various pain conditions that include postoperative pain, headaches, and neck, back, and joint pain. 3,50- 53 ● MBSR, which is also discussed under behavioral health approaches, and which has evidence of statistically significant beneficial effects for low- back pain and is shown in a meta-analysis to significantly reduce the intensity and frequency of primary headache pain. 39,54 ● Yoga, which uses stretching, breathing, and meditation and has been shown to be therapeutic in the treatment of various chronic pain conditions, particularly low-back pain. 55-58 Risks are minimal, and yoga can generally be practiced safely, especially when delivered in group settings. 3,59 ● Tai chi, which originated as a Chinese martial art and uses slow movements and meditation, and which has demonstrated long-term benefit for osteoarthritis and other musculoskeletal pain conditions. 60,61 Like yoga, it is generally safe and
has the benefits of a group setting and availability via telehealth. 3 ● Spirituality, which encompasses a broad range of resources and practices, such as prayer and meditation, has growing evidence of benefit for people with pain. 62 It has long been integral to palliative and supportive care, and is gaining support as a means to help patients cope with and manage ongoing pain. 3 Self-Assessment Question 3 Which factors influence pain according to the International Which noninvasive, nonpharmacologic approaches to pain management would be categorized as restorative?
a. Acupuncture. b. Biofeedback. c. Mindfulness-based stress reduction. d. Physical therapy.
NONOPIOID PHARMACOLOGIC OPTIONS FOR PAIN
Numerous nonopioid pharmacologic therapies are available for pain, and these should be tried or considered, alone or in combination, before initiating long-term opioid therapy. 3 Acetaminophen (ACET) is used to treat mild-to- moderate pain without inflammation. All ACET products carry an FDA-required black box warning highlighting the potential for severe liver damage and potential for allergic reactions. 63 HCPs and patients should be aware of the dose levels from all prescribed and over-the-counter medication sources to avoid exceeding the recommended daily dosage. Nonsteroidal anti-inflammatory drugs (NSAIDs) include aspirin, ibuprofen, naproxen, and cyclooxygenase-2 (Cox-2) inhibitors and are used to treat mild-to-moderate pain and inflammation. Indications are numerous and include arthritis, bone fractures or tumors, muscle pains, headache, and acute pain caused by injury or surgery. 3 Nonselective NSAIDs are those that inhibit the activity of both COX-1 and COX-2 enzymes and can be associated with gastritis, gastric ulcers, and gastrointestinal (GI) bleeding. 3 COX-2 inhibitors have fewer GI adverse effects. 1 Risks are elevated with NSAIDs for heart attack, stroke, GI bleeding or perforation, and renal and cardiovascular abnormalities, particularly at higher doses and longer duration of use. 64 Anticonvulsants, such as gabapentin and pregabalin, have mild-to-moderate benefit for neuropathic pain syndromes, including postherpetic neuralgia and peripheral neuropathy, and are also commonly used to treat migraine and as part of a multimodal approach to treating perioperative pain. 3 Adverse effects include drowsiness, cognitive slowing, 32 and a risk of misuse, particularly in people with a history of misusing opioids. 62 Gabapentin dose should be adjusted in chronic kidney disease. Antidepressants, including selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and tricyclic
antidepressants, are used in low doses for insomnia and neuropathic pain. Doses are typically lower for analgesia than those required to treat depression. SSRIs (e.g., fluoxetine, sertraline, citalopram, and paroxetine) have less analgesic effect compared with other antidepressant classes. 3 SNRIs (e.g., venlafaxine, duloxetine) are effective for a variety of chronic pain conditions, including musculoskeletal pain, fibromyalgia, and neuropathic pain, and are associated with less drowsiness, memory impairment, and cardiac conduction abnormalities than tricyclic antidepressants. Tricyclics (e.g., desipramine, nortriptyline, amitriptyline) are initiated at low doses and gradually titrated to effect. Depending on class, risks and adverse effects may include dry mouth, dizziness, sedation, memory impairment, orthostatic hypotension, urinary retention, cardiac conduction abnormalities, sexual dysfunction, weight gain, emotional blunting, and suicidal thoughts. 3,32 Second- generation tricyclic antidepressants (e.g., nortriptyline) tend to be better tolerated than the first generation (e.g., amitriptyline). Withdrawal reactions are possible when antidepressants are suddenly stopped. Musculoskeletal agents for pain and muscle spasm are for short-term use with sedation being a common adverse effect. Common medications used in pain treatment include baclofen, tizanidine, and cyclobenzaprine. Particular risks are notable with carisoprodol (toxicity, unclear therapeutic benefit) and benzodiazepines (SUD, respiratory depression leading to overdose) when prescribed in combination with opioids. 32 Considering the risks with carisoprodol and benzodiazepines and the availability of other agents, these medications are not recommended to treat pain from muscle spasm. 3 Topical medications include lidocaine, ketamine, capsaicin, and anti-inflammatory drugs such as ketoprofen and diclofenac. Anti- inflammatory topicals are proven beneficial for musculoskeletal pain, as is capsaicin for neuropathic pain. 32
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Book Code: MDCO1025
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