Pain SHP

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Jointly sponsored by
University of Kentucky
College of Pharmacy
and Vemco MedEd

This activity is supported
by an educational grant from
Janssen Pharmaceuticals, Inc.,
administered by
Janssen Scientific Affairs, LLC

The online tutorial series with a case reinforces practical application of tools and competencies acquired during the live activity. Each tool is a combination of essentials in clinical practice, links to relevant scientific publications, and printable handout material for reference. Clinical Case following the online tutorials gives the learners an opportunity to earn extra CE credit upon completion.

Know Your Drugs: Non-Opioids

The goal of chronic pain management is to decrease pain while improving function and reducing psychosocial suffering while minimizing adverse events. An important approach to achieve this goal is utilizing a multimodal treatment approach. Multimodal interventions utilize more than one type of therapy (e.g., an opioid with a co-analgesic/adjunctive medication) in order to address the pain through multiple mechanisms. To implement multimodal treatment strategies, it is important for clinicians to understand the various treatment options when managing chronic pain.

Co-Analgesics

Drug/Drug class	Benefits	Risks
Acetaminophen	Weak anti-inflammatory activity (COX-1 inhibitor) Addresses the central pain mechanism: good evidence to suggest activity in descending serotonergic pain pathway	Hepatotoxicity Increased risk with acute or chronic alcohol use Chronic daily use ≥ 4000 mg/day Limited evidence on renal toxicity
NSAIDs	Strong anti-inflammatory activity with oral NSAIDs but need to be prescribed with a proton pump inhibitor or misoprostol Multiple clinical trials demonstrating safety and efficacy of topical NSAIDs for superficial joint pain in elderly with minimal evidence of adverse effects (e.g. renal impairment, hypertension, bleeding)	Adverse effects including GI bleeding, platelet inhibition, hypertension, renal toxicity, aspirin cardioprotection interference Drug interactions with SSRIs, diuretics, ACE inhibitors, corticosteroids

Adjunctive Medications

Antidepressants
Serotonin norepinephrine reuptake inhibitors (SNRIs)	Cornerstone in treatment of fibromyalgia, post-herpetic neuralgia, painful poly-neuropathy, and chronic musculoskeletal pain	Examples include: Duloxetine Milnacipran Venlafaxine
Tricyclic antidepressants (TCAs)	Clinical evidence demonstrates efficacy in treatment of neuropatic pain Risk: anticholinergic side effects with high doses	Examples include: Amitriptyline Nortryptyline
Anticonvulsants
	Clinical evidence suggests efficacy in the treatment of neuropathic pain and fibromyalgia with some agents Inconclusive results on treatment of neuropathic pain with topiramate, levetiracetam, valproate, and oxcarbazepine	Examples include: Gabapentin Pregabalin Lamotrigine

Suggested Reading:

Finnerup NB, Sindrup SH, Jensen TS. The evidence of pharmacological treatment for neuropathic pain. Pain. 2010;150:573-581. Abstrat available at: www.ncbi.nlm.nih.gov/pubmed/20705215.
Harvey WF, Hunter DJ. Pharmacologic intervention for osteoarthritis in older adults. Clin Geriatr Med. 2010;26:503-515. Abstract available at: www.ncbi.nlm.nih.gov/pubmed/20699168.
American Society of Anesthesiologists. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010;112:810-833. Article available at: www.asahq.org/~/media/For%20Members/Practice%20Management/PracticeParameters/ChronicPainManagement.ashx.
Smith HS, Barkin RL. Fibromyalgia syndrome: a discussion of the syndrome and pharmacotherapy. Am J Ther. 2010;17:418-439. Abstract available at: www.ncbi.nlm.nih.gov/pubmed/20562596.