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Cite article. Originally developed by the World Health Organisation WHO to improve management of cancer pain ; the 3 step WHO analgesic ladder is also used for providing stepwise pain relief for pain due to other causes. They work in the central nervous system by binding to opioid receptors in the pre- and post-synaptic membrane stopping the passage of neurotransmitters across the nerve synapse which blocks or attenuates the experience of pain.
Opioid medications include morphine, oxycodone, codeine, tramadol, buprenorphine, fentanyl and diamorphine heroin. With either route slow or modified release preparations are often used to minimise fluctuations in pain relief and reduce the of tablets that need to be administered. Examples of slow or modified release medicines which work over 12 or 24hrs include tramadol preparations such as Zydol or Zamadol .
Fentanyl and Buprenorphine may be administered via transdermal patches which are applied every few days. Opioid receptors are present in tissues throughout the body and the interaction of the drugs with these receptors is responsible for the side effects associated with opioid medications. In the GIT these include nausea and vomiting and, as a result of decreased gut motility, constipation. Opioids also reduce the sensitivity of the respiratory centres in the brain stem to CO2 leading to respiratory depression. Other effects include drowsiness and dizziness and prolonged use can lead to hormonal changes which can lead to reduced libido, infertility and depression .
The use of opioids for chronic non-cancer pain is controversial. Pain is rarely abolished and the use of analgesia is to enable the individual to participate in rehabilitation to restore function and maximise quality of life. There is evidence that people with chronic pain may not benefit from opioid use. People who use opioids for a prolonged time may develop hyperalgesia which is distinct from their original pain problem and may present as a more diffuse less defined pain  A Danish study reported ificant associations between opioid use and an increase in moderate to severe pain as well as a reduction in quality of life scores and poorer self-rated health in people with chronic pain taking opioid medication versus those who were not.
Using opioids was also linked to low levels of exercise, unemployment and higher health care usage. The WHO analgesic ladder  recommends that patients are prescribed additional medication to manage the symptoms of neuropathic pain resulting from post hepatic neuralgia, phantom limb pain, peripheral neuropathy and pain caused by nerve compression e.
Because of their dual role, it is important that patients understand that they are prescribed these medications to control of troublesome pain symptoms rather than because of epilepsy or a mental health condition. NICE Guidelines CG recommends offering a choice of Amitriptyline, Gabapentin, Pregabalin or Duloxetine as initial treatment for neuropathic pain changing to another drug if the first is ineffective or poorly tolerated.
Topical analgesics can provide localised pain relief and are used to treat acute and chronic pain, such as musculoskeletal and neuropathic pain, as well as muscle pain related to trauma. Rubifactants include a wide range of gels and creams; some are available over the counter OTC and others require a prescription PoM. They are thought to provide a counter-irritant effect by stimulating the sensory nerve endings and altering the pain in tissue muscle and ts innervated by the same nerve. They also cause skin reddening and produce a comforting warmth. Topical capsicum may be prescribed for chronic pain conditions such as post herpatic neuralgia and diabetic neuropathy.
It is formulated either as a cream 0. The cream is licenced for the treatment of postherpatic neuralgia and diabetic neuropathy and the patch for peripheral neuropathic pain in non-diabetic patients . The patch has been shown to be more effective than the cream NNT's of 8. Initial sensations of burning, tingling or itching are followed by a refractory period of decreased sensitivity and multiple applications can result in sustained desensitisation and relief from pain. Topical NSAIDs including ibuprofen, naproxen and diclofenac are used in acute and chronic pain conditions.
The version had similar findings, noting in particular that topical diclofenac and topical ketoprofen provide good levels of pain relief beyond carrier for osteoarthritis, but only for a minority of people. The review also found that there is no evidence for their use in other chronic pain conditions. Topical local anaesthetic for example lignocaine patch can be used in chronic pain states such as post-hepatic neuralgia, chronic low back pain and complex regional pain syndrome CRPS.
The efficacy of lignocaine patches is disputed; a recent systematic review concludes that although some studies and patients report benefit overall there is no evidence to support the use of lignocaine patches for the treatment of neuropathic pain. Systemic local anaesthetics such as intravenous lignocaine may be used to treat chronic neuropathic pain conditions including fibromyalgia. These drugs act as sodium channel blockers. Sodium channels are thought to be only present in peripheral nerves.
When nerves are damaged or irritated excitability and spontaneous firing increases mediated by the increased flow of sodium ions across the cell membrane. Sodium channel blockers slow or stop the flow of ions reducing the excitability of the cell and producing a decrease in the sensation of pain. Sodium channel blockers are also thought to have an effect on glutamate production in the dorsal horn reducing nerve cell activity .
People with persistent pain benefit from a biopsychosocial approach which addresses their thoughts and feelings about their condition combined with a programme to increase levels of activity and promote self-management. It is important to understand the limitations of the pharmacological management of chronic pain, the importance of combining pharmacological approaches with non-pharmacological management of chronic pain and the use of such strategies alongside appropriate evidence-based active self-management strategies. The content on or accessible through Physiopedia is for informational purposes only.
Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. . Search Search. Toggle p Physiopedia. Contents Editors Share Cite. Contents loading Pharmacology in Pain Management. Jump to: , search. The physiological framework of pharmacology. Birmingham City University British National Formulary. Opioids for persistent pain:good practice. Opioid therapy for chronic pain. New England Journal of Medicine Critical issues on opioids in chronic non-cancer pain.
An epidemiological study. Opioids for chronic low-back pain. National Institute for Health and Care Excellence London accessed Neuropathic pain - drug treatment. Amitriptyline for neuropathic pain and fibromyalgia in adults. Frequently Asked Questions. Independent prescribing by physiotherapists and podiatristsfckLR accessed Gabapentin for chronic neuropathic pain and fibromyalgia in adults.
Gabapentin accessed Patient-reported-outcomes in subjects with painful lumbar or cervical radiculopathy treated with pregabalin: evidence from medical practice in primary care settings. Pregabalin accessed Current Neuropharmacology. Duloxetine for painful diabetic neuropathy and fibromyalgia pain: systematic review of randomised trials.
BMC Neurology Accessed Duloxetine for treating painful neuropathy, chronic pain or fibromyalgia. Cochrane Database Syst Rev. Duloxetine accessed Topical Analgesics. Multimodal approaches to the management of neuropathic pain: the role of topical analgesia. Journal of Pain Symptom Management.
Topical analgesics introduction accessed National Institute of Health and Care Excellence accessed Topical capsaicin high concentration for chronic neuropathic pain in adults. Topical capsaicin for chronic pain accessed Effectiveness and safety of topical capsaicin cream in the treatment of chronic soft tissue pain.Classification of pain medications
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