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This chapter focuses on pharmacological approaches to chronic low-back pain (CLBP). In CLBP, one of the major issues for the ED caregiver is use of opioids. The utility of opioids in CLBP is limited not only by their marginal analgesic efficacy, but also by the risk of addictive behavior. Although studies of truly CLBP are lacking, it is reasonable to use NSAIDs provided that potential side effects risks are incorporated into therapeutic decision-making. Some authors recommend avoiding the potential cardiovascular risk with COX-2 selective NSAIDs by instead prescribing dual therapy with a non-selective NSAID and a proton pump inhibitor. A 2003 meta-analysis found five RCTs demonstrating some CLBP relief with cyclic anti-depressants. The benefits of these cyclic anti-depressants are independent of their anti-depressant effects, since studies demonstrating the agents' efficacy excluded patients with clinical depression.
This chapter overviews the importance of analgesia as an important endpoint in prehospital care. Analgesia's importance is magnified by the frequency with which EMS providers interact with injured patients in significant pain. The chapter focuses on prehospital medication administration, with the understanding that not all medications will be available in all EMS systems. The perceived problem with out-of-hospital analgesia administration is that the drugs incur risk of hemodynamic or respiratory compromise. Examination-related issues other than the neurological evaluation are also prominent reasons for physicians not to administer prehospital analgesia. The opioids are the primary analgesic approach available to most EMS services. The prototypical opioid for use in prehospital care is morphine, which is demonstrated to be useful for a variety of adult and pediatric conditions encountered in EMS. Regional nerve blocks with local anesthetic injection are efficacious for field use in settings where physician prehospital providers are available.
Hemodynamic therapy remains the foundation of aortic dissection (AD) care, and successful control of blood pressure and heart rate improves patient comfort. The first step in AD care, anti-impulse therapy, serves as optimal medical management and also provides pain relief. Ongoing pain after beta-blocker administration usually indicates incomplete blood pressure control. In such cases, pain relief (and optimal medical management) is facilitated by vasodilation. When AD is accompanied by cardiac ischemia, the calcium channel blocker nicardipine is indicated. Citing sedative and anxiolytic properties, expert reviewers recommend morphine for AD pain, but there is no evidence demonstrating its superiority over other opioids. Patients in pain from AD tend to be hypertensive, but in those cases where blood pressure is borderline or low, fentanyl's limited hemodynamic impact is attractive. Anesthesiologists confirm fentanyl's utility for AD, including in cases where there are complicating conditions such as subarachnoid hemorrhage or pregnancy.
Cancer and tumor pain (CTP) is traditionally described as resulting from somatic, visceral, or neuropathic origins. NSAIDs have been deemed the preferred class for bony (or somatic) pain. Opioids have been considered beneficial for visceral, but not bony or neuropathic CTP. While agents such as sedatives may be helpful in patient management, the adjuvant medications are believed to augment efficacy of coadministered opioids or NSAIDs. Anticonvulsants are frequently used as an adjunct for the treatment of neuropathic CTP. For bone pain, bisphosphonates, in particular pamidronate and zoledronic acid, are shown in multiple trials to be effective in reducing bony CTP from metastatic disease. The corticosteroids are, at best, marginally effective as an opioid-sparing adjunct for CTP in general, this class may have a role in tumor-related bowel obstruction. The antisecretory agents aim to relieve bowel obstruction CTP and eliminate the need for uncomfortable nasogastric tubes.
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