What is the Type of Pain? An introduction

What is the Type of Pain? An introduction

Dr Dominic Aldington, Consultant in Pain Management

When considering medication for pain the first step is probably to determine what type of pain is present; that is, what is the underlying mechanism for the pain. If the pain could have a neuropathic component then the options are probably different to those where it is thought to be solely nociceptive. The difficulty is that traditionally neuropathic pain was considered a relatively rare event while the modern concept is that it is probably far more common than initially thought.

Nociceptive Pain

The traditional starting point for nociceptive pain has become the Acute Pain Ladder. This suggests that the initial agent should be paracetamol, and if this is not sufficient then the next step up on the ladder is taken where an NSAID or weak opiate is introduced into the mix. However the usual point is to add to the paracetamol and not to replace it. If this is not sufficient to control the pain then a strong opiate should be introduced as well. The aim is then to climb down the ladder as the pain recedes – rather than jumping from the top rung to the ground!

Figure 1. Acute Pain Ladder

painchart

Neuropathic Pain

It may be possible to consider a similar scheme for neuropathic pain. One can consider starting with a tricyclic antidepressant. If this is insufficient add in an anticonvulsant such as gabapentin or pregabalin. If these do not help then specialist support should be sought.

Module 3 focuses on optimising the pharmacological management based on a mechanism–based treatment approach.

Completion of this module aims to increase your knowledge of the following topics:

  • Introduction to mechanism-based approach
  • Mechanisms of neuropathic and nociceptive pain
  • Neuropathic pain component and typical indications
  • Current drugs and their efficacy in neuropathic, nociceptive pain
  • Rational choice, combinations with current drugs and difficulties
  • Dual pain pathway approach: the Mu opioid receptor system and the monoaminergic system
February 2016, UK/C16 0006