Adequate Treatment

The pharmacological treatment of  pain must follow the principles of treatment of any condition. The correct medicine must be selected; the proper doses prescribed; and the risks and side-effects must be carefully monitored and weighed against the benefits. With pain medications utilized for intractable pain, the most serious considerations are for excessive sedation, severe constipation, and underdosage. If the patient is not adequately relieved of the pain, or is relieved for only a part of the day, the treatment is inadequate. From among the pain-killing drugs, one must choose a medicine strong enough so that excessive numbers of pills are not required to accomplish pain relief. Because of the inclusion of phenacetin in combination oral pain medicines, large numbers of pills (greater than six to eight a day) should be avoided through the use of a stronger class of pain reliever.

Sustained relief formulations are preferable to short-acting, to effect sustained relief. In severe pain, fentanyl patches and morphine-sulfate patches and suppositories, should be considered. In the most severe cases, in which oral and transdermal routes are inadequate, implantable pumps and invasive blocks are life-saving. If the pain is legitimate, it must be treated aggressively and with pharmacological sophistication.

Consideration must be also given to what has been described as a neuropathic element in pain, which is thought to arise from direct injury to nerves and nervous tissue. Probably a factor in all pain, neuropathic pain sometimes responds to medications which stabilize nervous tissue activity, such as Neurontin and Depakote. In some cases the patients pain can be relieved by the addition of these medications, which reduces the amount of opiate-derived medication required to achieve sustained relief.