Overview ===== ===== Overview =====
  
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 ===== V. Pharmacologic Drug Classes ===== ===== V. Pharmacologic Drug Classes =====
  
-Pain pharmacotherapy must match mechanism.+Pain pharmacotherapy must match mechanism. This series will cover the drugs that can be used for pain
  
-This series will cover the following drug classes: +See: [[pain_management:drug_classes|Pain Pharmacotherapy]]
- +
----- +
- +
-==== Anti-Inflammatory Agents ==== +
- +
-  * [[cardio:anti_inflammatory:nsaids|NSAIDs]] +
-  * [[endocrine:corticosteroids|Corticosteroids]] +
-  * [[pain_management:acetaminophen|Acetaminophen]] +
- +
-Mechanism: +
-  Decrease prostaglandin-mediated sensitization. +
- +
----- +
- +
-==== Voltage-Gated Sodium Channel Antagonists ==== +
- +
-  * [[neuro:local_anesthetics|Lidocaine]] +
-  * Suzetrigine (Nav 1.8 selective antagonist) +
- +
-Mechanism: +
-  Block action potential propagation in nociceptors. +
- +
----- +
- +
-==== Gabapentinoids ==== +
- +
-  * [[neuro:anticonvulsants|Gabapentin]] +
-  * [[neuro:anticonvulsants|Pregabalin]] +
- +
-Mechanism: +
-  Bind α2δ calcium channel subunit → decrease glutamate & substance P release. +
- +
----- +
- +
-==== Serotonin & Norepinephrine Reuptake Inhibitors ==== +
- +
-  * [[psychiatry:snri|SNRIs]] +
-  * [[psychiatry:tca|Tricyclic Antidepressants (TCAs)]] +
- +
-Mechanism: +
-  Enhance descending inhibitory pathways. +
- +
----- +
- +
-==== NMDA Receptor Antagonists ==== +
- +
-  * [[neuro:nmda_antagonists|Ketamine]] +
- +
-Mechanism: +
-  Reduce central sensitization and wind-up. +
- +
----- +
- +
-==== Opioid Analgesics ==== +
- +
-  * [[controlled_substances:opioids|Opioids]] +
- +
-Mechanism: +
-  μ-receptor activation → decrease ascending pain transmission. +
- +
----- +
- +
-==== NK1 Receptor Antagonists (Investigational for Pain) ==== +
- +
-  * [[gi:antiemetics:nk1_antagonists|NK1 Antagonists]] +
- +
-Mechanism: +
-  Block Substance P at NK1 receptors. +
- +
-Clinical role in chronic pain remains limited. +
- +
----- +
- +
-==== Nerve Growth Factor (NGF) Antibodies ==== +
- +
-  * Tanezumab +
-  * Fasinumab +
- +
-Mechanism: +
-  Block NGF-mediated nociceptor sensitization. +
- +
-Not currently approved due to safety concerns. +
- +
----- +
- +
-==== Cannabinoids ==== +
- +
-  * THC +
-  * CBD +
- +
-Mechanism: +
-  CB1/CB2 receptor modulation (evidence evolving).+
  
 ---- ----
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 <WRAP round important 80%> <WRAP round important 80%>
-• Pain classification determines therapy   +  * • Pain classification determines therapy   
-• Chronic pain often reflects central amplification   +  * • Chronic pain often reflects central amplification   
-• Mechanism-directed prescribing improves outcomes   +  * • Mechanism-directed prescribing improves outcomes   
-• Opioids are powerful but limited tools   +  * • Opioids are powerful but limited tools   
-• Multimodal therapy reduces risk  +  * • Multimodal therapy reduces risk  
 </WRAP> </WRAP>
  
