Non-drug treatment

• Exercise

• Transcutaneous electrical nerve stimulation (TENS)

• CBT, biofeedback, progressive relaxation

• Acceptance and commitment therapy

Drug treatment

• WHO analgesic ladder

Non-opioid analgesics

• Paracetamol

• NSAIDS: diclofenac potassium 75-150mg TDS PO, diclofenac sodium 75-150mg PR (in daily divided doses)

Opioid analgesics

• Co-codamol 8/500mg, 15/500mg, 30/500mg 2 QDS PRN

• Codeine phosphate: 30-60mg 3-4x/day 

• Tramadol hydrochloride: 50-100mg every 4-6 hours (max 400mg/24hours)

• Oxycodone

• Morphine e.g. 5-10mg every 4 hours, diamorphine 1.25-5mg

A 53-year-old man has chronic kidney disease (CKD) with an eGFR of 16 ml/min. He has severe chronic pain and requires an opioid for pain control.

Opioids that are transformed to active or toxic metabolites and are dependent on the kidneys for excretion should be avoided, e.g. codeine, morphine, pethidine and tramadol.

Opioids that are least likely to cause harm to patients with severe renal impairment are fentanyl and buprenorphine.

Adjuvant analgesics: drugs such as..:

• Antidepressants (amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine, sertraline)

• Antiepileptics

• Benzodiazepines & other muscle relaxants

• Corticosteroids

• Topical capsaicin (neuropathic pain / osteoarthritis)

• Lidocaine

• Rubefacients

* Pregabalin and gabapentin (indications for neuropathic pain, focal seizures, anxiety): following concerns about abuse, pregabalin has been reclassified as a Class C controlled substance and is now a Schedule 3 drug, but is exempt from safe custody requirements. Healthcare professionals should evaluate patients carefully for a history of drug abuse before prescribing pregabalin, and observe patients for signs of abuse and dependence. Patients should be informed of the potentially fatal risks of interactions between pregabalin and alcohol, and with other medicines that cause CNS depression, particularly opioids.

https://bnf.nice.org.uk/drugs/gabapentin/

https://bnf.nice.org.uk/drugs/pregabalin/ 

Questions

A 42-year-old woman with a 2-year history of a chronic primary orofacial pain syndrome is interested in psychological treatment to address her pain. She has previously had cognitive behavioural therapy which she did not find helpful.

Which ONE of the following treatments is recommended by National Institute of Health and Care Excellence (NICE)? 

A. Biofeedback training

B. Psychodynamic psychotherapy

C. Counselling

D. Person-centred therapy

E. Acceptance and commitment therapy

NICE recommend acceptance and commitment therapy (ACT) as well as cognitive behavioural therapy (CBT). Biofeedback training is specifically advised against, and NICE do not comment on other forms of psychotherapy.

Resource:

NICE. Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NG193. 2021.