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office_hours:pain:start [2026/02/14 17:22] – 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: +
- +
----- +
- +
-== NSAIDs (Most Anti-Inflammatory → Least) == +
- +
-^ Drug ^ Primary Pain Type(s) ^ Acute vs Chronic ^ Best Clinical Use ^ Key Pearls / Major Cautions ^ +
-| [[cardio:anti_inflammatory:indomethacin|Indomethacin]] | Nociceptive, inflammatory | Acute | Acute gout | Strong anti-inflammatory; higher CNS/GI adverse effects | +
-| [[cardio:anti_inflammatory:diclofenac|Diclofenac]] | Nociceptive, inflammatory | Acute + Chronic | OA (esp topical) | Higher CV risk; topical less systemic exposure | +
-| [[cardio:anti_inflammatory:naproxen|Naproxen]] | Nociceptive, inflammatory | Acute + Chronic | OA, tendinitis | Longer duration; GI/renal risk | +
-| [[cardio:anti_inflammatory:ibuprofen|Ibuprofen]] | Nociceptive (somatic), inflammatory | Acute + Chronic | MSK pain, OA flares | GI/renal risk; ↑BP; ceiling effect | +
-| [[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 | +
- +
------- +
- +
-== Acetaminophen == +
- +
-^ Drug ^ Primary Pain Type(s) ^ Acute vs Chronic ^ Best Clinical Use ^ Key Pearls / Major Cautions ^ +
-| [[pain_management:acetaminophen|Acetaminophen]] | Nociceptive (mild) | Acute + Chronic | Baseline analgesic, combination therapy | Liver toxicity risk; ceiling effect; safer in CKD than NSAIDs | +
- +
------- +
- +
-== Corticosteroids (Anti-Inflammatory Strength Similar; Ordered by Clinical Potency) == +
- +
-^ Drug ^ Primary Pain Type(s) ^ Acute vs Chronic ^ Best Clinical Use ^ Key Pearls / Major Cautions ^ +
-| [[endocrine:dexamethasone|Dexamethasone]] | Inflammatory, cancer-related edema | Acute | Severe inflammation/edema | Most potent per mg; long acting; hyperglycemia, insomnia | +
-| [[endocrine:methylprednisolone|Methylprednisolone]] | Inflammatory | Acute | Dose packs/flares | Intermediate potency | +
-| [[endocrine:prednisone|Prednisone]] | Inflammatory pain | Acute (bursts) | Radiculitis flares | Not analgesic; treat inflammation; hyperglycemia, mood, BP | +
- +
------- +
- +
-== Voltage-Gated Sodium Channel Antagonists == +
- +
-^ Drug ^ Primary Pain Type(s) ^ Acute vs Chronic ^ Best Clinical Use ^ Key Pearls / Major Cautions ^ +
-| [[pain_management:drugs:suzetrigine|Suzetrigine]] | Nociceptive (acute), mixed | Acute | Oral peripheral analgesia (Nav1.8) | Emerging agent; selective peripheral action | +
-| [[neuro:local_anesthetics:lidocaine|Lidocaine]] | Neuropathic (localized), procedural | Acute + Chronic | Topical neuropathic pain; procedures | Helpful in PHN; systemic toxicity if misused | +
- +
------- +
- +
-== Antiepileptics (Neuropathic Pain Efficacy Strength) == +
- +
-^ Drug ^ Primary Pain Type(s) ^ Acute vs Chronic ^ Best Clinical Use ^ Key Pearls / Major Cautions ^ +
-| [[neuro:carbamazepine|Carbamazepine]] | Neuropathic (paroxysmal) | Chronic | Trigeminal neuralgia | Gold standard TN; hyponatremia; CBC/LFT monitoring | +
-| [[neuro:pregabalin|Pregabalin]] | Neuropathic, nociplastic | Chronic | DPN, fibromyalgia | Strong evidence; edema; CKD dose adjust | +
-| [[neuro:gabapentin|Gabapentin]] | Neuropathic | Chronic | DPN, PHN | Sedation; CKD dose adjust | +
-| [[neuro:oxcarbazepine|Oxcarbazepine]] | Neuropathic | Chronic | Trigeminal neuralgia alt | Hyponatremia | +
-| [[neuro:lamotrigine|Lamotrigine]] | Neuropathic (selected) | Chronic | Selected cases | Rash/SJS risk | +
- +
------- +
- +
-== SNRIs (Descending Inhibition Strength) == +
- +
-^ Drug ^ Primary Pain Type(s) ^ Acute vs Chronic ^ Best Clinical Use ^ Key Pearls / Major Cautions ^ +
