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Chronic pain 55
have recommended NSAIDs for chronic low-back pain; these recommenda-
tions were modified by the reviewers’ subsequent clarification that the supporting
evidence came from studies of six (or fewer) weeks of NSAID use. 4,5
The side effect problems of NSAIDs in chronic use may be ameliorated by
use of agents with COX2 specificity. However, this practice brings with it
another set of potential problems with cardiovascular disease. Some authors
recommend avoiding the potential cardiovascular risk of COX2-selective
NSAIDs by prescribing dual therapy with a nonselective NSAID plus a proton
pump inhibitor. 6 This decision is not an easy one and should be informed by
case-specific variables such as cost and gastrointestinal and cardiovascular
risk profiles; some relevant risk-to-benefit information is presented in the
Arthritis chapter (p. 94).
Therefore, opioids and NSAIDs, which are the mainstays of acute care
analgesia, are often ineffective or contraindicated for chronic pain conditions.
The ED provider is left with some medication selections that are quite
out of the mainstream of acute care use. Effective analgesia in chronic pain
may be gained by use of antidepressants or anticonvulsants – in patients
who lack depressive symptoms or seizures. Pregabalin, calcitonin, and
bisphosphonates are understandably not at the forefront of ED provider’s
minds when the term “analgesia” is mentioned. Nonetheless, these medications,
used in conjunction with appropriate longitudinal follow-up care, may
be particularly helpful in some chronic pain conditions.
The approach of the ED provider toward the unique pharmacopoeia
of chronic pain should balance enthusiasm with caution. Care must be
taken to incorporate available evidence as wisely as possible. The various
chapters in this text outline specific evidence, but some examples are worth
highlighting. In the various neuropathic pain syndromes, for instance, there
is clinically significant (and diagnosis-dependent) variability even within
drug classes such as SSRIs and cyclic antidepressants. Furthermore, while
the tricyclic antidepressants are, generally speaking, the best drug class for
neuropathic pain, they have little benefit in some commonly encountered
neuropathic conditions (e.g. HIV-related neuropathy). The differences in
chronic versus acute pain medication use extend to the opioids. Tramadol,
as a rule, has a limited evidentiary role for most acute pain conditions – but