PAIN MANAGEMENT ( MEDICATION )
Pain is a signal our body that something is wrong. It may be due to physical injury, a type of illness or emotional disturbances. Most of the types of physical pain can be treated with painkillers.
Both the area of injury and how the brain processes pain signals in the affected or injured area . Generally, medicines, and to try to stop the transmission of pain at the site of injury or affect the brain directly.
The effects of drugs against pain are different for different people. In addition, pain tolerance varies greatly from person to person. For this reason, a drug is not suitable for everyone with the same injury. For example, some people are very satisfied with the medications prescribed by a sprained ankle, while others need a prescription pain reliever stronger. Drugs with proper pain depends on the person experiencing the pain, not in the condition that causes pain.
ANALGESICS ( PAIN KILLERS ) ANTI - INFLAMMATORY DRUGS FOR MUSCULOSKELETAL PROBLEMS
The key using drugs ,particularly in chronic disorders and the elderly ,is to balance risk and benefit and constantly to review their appropriateness.
SIMPLE AND COMPOUND ANALGESIC AGENTS
Simple agents such as paracetamol,aspirin ,or codeine compounds ( or combination preparation ) , used when necessary or regularly,relieve pain and improve function.Sleep may also be improved.Side effects are relatively ifrequent ,although drowsiness and constipation occur with codeine preparations, especially in the elderly.
Strong analgesics,such as dihydrocodeine or morphine drivatives,should be used only with severe pain.
NON-STEROIDAL ANTI-INFLAMMATORY DRUGS ( NSAIDs )
NSAIDs have anti-inflammatory and centrally acting analgesic properties.They inhibit cyclo-oxygenase (COX) ,a key enzyme in the formatin of prostaglandins, prostacyclins and thrombixanes .There are two specific cyclo-oxygenase enzymes : COX-1 ,the constitutive form,and COX-2 ,the form mainly induced by inflammation.Most of the older NSAIDs block both enzymes but with variable specificity : their therapeutic effects depends on blocking COX-2 and their side effects mainly on blocking COX-1.COX-1 is a constitutive enzyme present in many normal tissues.Inhibition of the enzyme by NSAIDs produce side effects caused,for example ,by the loss of gastric mucosal protection and a decrease in renal blood flow.
COX-2 is induced in response to pro-inflammatory cytokines and is not found in most normal tissues.It is associated with oedema and the nociceptive and pretic effects of inflammatio.COX-2 specific appears to be costitutive in the kidney ,COX-2 specicific NSAIDs are available.
USES
Short causes of NSAIds are used occasionally in osteoarthritis and spondylosis,even when there is minimal inflammatio .They are commonly used in musculoskeletal pain but simple analgesia is often more appropriate.In crystal synovitis .NSAIDs have a true anti-inflammatory effect.In chronic inflammatory synovitis ,NSAIDs do not alter the chronic inflammatory process,nor decrease the risk of joint damage ,but they do reduce pain and stiffness.Slow release preparation are useful for inflammatory arthritis and when more constant pain control is needed.NSAIDs gels have no proven role in chronic arthritis.
The use of NSAIDs in high doses rapidly reduces the pain and swelling.Initial doses,taken with food,are
NAPROXON: 750 mg immeditely ,then 500 mg every 8-12 hours.
DICLOFENAC: 750-100 mg immediately ,then 50 mg every 6-8 hours.
INDOMETHACIN: 75 mg immediately ,then 50 mg every 6-8 hours.
After 24-48 hours ,reduced doses are given for a further week
CAUTION: NSAIDs may cause renal impairment .In individuals with renal impairment or history of peptic ulceratio,alternative treatments include:
COLCHICINE: 1000 mg immediately ,then 500mg every 6-12 hours ,but this causes diarrhoea.
CORTICOSTEROIDS: intramuscular or intra-articular depot methylprednisolone.
ANALGESICS ( in order to potency )
Advice that they be taken only if needed .Maximum doses are indicated here.
PARACETAMOL 500-1000 mg 6 hourly
PARACETAMOL WITH CODIENE 1-2 tablets 6 hourly
PARACETAMOL WITH DEXTROPROPOXYPHENE 1-2 tablets every 6-8 hours
PARACETAMOL WITH DIHYDROCODIENE 1-2 tablets Every 6-8 hours
DIHYDROCODIENE 30-60 mg Every 6-8 hours
NON-STEROIDAL ANTI INFLAMMATORY DRUGS (NSAIDS)
Always to be taken with food.Use slow release preparations in inflammatory conditions or if more regular pain controls is needed .Examples
IBUPROFEN 200-400mg every 6-8 hours
IBUPROFEN SLOW RELEASE 600-8000 mg every 1-3 days
DICLOFENAC 25-50 mg 8 hourly
DICLOFENAC SLOW RELEASE 75-100 mg 1-2 daily
CELECOXIB* 200mg 1-2 daily.
ADVERSE EFFECTS
The most common side effects of standard ,COX non specific NSAIDs are indigestion or sin rashes. gastric erosions and peptic ulceration with perforation and bleeding also occur.Proton pump inhibitors are probably the best drugs to protect those at high risk from serious gastrointestinal events.H2 blockers nd prostaglandi -E2 analogues also help as gastro protective agents,The value of prostaglandin analogues is limited by their tendency to cause nausea and diarrhea.In the elderly,NSAIDs may cause gastric mucosal damage and gastrointestinal bleeding without warning symptoms,thereby causing significant morbidity and mrtality.They may also reduce renal function,especially in the elderly.COX -2 specific NSAIDs produce fewer gastrointestinal side efects (6% compared to 16% in one trial ) but role in arthritis is being evaluated .They are advised on health-economic grounds as first line treatment for ar risk patients and those over 65 years .Their higher cost is a disadvantage ,but may be offset if it proves safe to avoid the co-prescription of gastroprotective agents,even in individuals with previous peptic ulceration or other indicators of increased risk of ulceration,and if fewer major gastrointestinal complications requiring hospitalization result.
