Pain Clinic
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
- Paracetamol 1g qds.
- NSAIDs such as ibuprofen.
- Consider Non-drug Treatments.
STEP 2
- Medication in STEP 1, plus
- Consider adding weak opioids, such as tramadol or codeine phosphate.
- Whether the pain is neuropathic (see Analgesic Ladder for Neuropathic Pain).
- Whether referral to a multi-disciplinary Pain Clinic or another specialist is appropriate.
- The use of stronger opioids.
If after these steps the pain has not settled, consider:
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
- Topical treatments, such as capsaicin cream 0.075% or lignocaine gel.
- Paracetamol 1g qds.
- Consider Non-drug Treatments.
STEP 2
- Medication in STEP 1, plus
- 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
- Medication in STEP 1 and STEP 2 (if preferred).
- Consider Non-drug Treatments
- 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.
Links
Opioids in Benign Chronic Pain