Chronic Pain Syndromes: Current Concepts and Treatment Strategies _ _______________________________
PHARMACOTHERAPY FOR FIBROMYALGIA WITH GREATEST EVIDENCE OF EFFICACY
Drug
Dose Range 10–50 mg 30–60 mg 25–200 mg 150–450 mg
Supporting Evidence
Amitriptyline Duloxetine Milnacipran
Several RCTs, guideline recommended FDA approved, several RCTs, meta-analysis FDA approved, several RCTs, meta-analysis
Pregabalin
FDA approved, long-term efficacy demonstrated, guideline recommended
Gabapentin
1,200–2,400 mg
RCTs, guideline recommended
Cyclobenzaprine
10–40 mg 20–60 mg
One meta-analysis Three small RCTs One small RCT One large RCT
Fluoxetine Naltrexone Paroxetine Tramadol
4.5 mg 20 mg
50–300 mg
Guideline recommended
RCT = randomized controlled trial. Source: [329]
Table 14
The three FDA-approved drugs for fibromyalgia—duloxetine, milnacipran, and pregabalin—have been found superior to placebo on many measures, the exceptions being duloxetine for fatigue, milnacipran for sleep disturbance, and pregabalin for depressed mood [330]. Comorbid depression may not respond to the primary agent or the dose used to treat fibromyalgia, and separate antidepressant therapy may be required [329]. A 2012 Cochrane review of monoamine oxidase inhibitor efficacy in fibromyalgia found statistically significant improvement with pirlindole versus placebo in pain, tender points, and patient and physician assessment [331]. CONSIDERATIONS FOR NON-ENGLISH- PROFICIENT PATIENTS Cultural and demographic factors may contribute to lack of effective pain management. Expression of pain and the use of pain medication differ across cultures. For example, Hispanic and Filipino patients have been shown to be reluctant to report pain because of fear of side effects or addiction [332]. Even when effective opioids have been prescribed, access may be difficult, as inadequate supplies of opioids are more likely in pharmacies in primarily non-White neighborhoods. Communication with patients regarding level of pain is a vital aspect of caring for patients in the end of life. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient’s lack of proficiency in the English language, an interpreter is required.
CONCLUSION In the past decade, breakthroughs in the scientific knowledge of pain pathophysiology have dramatically transformed our understanding of how pain develops, progresses, persists, and responds to intervention. Consequently, some of the more established past strategies for treating chronic pain are now being challenged by research evidence. In turn, these advances in pain science have the potential to greatly assist healthcare providers in delivering more effective pain management care, partially through greater elucidation of disease-treatment relationships. The prevalence of chronic pain syndromes in the United States is expected to continue rising, in relation to an aging population, increasing rates of obesity and diabetes, continued advances in lifesaving trauma interventions, poorly managed postsurgical pain, and greater public awareness of pain as a condition warranting medical attention.
WORKS CITED https://qr2.mobi/chronic-pain-syndromes
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