The FDA currently sets a maximum limit of 325 mg of acetaminophen in prescription combination products (e.g., hydrocodone and acetaminophen) in an attempt to limit liver damage and other potential ill effects of these products. 32 Topical capsaicin and salicylates can both be effective for short term pain relief and generally have fewer side effects than oral analgesics, but their long-term efficacy is not well studied. 20,21 The burning sensation from topical capsaicin can be difficult to tolerate. Topical aspirin can help reduce pain from acute herpes zoster infection. 22 Topical NSAIDs and lidocaine may also be effective for short-term relief of superficial pain with minimal side effects. Topical agents can be simple and effective for reducing pain associated with wound dressing changes, debridement of leg ulcers, and other sources of superficial pain. 22
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Adjunct in opioid-tolerant patients with sickle cell crisis Adjunct in patients with obstructive sleep apnea
The goal of body weight reduction is a baseline weight loss of 7%-10% by calorie reduction and increased activity using a balanced diet with less than 30% of calories from fat, 15%-20% from protein, and 45%-60% from carbohydrates. 30 Passive options Acupuncture involves the stimulation of specific points on the body, most often involving skin penetration with fine metallic needles manipulated by hand but sometimes also including electrical stimulation or low intensity laser therapy. Potential adverse events include minor bruising and bleeding at needle insertion sites. 31 Transcutaneous electrical nerve stimulation (TENS) involves mild electrical pulses applied cutaneously. The electrical stimulation from TENS may block or disrupt pain signals to the brain, reducing pain perception. TENS machines can be used at home or in conjunction with other interventions like physical therapy. Cognitive and behavioral options Cognitive behavioral therapy (CBT) is a structured, time-limited (typically 3-10 weeks) intervention focused on how thoughts, beliefs, attitudes, and emotions influence pain and can help patients use their minds to control and adapt to pain. This therapy includes setting goals, often with recommendations to increase activity to reduce feelings of helplessness. 32 Meditation Mindfulness meditation programs typically include a time-limited (8 weeks; range 3-12 weeks) trainings with group classes and home meditation. The objective is to inculcate a long-term practice that helps patients refocus their minds on the present, increase awareness of self and surroundings, and reframe experiences. 33,34 Injection-based interventions Several types of injection therapies can help to ease pain and provide durable relief. In the spine, multiple pain generators can be targeted: facet joints, discs, nerves, and muscles. 35 Parts of the sympathetic nervous system can be accessed with therapeutic injections for patients with visceral pain, and injections into specific joints with steroid or viscosupplements can reduce joint pain. 35 Epidural steroid injections, radiofrequency ablation, pulsed and cooled radiofrequency procedures, and neuromodulation treatments (spinal cord stimulation, peripheral nerve stimulation) all have an important role in reducing chronic pain. 36-38
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• Dose °
Bolus IV: up to 0.35 mg/kg Infusion: up to 1 mg/kg/hour
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• Contraindications °
Poorly-controlled cardiovascular disease
° ° ° ° °
Pregnancy Psychosis
Severe hepatic disease
Elevated intracranial pressure Elevated intraocular pressure
Non-opioid options for chronic non-cancer pain
Non-pharmacologic approaches Physical rehabilitative and surgical approaches, procedural therapies (e.g., injections, nerve blocks), complementary therapies, and use of approved/cleared medical devices may all be potentially effective either alone or as part of a comprehensive pain management plan, particularly for musculoskeletal pain and chronic pain. 26 Movement-based options Muscle-strengthening, stretching, and aerobic exercise (e.g., walking, aquatics) may all be helpful for patients in chronic pain. Recommended exercise programs typically occur one to three times a week for a total of 60-180 minutes per week, but any regimen must be carefully tailored to a patient’s existing level of physical conditioning, comorbidities, and cognitive status. 27-29 Additional movement-based options include: • Physical therapy supervised by a licensed physical therapist, which can include resistance, aerobic, balance, and flexibility exercises as well as elements of massage, manipulation, or transcutaneous electrical nerve stimulation. • Tai chi, a mind-body practice that combines controlled movements, meditation, and deep breathing. “Chair tai chi” can be an option for patients with limited mobility. • Yoga, exercises or a series of postures designed to align muscle and bones, and increase strength and flexibility. It can also relax mind and body through breathing exercises and meditation. Gentler forms of yoga that may be more appropriate for older patients include Iyengar, Hatha, or Viniyoga. Weight loss Some pain syndromes, such as knee osteoarthritis, are worsened by obesity. For some patients, pain due to this condition is improved by reducing body weight, which lowers physical stresses on affected joints.
Anticonvulsants
Anticonvulsants, gabapentin, pregabalin, oxcarbazepine, and carbamazepine, are often prescribed for chronic neuropathic pain (e.g., post-herpetic neuralgia and diabetic neuropathy) although evidence for efficacy in acute pain conditions is weak. 23 A 2017 trial, for example, randomized 209 patients with sciatica pain to pregabalin 150 mg/day titrated to a maximum of 600 mg/day vs. placebo for 8 weeks. 24 At 8 weeks there was no significant difference in pain between groups (mean leg pain intensity on a 0-10 scale 3.7 with pregabalin vs. 3.1 with placebo, P=0.19). Potential side effects of anticonvulsants include sedation, dizziness, and peripheral edema. Pregabalin and gabapentin also have some abuse potential in the general population because some users report euphoric effects. Abrupt cessation of anticonvulsants may precipitate withdrawal symptoms. 23 such as Ketamine Ketamine has been used as a general anesthetic since the 1960s, but its use in subanesthetic concentrations for analgesia has grown rapidly in recent years, due, in part, to efforts to reduce the risks of chronic opioid use. 25 Ketamine has been successfully used to treat such acute pain conditions as sickle cell crises, renal colic, and trauma. 25 In 2018 the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists released joint recommendations for subanesthetic ketamine (including transdermal ketamine) for acute pain with the following guidelines: 25 • Indications ° Perioperative use in surgery with moderate to severe postoperative pain
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Perioperative use in patients with opioid tolerance
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