ADJUVANT PAIN

TREATMENTS
• Adjuvant medications can be used alone or in conjunction with
other pain medication (opioids)
• Medication can be titrated to pain relief and avoid side effects
• A patient may benefit most from adjuvants in pain symptoms in
neuropathic or visceral
 CASE 1

Mary is a 60 year old female with a history of metastatic breast cancer. She
has had increased pain in her Right flank , radiating around her chest. She
is on Morphine SR 15mg BID. But the pain is getting worse. She describes
it as sharp.
What do you recommend??
DIFFERENTIAL DIAGNOSIS?

• Bone metastasis spine

• Nerve impingement
• Herpes Zoster
• Localized bone metastasis
• Fracture
• Doctor examines her and there is no localized rash or blisters. She
has hypersensitivity to touch but no localized pain.
• X ray is negative for rib fracture, shows osteopenic bone.
• MRI T spine shows Mets to her T spine and compression fracture
with nerve impingement
TREATMENT OPTIONS?
ACETAMINOPHEN

• Acetaminophen can be used for mild to moderate pain .

• 650mg-1000mg q6hr. Max dose 4000mg/24 Hr.
• Acetaminophen IV has been effective in immediate post op pain
control. Only approved for Post op use now. Less need for narcotics.
ANTI-INFLAMMATORIES

• NSAIDS and Cox 2 inhibitors

• Can be used for inflammation, bone pain and as an adjuvant to
narcotics
• Risk vs. benefit in thrombotic risk for CAD or CVA patients
• Risk GI bleed or renal insufficiency, inhibit platelet aggregation
• Poor choice for patients with poor PO intake and risk GI side
effect.
• Consider GI prophylaxis
CORTICOSTEROIDS

• Often useful as adjuvant in pain control

• Bone metastasis
• Increased intracranial pressure
• Nerve impingement
• Acute internal inflammation (visceral pain)

• Also caution for GI bleed, glucose control and Altered mental status and
delirium especially in elderly or patients with neurologic dysfunction
ANTIDEPRESSANTS

• Tricyclic Antidepressants (amitryptiline, nortriptiline, desipramine)

• For neuropathic pain
• High side effects- Anticholinergic
• Use with caution in elderly, often sedating
• SSRI’s (sertraline), SNRI’s (venlafaxine, duloxetine)
• Can be used as adjuvant medication
• Duloxetine is approved for diabetic neuropathy (off label for post herpetic
neuralgia)
 ANTICONVULSANTS

• Anti seizure medications

• Carbamazepine, phenytoin
• Monitor LFT
• Monitor CBC with carbamezepine (risk aplastic anemia)
• Risk for sedation
• Pregabalin (lyrica)
• Approved for diabetic neuropathy and post herpetic neuralgia
• 25-100mg tid dosing
• Adjust to renal dose
 GABAPENTIN

• Good results for neuropathic pain

• Sharp shooting pain, numbness, burning
• Usual effective dose 900-3600mg/day
in 3 divided doses
• Slow and gradual dose increase
• 100mg QD to start, increase by 100mg every 3-5 days as tolerated
• 100mg bid-100mg tid etc…
 ANTICONVULSANT SIDE EFFECTS

• Monitor for dizziness

• Altered mental status
• Lethargy
• Anorexia or nausea
 ALPHA-2 RECEPTOR AGONISTS

• Clonidine- tablets, patch, epidural

• Post op use showed decreased narcotic consumption
• Increased time to next analgesic need
• Risk of sedation and bradycardia, but no increased risk hypotension
• Side effects dizziness, CNS depression, xerostomia
• Rebound hypertension, withdraw gradually
 ANTISPASM DRUGS

May help in muscle spasm eg: MS, spinal cord injuries

• Muscle relaxants
• May be helpful in muscle spasm
• baclofen, carisoprodol, cyclobenzaprine, methocarbamol
• Monitor for side effects: sedation, confusion
• Benzodiazepines
• clonezepam, lorazepam, diezepam
• Risk for sedation, confusion
 N-methyl-D-aspartate receptor 

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR

ANTAGONISTS
• The NMDA receptor is thought to be very important for
controlling mediating learning and memory functions
• Methadone
• Ketamine
• -Opioid sparing
• Studies show reduced opioids need
• Side effects dizziness, hallucinations
 PARENTAL LIDOCAINE

 Can be an effective agent to treat severe pain especially when neuropathic and
thus has potential to improve a patient’s quality of life
 side effects are short lived (usually light-headedness, nausea, phlebitis at site of
infusion) with no untoward long term effects
 Use of opioid medications can often be reduced, minimizing their side effects
 Start with a lidocaine bolus/loading dose, then start a continuous IV or SC
infusion, the goal is the lowest dose possible that still controls the pain
OTHER PHARMACOLOGIC STRATEGIES

• Topical anesthetics
• Lidocaine Patch
• Heated rubs (BenGay, icy hot etc.)
• Topical NSAID creams
• Capsaicin cream
NON PHARMACOLOGIC

• Physical interventions
• Heat/cold (ice)
• Massage
• Repositioning, bracing
• Acupuncture/Acupressure
• Physical therapy
NON PHARMACOLOGIC THERAPY

• Other
• Relaxation
Guided imagery
Distraction
• Cognitive therapy
• Support group
• Spiritual