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Dealing with pain 

Dealing with pain

Dealing with pain

Henry McQuay


May 31, 2012: This chapter has been re-evaluated and remains up-to-date. No changes have been necessary.

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date: 30 March 2017

Pain is complex—it is too simple to view pain transmission as a hard-wired, line-labelled system, because that cannot explain complexities such as phantom limb pain. The crucial mechanistic distinction for clinical practice is between normal (nociceptive) and nerve damage (neuropathic) pain.

Types of analgesics—conventional analgesics, from paracetamol through to morphine, work well in nociceptive pain and less well in neuropathic pain. Unconventional analgesics, antidepressants, and antiepileptic drugs work well in neuropathic and less well in nociceptive pain.

Treating pain—most pains are dynamic rather than static, hence patients need to be able to deal with mild through to severe pain. In both nociceptive and neuropathic pain a three-stage algorithm provides a framework for both patient and prescriber. For nociceptive pain: (1) mild pain—paracetamol (acetaminophen); (2) moderate pain—add (not substitute) weak opioid or non-steroidal anti-inflammatory drug; (3) severe pain—add (not substitute) strong opioid. For neuropathic pain: (1) mild pain—antidepressant; (2) moderate pain—add (not substitute) antiepileptic, e.g. gabapentin, pregabalin; (3) severe pain—add (not substitute) opioid.

Difficult pain—patients with complex pains, or with pain and complex needs, may need multidisciplinary approaches to untangle their pain, disability, and distress: tackling the elements singly is unlikely to succeed. There is no convincing evidence of the analgesic effectiveness of complementary approaches, but it is important to acknowledge that these interventions may make people feel better, although they rarely obviate the need for effective analgesia.

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