A Synopsis of AFPs "Pharmacologic Therapy for Acute Pain"

Pharmacologic Therapy for Acute Pain
RICHARD D. BLONDELL, MD; MOHAMMADREZA AZADFARD, MD; and ANGELA M. WISNIEWSKI, PharmD, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York
Am Fam Physician. 2013 Jun 1;87(11):766-772.
http://www.aafp.org/afp/2013/0601/p766.pdf

     When treating pain, using a pain scale helps determine the severity at baseline and the effectiveness of the treatment.  The WHO's "pain relief ladder" can help with management. At any point during management, Adjuvant medications (antidepressants, anticonvulsants, and glucocorticoids) can be added.
     The first step on the ladder are non-opioids such as acetaminophen and NSAIDs (celecoxib, aspirin, naproxen). These medications have similar effectiveness. Acetaminophen does not have any anti-inflammatory effects. There is a ceiling for the analgesic effects of NSAIDs, but not for its anti-inflammatory properties. NSAIDs better for treating osteoarthritis. Aspirin and the other NSAIDs can cause GI bleeding and ulcers. Aspirin is as effective as sumatriptan for acute migraines, with less adverse effects.
     Celecoxib is a COX-2 selective inhibitor. It has anti-inflammatory properties without the GI problems seen in the COX-1 aspect. It can be used for bone pain, dental pain, dysmenorrhea, headache, osteoarthritis, RA, and AS. They are more expensive than other traditional NSAIDs with similar effectiveness. There is less incidence of GI bleeding with these as well. They will increase the risk of a cardiovascular event at high doses.
     The next step on the ladder is opioid combinations with acetaminophen or NSAIDs. The combination is especially effective for postoperative pain. Concern over acetaminophen-induced liver injury has caused limitations in the dose of these medications. Patients should not used more than 4g of acetaminophen per day.
     If the combinations are not effective for pain control, then full opioids can be considered. Morphine is more effective than codeine, due to the lower receptor affinity. Adverse effects include nausea, vomiting, constipation, pruritus, and respiratory depression. Opioid induced gastroparesis can be treated with metoclopramide, but extrapyramidal side effects can occur.
     Dual action medications, (muopioid agonist and norepinephrine reuptake inhibitor) such as tapentadol, are as effective as oxycodone without as much nausea, vomiting and constipation. Tramadol is considered a second tier medication in this class.
    Opioids have a high potential for abuse and most patients are first introduced to these meds as properly prescribed treatments. Doctors need to counsel their patients.