Meet the Professor: Pain Management

Suneil Kapur, MD, BSc, Stephanie Myckatyn, MD, BSc


Rheumatologists and primary care physicians are commonly faced with managing chronic pain. The various approaches to pain management were discussed in detail amongst an international group of rheumatology healthcare professionals. These approaches include:
 •  Cognitive-behavioural therapy
 •  Physical therapy
 •  Pharmacotherapy
 •  Surgery.

Before initiating therapy, it is important to accurately evaluate the patient to:

•	Distinguish between acute and chronic pain
•	Make an accurate medical diagnosis
•	Assess pain status for possible psychosocial diagnoses, life stressors or secondary pain
•	Categorize pain as either inflammatory, neuropathic or degenerative/mechanical.

Cognitive-behavioural interventions include relaxation training (e.g. meditation, biofeedback, breathing techniques), which shifts attention away from pain, reduces muscle tension and improves the rest/sleep cycle. Other interventions are:
 •  Imagery training
 •  Cognitive restructuring
 •  Psychotherapy
 •  Support groups
 •  Pacing.

The purpose of physical therapy is to improve and maintain function, strength, mobility, range of motion and balance. This will attenuate pain, spasm, contractures and abnormal tone or gait. Modalities such as electrical stimulation, heat/cold and massage are temporizing, whereas exercise, stretching and adaptive devices (braces, splints, orthoses) have more long-term effects.

Acupuncture can be efficacious as adjunctive therapy for chronic pain syndromes (osteoarthritis, fibromyalgia, myofascial pain, carpal tunnel syndrome), but further research is needed to identify other areas of use.

As a group, anticonvulsants (e.g. gabapentin, carbamazepine, phenytoin, lamotrigine) are effective for neuropathic pain, although the actual mechanism of action is unknown. Carbamazepine has been considered the gold standard for trigeminal neuralgia. However, its side-effect profile, including aplastic anemia, agranulocytosis, and rashes (TEN), has limited its use. Despite having no FDA approval for pain control, gabapentin (Neurontin) is becoming the drug of choice for neuropathic pain. It is less toxic, the main side effects being drowsiness, dizziness, dyspepsia and diplopia. Phenytoin (Dilantin) should not be first-line therapy for diabetic neuropathy, due to conflicting studies regarding efficacy and its side-effect profile.

Tricyclic antidepressants are useful in neuropathic pain at medium range doses. The analgesic effect is not immediate but occurs sooner than the antidepressant effect. The majority of studies have focused on amitriptyline (Elavil), but other agents (e.g., doxepin (Sinequan)), with less anticholinergic side effects, are now in favour.

Amongst the selective serotonin reuptake inhibitors (SSRIs), paroxetine (Paxil) is shown to be efficacious in diabetic neuropathy. Anecdotal reports suggest that venlafaxine (Effexor) can be helpful in neuropathic pain. Topical preparations, such as capsaicin and lidocaine, can be used for neuropathic pain, with minimal systemic side effects.

For mechanical pain, such as muscle spasm, therapeutic options include muscle relaxants, which have limited side effects. Sleep restoration is important in the management of chronic pain. Zaleplon (Sonata) and zolpidem (Ambien) are structurally related to benzodiazepines, short acting and less addictive compared with benzodiazepines.

Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of treatment for chronic pain. Opioids can be used for those patients who have failed all conventional therapy. Short-acting agents include:
 •  Morphine (the gold standard)
 •  Codeine
 •  Hydrocodone
 •  Oxycodone
 •  Hydromorphone.

Meperidine should not be used long-term, due to toxic central nervous system (CNS) metabolites. Once an adequate dose of a short-acting agent is established, long-acting narcotics can be introduced, including methadone (inexpensive), fentanyl transdermal patch and oxycontin.

Surgery is considered as a last resort for chronic pain and includes medication pumps, spinal cord stimulation, deep brain stimulation and total joint replacement.


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This program has been provided through an unrestricted educational grant from McNeil Consumer Healthcare, the makers of TYLENOL*(acetaminophen).