 ---- ----
  
-===== Pharm Reference: Pain Drug Reference (Mechanism → Best Use) ===== 
- 
-^ Class ^ Drug ^ Primary Pain Type(s) ^ Acute vs Chronic ^ Best Clinical Use ^ Key Pearls / Major Cautions ^ 
- 
-^ [[cardio:anti_inflammatory:nsaids|NSAIDs]] ||||||  
-| | [[cardio:anti_inflammatory:ibuprofen|Ibuprofen]] | Nociceptive (somatic), inflammatory | Acute + Chronic | MSK pain, OA flares | GI/renal risk; ↑BP; avoid CKD/dehydration; ceiling effect | 
-| | [[cardio:anti_inflammatory:naproxen|Naproxen]] | Nociceptive, inflammatory | Acute + Chronic | OA, tendinitis | Similar NSAID risks; longer duration | 
-| | [[cardio:anti_inflammatory:diclofenac|Diclofenac]] | Nociceptive, inflammatory | Acute + Chronic | OA (esp topical) | Higher CV risk; topical less systemic exposure | 
-| | [[cardio:anti_inflammatory:indomethacin|Indomethacin]] | Nociceptive, inflammatory | Acute | Acute gout | More CNS/GI adverse effects | 
-| | [[cardio:anti_inflammatory:celecoxib|Celecoxib]] | Nociceptive, inflammatory | Acute + Chronic | OA/RA, GI-risk patients | COX-2 selective → less GI ulcer risk; still CV/renal risk | 
- 
-^ [[pain_management:acetaminophen|Acetaminophen]] ||||||  
-| | [[pain_management:acetaminophen|Acetaminophen]] | Nociceptive (mild) | Acute + Chronic | Baseline analgesic, combination therapy | Liver toxicity risk; safer in CKD than NSAIDs; ceiling effect | 
- 
-^ [[endocrine:corticosteroids|Corticosteroids]] ||||||  
-| | [[endocrine:prednisone|Prednisone]] | Inflammatory pain | Acute (bursts) | Radiculitis flares | Not analgesic; treat inflammation; hyperglycemia, mood, BP | 
-| | [[endocrine:methylprednisolone|Methylprednisolone]] | Inflammatory | Acute | Dose packs/flares | Short courses preferred | 
-| | [[endocrine:dexamethasone|Dexamethasone]] | Inflammatory, cancer-related edema | Acute | Severe inflammation/edema | Potent/long acting; insomnia, hyperglycemia | 
- 
-^ [[neuro:sodium_channel_blockers|Na⁺ Channel Antagonists]] ||||||  
-| | [[neuro:local_anesthetics:lidocaine|Lidocaine]] | Neuropathic (localized), procedural | Acute + Chronic | Topical neuropathic pain; procedures | Topical helpful in PHN; systemic toxicity if misused | 
-| | [[pain_management:drugs:suzetrigine|Suzetrigine]] | Nociceptive (acute), mixed | Acute | Oral peripheral analgesia (Nav1.8) | Emerging agent | 
- 
-^ [[neuro:anticonvulsants|Antiepileptics]] ||||||  
-| | [[neuro:gabapentin|Gabapentin]] | Neuropathic | Chronic | DPN, PHN | Sedation; CKD dose adjust | 
-| | [[neuro:pregabalin|Pregabalin]] | Neuropathic, nociplastic | Chronic | DPN, fibromyalgia | Edema; CKD dose adjust | 
-| | [[neuro:carbamazepine|Carbamazepine]] | Neuropathic (paroxysmal) | Chronic | Trigeminal neuralgia | Hyponatremia; CBC/LFT monitoring | 
-| | [[neuro:oxcarbazepine|Oxcarbazepine]] | Neuropathic | Chronic | Trigeminal neuralgia alt | Hyponatremia | 
-| | [[neuro:lamotrigine|Lamotrigine]] | Neuropathic (selected) | Chronic | Selected cases | Rash/SJS risk | 
- 
-^ [[psychiatry:snri|SNRIs]] ||||||  
-| | [[psychiatry:duloxetine|Duloxetine]] | Neuropathic, nociplastic, chronic MSK | Chronic | DPN, fibromyalgia, chronic back pain | Nausea; BP monitoring | 
-| | [[psychiatry:venlafaxine|Venlafaxine]] | Neuropathic | Chronic | Neuropathic alt | Withdrawal risk | 
- 
-^ [[psychiatry:tca|TCAs]] ||||||  
-| | [[psychiatry:amitriptyline|Amitriptyline]] | Neuropathic, nociplastic | Chronic | Neuropathic pain + sleep | Anticholinergic; QTc | 
-| | [[psychiatry:nortriptyline|Nortriptyline]] | Neuropathic | Chronic | Better tolerated TCA | Still anticholinergic | 
- 
-^ [[neuro:nmda_antagonists|NMDA Antagonists]] ||||||  
-| | [[neuro:ketamine|Ketamine]] | Hyperalgesia, severe acute pain | Acute | Opioid-refractory pain | Dissociation; BP elevation | 
-| | [[controlled_substances:methadone|Methadone]] | Mixed, neuropathic component | Chronic | Severe chronic pain | QTc; complex kinetics | 
- 
-^ [[controlled_substances:opioids|Opioids]] ||||||  
-| | [[controlled_substances:morphine|Morphine]] | Severe nociceptive | Acute + Chronic | Severe pain, cancer pain | Constipation; resp depression | 
-| | [[controlled_substances:oxycodone|Oxycodone]] | Severe nociceptive | Acute + Chronic | Severe acute pain | Misuse risk | 
-| | [[controlled_substances:hydrocodone|Hydrocodone]] | Moderate-severe nociceptive | Acute | Short-term acute pain | Often combined with APAP | 
-| | [[controlled_substances:fentanyl|Fentanyl]] | Severe pain | Acute | OR/ICU | Patch for opioid-tolerant only | 
-| | [[controlled_substances:buprenorphine|Buprenorphine]] | Mixed | Chronic | Pain + OUD overlap | Partial agonist | 
-| | [[controlled_substances:tramadol|Tramadol]] | Mixed | Acute/Chronic | Selected cases | Seizure risk; serotonin syndrome | 
-| | [[controlled_substances:tapentadol|Tapentadol]] | Mixed | Acute/Chronic | Severe pain w/ neuropathic component | μ + NE mechanism | 
- 
-^ [[pain_management:topical_agents|Topical Agents]] ||||||  
-| | [[neuro:local_anesthetics:lidocaine|Topical Lidocaine]] | Neuropathic | Chronic | PHN | Local irritation | 
-| | [[pain_management:drugs:capsaicin|Capsaicin]] | Neuropathic | Chronic | Peripheral neuropathy | Initial burning | 
  
-^ [[pain_management:cannabinoids|Cannabinoids]] ||||||  
-| | [[pain_management:drugs:thc|THC]] | Neuropathic (modest) | Chronic | Adjunct therapy | Cognitive effects | 
-| | [[pain_management:drugs:cbd|CBD]] | Mixed | Chronic | Adjunct | Variable evidence | 
office_hours/pain/start.1771089328.txt.gz · Last modified: by andrew2393cns