Adjuvant Analgesia

for Management of Pain

Part-II
4.05.2020
 Amphetamine

 Amphetamine has been used to enhance morphine analgesia, and to decrease

morphine-related side effects such as nausea, sedation, constipation, and loss
of alertness.
 As a class, amphetamine is not widely used due to the risk of increased
tolerance and dependence in chronic use, and the potential for withdrawal.
 Amphetamines can increase blood pressure and exacerbate an underlying
coronary artery disease.
 Hypnotics/Sedatives

 A common problem associated with chronic pain is the inability to have a

restful sleep.
 The resulting decreased capacity for the body to recuperate and to
rejuvenate inevitably adds to the suffering of patients with chronic pain.
 Sleep management is, therefore, an essential part of pain management.
 Most commonly prescribed hypnotics include the benzodiazepines, chloral
hydrate, zopiclone, and zolpidem.
 Hypnotics suppress the reticular formation of the midbrain resulting in
sedation, sleep, or anesthesia.
 BZs bind to the BZ-GABA-chloride receptor complex in the brain while
zolpidem binds selectively to GABA A1 receptors.
Cont….

 Use of hypnotics is not recommended for treating sleep irregularities for more
than one or two weeks.
 Adverse side effects may include daytime sedation, anterograde amnesia, rebound
insomnia and, for high dosage, impaired respiration, and blood pressure.
 Discontinuation may produce withdrawal, rebound, and relapse. Drug interaction
profiles should be considered when prescribing hypnotics.
 Sleep problems, which persist after the pain is treated, should be referred to a
mental health clinician and/ or sleep laboratory.
 Provigil (Modafinil), a novel wake-promoting agent, has recently been added to
the list of adjuvants for treating sleep-wake problem.
 Modafinil has been shown to subjectively and objectively improve wakefulness,
vigilance, mood, and cognitive
 OTHER ADJUVANT ANALGESICS

 Antiarrhythmics. Current research supports the use of mexiletine as an

effective treatment for neuropathic pain.
 In one doubleblind crossover study, mexiletine not only decreased pain but
also the accompanying parasthesias and dysesthesias.
 Another study found mexiletine decreased pain and sleep disturbances
associated with painful diabetic neuropathy.
 This agent is not free of side effects and should be used carefully.
 Calcium channel blockers

 Verapamil is a calcium channel blocker commonly used to treat chronic pain

and has been successfully
 used to treat migraine and cluster headaches.45 It is unclear whether the
mechanism of action is primarily related to cerebral artery
 vasodilatation or interaction with serotonergic systems.
 KETAMINE

 Ketamine is an ideal anesthetic agent that works on the NMDA receptors.

 It can be used to treat cancer and non-cancer pain and may be indicated for
long term palliative care situations as well.
 A starting dose of 150 mg/day for subcutaneous infusion or 1 mg every 12
hours intrathecally has been suggested.
 More clinical trials are needed to justify more routine use in the management
of chronic pain.
 The topical form of this medication is clinically used.
 Ketamine can be used in highly opioiddependent patients undergoing major
surgeries.
 LIDOCAINE
 Systemic administration of lidocaine can produce sodium channel blocking activity
leading to analgesia.
 Pain with a more central mechanism, such as neuropathic pain and phantom pain,
seems to respond better.
 Low rate infusions have been used as a third or fourth line of treatment especially in
opioid–tolerant patients. Incremental rate infusions over 20 to 30 minutes can be used
as a therapeutic test before starting mexiletine in patients where anti-epileptic drugs
have not been effective.
 Cardiac monitoring is mandatory when using this medication.
 The idocaine (Lidoderm) 5% patch is a transdermal method of delivery for this local
anesthetic.
 Each adhesive patch contains lidocaine 700 mg (50 mg per gram adhesive) in an
aqueous base.
 It also contains methyparaben and propylparaben as preservatives. The patch is
applied once for up to 12 hours in a 24 hours period.
 CAPSAICIN
 Capsaicin can be used as a topical ointment against neuropathic pain.
 It acts by inhibiting substance P formation at the skin.
 It is effective in only 50% to 60% of patients.
 This agent can take up to a week to start working and the patient should be
advised of this lag time.
 BOTULINUM TOXIN
 This drug blocks pre-synaptic release of acetylcholine.
 The neurotoxin type A is used clinically while the type B is still in
development.
 Therapeutic effects last 3-4 months and are achieved through the sprouting of
new nerve terminals.
 MISCELLANEOUS DRUGS

 Certain radiopharmaceuticals (Strontium 89, Sumarium) have been used, with

success, in advanced and palliative cancer pain patients.
 Recent studies have also concluded that Pamidronate (Aredia) or other
bisphosphonates should be used routinely for metastatic bone disease,
especially in breast cancer.
 Non-pharmacological Adjuvant Analgesics

 Electrical Stimulation.
 Transcutaneous electrical nerve stimulation (TENS).
 Biofeedback
 EEG Biofeedback.
 Hypnosis.
 Relaxation therapy.
THANK YOU