Managing Chronic Pain Using Nonopioid Medications

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Tie mainstay for treating chronic pain is medication management. Most patients expect to receive a medication prescription when they see their primary care provider with a pain complaint. However, for some conditions, such as low back pain, the current recommendations for the acute phase is acetaminophen/nonsteroidal anti-inflammatory drugs (NSAIDs) and continued activity, rather than opioids and bed rest. About 15% of the patients who have acute low back pain progress to chronic low back pain. Medication management for chronic low back pain is recommended, accompanied by a plan of care that includes medications along with other therapies, such as physical therapy and counseling (D'Arcy, 2009b). Opioids are in most cases reserved for severe level pain that is impairing functionality.

Treatment of chronic pain with medications requires a comprehensive pain assessment, history and physical examination, and medication review that includes over-the-counter medications, herbal supplements, and vitamins (Bruckenthal, 2007). Most patients with chronic pain have tried various pain medications and know which work best and which are less effective. When patients have information about medications that are effective for relieving their pain, consider this information, which is similar to what a patient with diabetes provides about daily insulin doses to a new health care provider. Just because a patient is familiar with medication names and doses, do not assume the patient is a "drug seeker."

There are genetic factors that influence the effectiveness of pain medications in a specific individual, so when patients say the only medication that works for them is morphine, it may really be a reflection of how their genetic makeup has reacted to the medications that were tried in the past. Patients should never be penalized or labeled for providing information on how specific medications have worked for them in the past.

This section will provide information about using pain medications of various types: NSAIDs, opioids, and other coanalgesics, such as antidepressants. The information will be taken from current guidelines developed by the American Pain Society, the American Geriatrics Society, the American Academy of Pain Medicine, and other national organizations (Appendix A). Included will be an order set for pain management based on the World Health Organization Analgesic Ladder and medication charts. The topics of addiction, dependency, and tolerance will be discussed in Section III. Information on integrative therapies that can be combined with medication management will be provided in chapter 6.

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