Transcript Use of Non-Opioid Agents and Neuropathic Pain

USE OF NON-OPIOID AGENTS
AND NEUROPATHIC PAIN
Calvin Lui, MD
PGY2
February 8, 2014
OBJECTIVES
Learn about neuropathic pain and commonly
used agents and starting dosages
 Learn about common agents that address muscle
spasm
 Learn about common agents and modalities that
address cancer pain
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CLINICAL CASE
A 70-year-old male with recent diagnosis of
multiple myeloma presents to his PCP with pain
of his shoulders and back. His back pain has been
persistent for the past several months. It has two
components: some “running shock-like down to
his feet” and other “feeling as if his back is being
eaten at.” There is radiologic evidence of bony
metastases and DJD. Also, he feels as if his pain
tightens on a nightly basis. He has been given 15
mg of MS Contin PO BID, but his pain is still
uncontrolled. How would you address his pain.
“SHOCK-LIKE” PAIN
Likely neuropathic pain
 Common history items would include radiation
from the pain and tingling that he has.
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NEUROPATHIC PAIN
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Sympathetically mediated pain- pain arising from
a peripheral nerve lesion and associated with
autonomic changes
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Peripheral neuropathic- damage to a peripheral
nerve without autonomic change
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complex regional pain syndrome I and II
postherpetic neuralgia, neuroma formation
Central pain- abnormal central nervous system
(CNS) activity
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phantom limb pain, pain from spinal cord injuries,
and post-stroke pain
HISTORICAL CLUES TOWARDS
NEUROPATHIC AGENTS
Burning, sharp, tingling
 Possibly dermatomal or stocking-glove
 Worse with touch
 May have associated numbness
 Radiating
 Possibly associated with
 Changes in skin temperature/sweating
 Changes in sensation (itching/numbness)
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COMMON AGENTS
NEUROPATHIC PAIN AGENTS AND COMMON
DOSAGES
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Methadone (opioid with neuropathic facets)- 5 mg
PO BID or TID starting
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Ketamine: I.V.: 0.2-0.75 mg/kg
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May consider using as long acting and later short
acting
Larger gun, can be sedating and dissociative
Gabapentin (600 mg PO TID or 300 AM/600
Noon/900 PM
Be warned about drowsiness, need for weeks for
levels to build
 Reduce to as little as 300 mg daily in renal disease

NEUROPATHIC AGENTS CONTINUED
Pregabalin (150 mg PO daily with titration up to
300 mg PO daily)
 Duloxetine: 30 mg PO daily for 1 week, then
increase to 60 mg once daily as tolerated.
 Venlafaxine: 75-225 mg/day; onset of relief may
occur in 1-2 weeks, or take up to 6 weeks for full
benefit
 TCAs- nortripyline, desipramine, amytriptlyine

Nortripyline- 10-25 mg PO qHS
 Amytripline- 25 mg PO qHS with titration to 100 mg
qHS
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“SHOCK-LIKE” PAIN REGIMEN
Likely neuropathic pain
 Let’s start Duloxetine 60 mg daily
 Consider Gabapentin 300 mg TID with titration
up to 600 mg TID
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WHAT ABOUT HIS BACK TIGHTNESS

Likely muscle spasm
PAIN 2/2 TO MUSCLE SPASM
sudden, involuntary contraction of a group of
muscles
 Baclofen: 5 mg PO TID
 Methocarbamol :1.5 mg PO q6H for 2-3 days
 Carisoprodol: 250-350 mg PO TID and qHS
 Diazepam: 5mg q6-8H PRN

WHAT ABOUT HIS BACK TIGHTNESS
Likely muscle spasm
 Let’s start him on Baclofen 5 mg TID
 And now what is left to do is address his pain
from his malignancy.
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PAIN FROM BONY METASTASES
 Corticosteroids

Bone pain 2/2 to cancer
Dexamethasone
 least amount of mineralocorticoid effect
 typical dosage: 4mg q6H

 Radiation
therapy
 Bisphosphonates
 Zolendronate 4 mg IV
FINAL PAIN REGIMEN FOR PATIENT
Continue with MS Contin 15 mg PO BID
 Duloxetine 60 mg PO daily
 Consider gabapentin 300 mg TID with
uptitration to 600 mg TID
 Dexamethasone 4 mg PO q6H
 Baclofen 5 mg TID
 Consider Lidocaine patch for localized pain if
there is neuropathic pain in the region of the
injured wrist
 Radioablative therapy to spine for extensive mets

SUMMARY
Different types of pain need to addressed and
highlighted in each patient to provide sufficient
pain control
 Many agents exist for neuropathic pain and need
consideration of degree of neuropathic pain
 Bony Metastases may incur their own pain and
benefit from corticosteroids and radiation in some
cases
 Consider Muscle spasm as an etiology of pain and
know common medications to treat it
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REFERENCES
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