Pain Management

Peripheral
sensitization: proinflammatory and
1 st line treatment for pain:
immune mediators sensitize the
Always non-pharmacologic
nociceptors
Is the pain self limiting (Diet, Behavioural therapy,
Central sensitization: prolonged
and the result of a recent Integrative therapy,
activation causes a change in the
injury? Electroanalgesia, Physical
CNS pain pathways that allows
[e.g. exercise, physical
pain to occur with no presence of a Yes No therapy])
peripheral processes
Acute pain
Acute Pain/ protects from Chronic Pain/
Adaptive further injury Maladaptive
and encourages
healing

Tissue damage Stimuli causing a Chronic pain Pain in the bones,

Nerve
leading to sharp, shock-like, Perioperative Pain often persists
damage/injury? joints, tendons,
inflammation? tingling pain? past the normal ligaments and muscle?
healing process

Pre-op: 1 – 2 hours Neuropathic

Inflammatory Musculoskeletal
Nociceptive Pain before surgery, Prevent
Pain Pain
peripheral sensitization Pain

Intra-op: During 1 st line - Non-

operation, Prevent Trigeminal Postherpetic Diabetic pharm treatment:
1 st line - Pharm
Fibromyalgia Exercise and
treatment: central sensitization due Neuralgia Neuralgia peripheral
to incisional injury neuropathy Multidisciplinary
Acetaminophen and
management
NSAIDS
1 st line - Pharm 1 st line – Non-
Post-op: Reduce acute Prevention: 1 st line - Pharm
treatment: pharm treatment:
pain and prevent Shingles vaccine 2 nd line - Pharm
2 nd
line - Pharm Carbamazepine treatment:
chronic pain, ~1 week Physical activity, treatment:
treatment: Opioids and Pregabalin,
post-op, Oral preferred Education, and Acetaminophen
Combination opioids Duloxetine
2 nd line - Pharm 1 st line - Pharm Psychological and NSAIDS
treatment: treatment: support
rd Acetaminophen,
3 line - Pharm Oxcarbazepine Lidocaine patch 2 nd line - Pharm
treatment: Full opioid NSAIDs, Gabapentin, treatment: 3 rd line - Pharm
agonists Pregabalin, Local 2 nd
line - Pharm Gabapentin, treatment: Muscle
anesthetics, and 3 rd line - Pharm 2 ndline - Pharm relaxants, Weak
treatment: TCAs,
Opioids are preferred treatment: Combo treatment: opioids,
Amitriptyline, Venlafaxine
for perioperative pain therapy Gabapentin, Antidepressants
Duloxetine,
Pregabalin, Milnacipran,
Key: TCAs, Topical 3 rd line - Pharm
NSAIDS = Selective: Ibuprofen, Naproxen, Indomethacin; Non-selective: Celecoxib, Diclofenac Pregabalin, treatment: Combo
capsaicin Last line - Pharm
• Monitoring: Decreased renal clearance, increased blood pressure, increased risk of MI/stroke, avoid in pregnancy third trimester, Cyclobenzaprine, therapy
Tramadol treatment: Strong
nausea, GI bleed
• Non-selective: Antiplatelet activity, increased risk of GI bleed, risk of CNS effects, short term use only due to risk of renal and liver 3 rd line - Pharm opioids,
treatment: Last line - Pharm Anticonvulsants
failure
Tramadol 3 rd line - Pharm treatment:
• Selective: Increased risk of MI/stroke
treatment: Opioids
Acetaminophen
Gabapentin,
• Monitoring: Caution in alcohol use and liver dysfunction; Can cause hepatotoxicity and rarely severe skin reactions (SJS, TEN,
AGEP). Venlafaxine,
SSRIs,
Combination opioids = Hydrocodone & Acetaminophen
Cannabinoids
• Monitoring: Life-threatening respiratory depression, addiction, abuse, and misuse, life-threatening QT prolongation, and neonatal
opioid withdrawal syndrome
Opioids (Full opioid agonists) = Morphine, Hydromorphone, Codeine, Oxycodone, etc.
• Monitoring: Life-threatening respiratory depression, addiction, abuse, and misuse, life-threatening QT prolongation, and neonatal
opioid withdrawal syndrome
Muscle relaxants = Baclofen, Cyclobenzaprine, Methocarbamol, Carisoprodol
• Monitoring: Cause CNS depression and can have additive effects, should be used short term, should be discontinued if ineffective, add
risk for polypharmacy
Antidepressants = Duloxetine, Venlafaxine (TCA), Amitriptyline
• Monitoring: SSRIs - Increased risk for bleeding, avoid CrCl<30mL/min, avoid/caution in liver disease, dose adjustments with
renal/hepatic impairment. TCAs - Lower doses necessary for analgesia compared to MDD doses, multiple cardiac and anticholinergic
adverse effects
Anticonvulsants = Gabapentin, Pregabalin, Topiramate, Lamotrigine, Carbamazepine
• Monitoring: CNS depression, increased risk for impairment, drug rashes and hepatotoxicity, blood dyscrasias, bone loss, suicide risk