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Pain Clinic

A17

Drug Treatments

Using medicines to treat pain is a simple first step. We recommend that initial treatment follows the WHO analgesic ladder recommendations, both for pain that is of recent onset (acute) and pain that is longstanding (chronic). For neuropathic pain (see Assessment Tool for Neuropathic Pain) different drugs are used (see Analgesic Ladder for Neuropathic Pain).

Occasionally, it can be appropriate to try using opioids for non-malignant pain, and this web site provides advice on doing so (see Opioids in Benign Chronic Pain).


Analgesic Ladder for Acute and Chronic Pain

STEP 1

  1. Paracetamol 1g qds.
  2. NSAIDs such as ibuprofen.
  3. Consider Non-drug Treatments.
STEP 2
  1. Medication in STEP 1, plus
  2. Consider adding weak opioids, such as tramadol or codeine phosphate.
  3. If after these steps the pain has not settled, consider:

  4. Whether the pain is neuropathic (see Analgesic Ladder for Neuropathic Pain).
  5. Whether referral to a multi-disciplinary Pain Clinic or another specialist is appropriate.
  6. The use of stronger opioids.

Analgesic Ladder for Neuropathic Pain

Neuropathic pain often presents as burning or searing pain, usually in a dermatomal distribution. Common examples of neuropathic pain include sciatica or post-herpetic neuralgia. The drugs that are often used to control neuropathic pain include topical treatments such as capsaicin cream, 0.075% as well as drug treatments. The first line approach after simple measures and topical treatment is a tricyclic antidepressant (TCA) at low dose. Anti-convulsant drugs can be used also, but we would recommend this only after trial of TCAs, and after considering referral to a multi-disciplinary Pain Clinic.

STEP 1
  1. Topical treatments, such as capsaicin cream 0.075% or lignocaine gel.
  2. Paracetamol 1g qds.
  3. Consider Non-drug Treatments.
STEP 2
  1. Medication in STEP 1, plus
  2. Antidepressants
Antidepressants

Tricyclic antidepressants are effective in the treatment of neuropathic pain (NNT=3.0), and are widely used.

Often women, older patients and some younger men tolerate lower doses than other patients. If patients are unable to tolerate amitriptyline, we recommend the use of nortriptyline as sedation is usually less.

We recommend that patients gradually increase their dose, not expecting to see a reduction in pain for four to six weeks. They should keep the dose steady when they find a dose that suits them. Any reduction in dose should be carried out slowly, as failure of analgesia and dysphorias can occur with rapid dose reductions.

Side effects may occur, and these may either limit the maximum dose or prevent the patient continuing with the drug. If this does happen, the drug should be stopped over a couple of weeks if possible.

Amitriptyline or Nortriptyline dosing schedule

Week · Dose (in the evening)
Week 1 · 10mg
Week 2 · 20mg
Week 3 · 30mg
Week 4 · 40mg
Week 5 · 50mg


If STEP 2 doesn’t adequately control the pain, consider STEP 3.

STEP 3
  1. Medication in STEP 1 and STEP 2 (if preferred).
  2. Consider Non-drug Treatments
  3. Anticonvulsants
Anticonvulsants

Anticonvulsants are effective in neuropathic pain (NNT = 3.0) and are widely used.

The use of anticonvulsants is ideally combined with other aspects of a multi-disciplinary approach, such as that provided by the Bath Pain Clinic. However, should a General Practitioner wish to trial an anticonvulsant drug before the patient arrives at the Pain Clinic, or before referral, the following dose schedules are recommended.

We recommend that gabapentin is trialled before pregabalin. Some neuropathic pain, such as trigeminal neuralgia, tends to respond better to carbamazepine.

Often women, older patients and some younger men tolerate lower doses than other patients.

We recommend that patients gradually increase their dose, not expecting to see a reduction in pain for four to six weeks. They should keep the dose steady when they find a dose that suits them. Any reduction in dose should be carried out slowly, as failure of analgesia and dysphorias can occur with rapid dose reductions.

Side effects may occur, and these may either limit the maximum dose or prevent the patient continuing with the drug. If this does happen, the drug should be stopped over a couple of weeks if possible.

Gabapentin dosing schedule, starting at 300mg

Week Morning Noon Evening
Week 1 0 0 300mg
Week 2 300mg 0 300mg
Week 3 300mg 300mg 300mg
Week 4 300mg 300mg 600mg
Week 5 600mg 300mg 600mg
Week 6 600mg 600mg 600mg
Week 7 600mg 600mg 900mg
Week 8 900mg 600mg 900mg
Week 9 900mg 900mg 900mg
Week 10 900mg 900mg 1200mg
Week 11 1200mg 900mg 1200mg
Week 12 1200mg 1200mg 1200mg


Note: If there is no response at a dose of 600mg tds, please consider referral to the Pain Clinic.

If 300mg is poorly tolerated as a starting dose, gabapentin can be started at a much lower dose, and increased more gradually. We recommend the following dosing schedule in this case:

Gabapentin dosing schedule, starting at 100mg

Week Morning Noon Evening
Week 1 0 0 100mg
Week 2 100mg 0 100mg
Week 3 100mg 100mg 100mg
Week 4 100mg 100mg 200mg
Week 5 200mg 100mg 200mg
Week 6 200mg 200mg 200mg
Week 7 200mg 200mg 300mg
Week 8 300mg 200mg 300mg
Week 9 300mg 300mg 300mg
Week 10 300mg 300mg 400mg
Week 11 400mg 300mg 400mg
Week 12 400mg 400mg 400mg
Week 13 400mg 400mg 500mg
Week 14 500mg 400mg 500mg
Week 15 500mg 500mg 500mg
Week 16 500mg 500mg 600mg
Week 17 600mg 500mg 600mg
Week 18 600mg 600mg 600mg
Week 19 600mg 600mg 700mg
Week 20 700mg 600mg 700mg
Week 21 700mg 700mg 700mg
Week 22 700mg 700mg 800mg
Week 23 800mg 700mg 800mg
Week 24 800mg 800mg 800mg


Note: If there is no response at a dose of 600mg tds, please consider referral to the Pain Clinic.

Pregabalin dosing schedule

Week Morning Evening
Week 1 50mg 50mg
Week 2 75mg 75mg
Week 3 150mg 150mg
Week 4 300mg 300mg


Note: If there is no response at a dose of 75mg bd, please consider referral to the Pain Clinic.

Carbamazepine dosing schedule

Week Morning Noon Evening
Week 1 100mg 100mg 100mg
Week 2 200mg 200mg 200mg
Week 3 300mg 300mg 300mg
Week 4 400mg 400mg 400mg


If the response to a single drug is poor, consider using combinations of drugs, particularly a combination of a tricyclic and an anticonvulsant.

Consider referral to the Bath Pain Clinic.

Consider Non-drug Treatments.

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