-| [[psychiatry:duloxetine|Duloxetine]] | Neuropathic, nociplastic, chronic MSK | Chronic | DPN, fibromyalgia, chronic back pain | Strongest analgesic evidence; nausea; BP monitoring | +
-| [[psychiatry:venlafaxine|Venlafaxine]] | Neuropathic | Chronic | Neuropathic alternative | Dose-dependent NE effect; withdrawal risk | +
- +
------- +
- +
-== TCAs (Analgesic Strength > Tolerability) == +
- +
-^ Drug ^ Primary Pain Type(s) ^ Acute vs Chronic ^ Best Clinical Use ^ Key Pearls / Major Cautions ^ +
-| [[psychiatry:amitriptyline|Amitriptyline]] | Neuropathic, nociplastic | Chronic | Neuropathic pain + sleep | Most potent TCA; anticholinergic; QTc | +
-| [[psychiatry:nortriptyline|Nortriptyline]] | Neuropathic | Chronic | Better tolerated TCA | Still anticholinergic | +
- +
------- +
- +
-== NMDA Antagonists == +
- +
-^ Drug ^ Primary Pain Type(s) ^ Acute vs Chronic ^ Best Clinical Use ^ Key Pearls / Major Cautions ^ +
-| [[neuro:ketamine|Ketamine]] | Hyperalgesia, severe acute pain | Acute | Opioid-refractory pain | Very potent acute analgesic; dissociation; BP elevation | +
-| [[controlled_substances:methadone|Methadone]] | Mixed, neuropathic component | Chronic | Severe chronic pain | NMDA activity + μ agonist; QTc; complex kinetics | +
- +
------- +
- +
-== Opioids (Most Potent → Least Potent Relative to Morphine) == +
- +
-^ Drug ^ Primary Pain Type(s) ^ Acute vs Chronic ^ Best Clinical Use ^ Key Pearls / Major Cautions ^ +
-| [[controlled_substances:fentanyl|Fentanyl]] | Severe nociceptive | Acute | OR/ICU | ~100× morphine potency; patch for opioid-tolerant only | +
-| [[controlled_substances:buprenorphine|Buprenorphine]] | Mixed | Chronic | Pain + OUD overlap | High receptor affinity; partial agonist; safer respiratory profile | +
-| [[controlled_substances:methadone|Methadone]] | Mixed, neuropathic component | Chronic | Severe chronic pain | 3–10× morphine; QTc; long half-life | +
-| [[controlled_substances:oxycodone|Oxycodone]] | Severe nociceptive | Acute + Chronic | Severe acute pain | ~1.5× morphine potency; misuse risk | +
-| [[controlled_substances:morphine|Morphine]] | Severe nociceptive | Acute + Chronic | Reference opioid | Standard comparator | +
-| [[controlled_substances:hydrocodone|Hydrocodone]] | Moderate-severe nociceptive | Acute | Short-term acute pain | Often combined with APAP | +
-| [[controlled_substances:tapentadol|Tapentadol]] | Mixed | Acute/Chronic | Severe pain w/ neuropathic component | μ + NE mechanism; less potent | +
-| [[controlled_substances:tramadol|Tramadol]] | Mixed | Acute/Chronic | Selected cases | Weakest μ effect; seizure risk; serotonin syndrome | +
- +
------- +
- +
-== Topical Agents == +
- +
-^ Drug ^ Primary Pain Type(s) ^ Acute vs Chronic ^ Best Clinical Use ^ Key Pearls / Major Cautions ^ +
-| [[neuro:local_anesthetics:lidocaine|Topical Lidocaine]] | Neuropathic | Chronic | PHN | Strong localized effect | +
-| [[pain_management:drugs:capsaicin|Capsaicin]] | Neuropathic | Chronic | Peripheral neuropathy | Moderate effect; initial burning | +
- +
------- +
- +
-== Cannabinoids ==+
  
-^ Drug ^ Primary Pain Type(s) ^ Acute vs Chronic ^ Best Clinical Use ^ Key Pearls / Major Cautions ^ +See: [[pain_management:drug_classes|Pain Pharmacotherapy]]
-| [[pain_management:drugs:thc|THC]] | Neuropathic (modest) | Chronic | Adjunct therapy | Psychoactive; variable response | +
-| [[pain_management:drugs:cbd|CBD]] | Mixed | Chronic | Adjunct | Limited high-quality evidence |+
  
 ---- ----
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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>
  
office_hours/pain/start.1771089734.txt.gz · Last modified: by andrew2393cns