Advantages and disadvantages of pain therapies

Pain & HIV/AIDS

Intervention Advantages Disadvantages

Oral analgesics
Acetaminophen
Aspirin
NSAIDs 1. Useful for a wide variety of mild to moderate pains. 1. Ceiling effect to analgesia.

2. Widely available, some over the counter. 2. Side effects, especially gastritis and renal toxicity, can be serious.

3. Additive analgesia when combined with opioids and other modalities. 3. May risk bleeding in severely thrombocytopenic patients.

4. Can be administered by patient or family. 4. Only one NSAID (ketorolac) is available now for parenteral administration

5. Some are inexpensive. 5. Many are expensive.

Oral opioids 1. Effective for both localized and generalized pain. 1. Side effects may limit analgesic effectiveness.

2. Ceiling to analgesic effectiveness imposed only by side effects. 2. Prescription of these substances is regulated.

3. Multiple drugs choices in this class. 3. Stigma or fears associated with use.

4. Sedative and anxiolytic properties useful in some acute treatment settings.

5. Can be administered by patient or family.

6. Some are inexpensive.

7. Long acting, controlled-release forms available.

Transdermal opioids(fentanyl) 1. Long duration of action (48 - 72 hours) from single patch. 1. Side effects may not be as quickly as in oral opioid administration.

2. Allows use of a strong opioid (fentanyl) in outpatient settings for some patients who have not tolerated morphin and related drugs. 2. Difficult to modify dosage rapidly.

3. Many patients find them easy to use. 3. Relatively slow onset of action.

4. Provides continuous administration of an opioid without use of needles or pumps. 4. Requires additional short-acting medicine for breakthrough pain.

5. Can be administered by patient or family. 5. Expensive.

Rectal opioids 1. Relatively easy-to-use alternative route when the oral route is unavailable. 1. Not widely accepted by patients or families.

2. Other opioid suppositories available for morphine intolerant patients. 2. Side effects may limit analgesic effectiveness.

3. Can be administered by patient or family. 3. Relatively slow onset of action.

4. Less expensive than subcutaneous or intravenous infusions. 4. Contraindicated if low white blood cell or platelet count (risks of infection, bleeding).

Subcutaneous infusion 1. Can provide rapid pain relief without intravenous access. 1. Only a limited volume infusate can be administered (e.g. 2 to 4 ml/hour).

2. Morphine or hydromorphone are the preferred drugs for this route when administered in the home. 2. Induration, irritation at infusion site may be a complication.

3. When used in PCA mode, allows for rapid individual dose titration and provides sense of control for patient. 3. Requires skilled nursing and pharmacy support.

4. Often requires expensive drug infusion pump and recurring charges for disposables.

Intravenous infusion 1. Can provide rapid pain relief. 1. Infection and infiltration of intravenous lines are potential complications.

2. Almost all opioids can be given by this route. 2. Requires skilled nursing and pharmacy support.

3. Not limited by infusate volumes. 3. Often requires expensive drug infusion pump and recurring charges for disposables.

4. When used in PCA mode, allows for rapid individual dose titration and provides sense of control for patient.

Epidural, intrathecal, and intracerebral ventricular routes 1. Useful for pain that has not responded to less invasive measures. 1. Tolerance may occur sooner than with oral or rectal administration.

2. Local anesthetics may be added to spinal opioids and may produce additive analgesia. 2. Infection at catheter site can produce meningitis and/or epidural abscess.

3. Pruritus and urinary retention are more common than with oral or parenteral opioid administration.

4. Contraindicated in presence of acute spinal cord compression.

5. Requires special expertise.

6. Requires careful monitoring, especially when therapy begins and when doses are increased.

7. May require expensive drug infusion pump, intervention fees, and recurring charges for disposables.

Regional neurolytic blocks 1. Effective for pain relief with certain diagnoses (e.g pancreatic cancer). 1. Risk of postural hypotension, bowel and bladder incontinence, and leg weakness.

2. May be useful for movement-related and abdominal visceral pain that is refractory to drug therapy. 2. Procedure is irreversible.

3. Can allow dosage (and side effect) reduction of systemic drugs for localized pain. 3. Requires special expertise.

4. Expenses for specialized care and operating room costs.

Ablative neurosurgery 1. May be useful for movement-related lower body pain that is refractory to drug therapy. 1. Six-month duration of pain relief for cordotomy is only 50%.

2. Fast onset of pain relief. 2. Procedure is irreversible.

3. Percutaneous cordotomy can be done under local anesthesia. 3. Requires special expertise.

4. Can allow dosage (and side effect) reduction of systemic drugs for localized pain. 4. Expensive because of specialized care and operating room costs.

Corticosteroids 1. Effective in pain associated with inflammatory component (e.g., bone pain). 1. Prolonged use associated with adrenal suppression, fluid and electrolyte disturbance.

2. Can produce cytotoxic effect against some tumors. 2. Increases risk of gastritis.

3. May be given orally or intravenously. 3. Prolonged use may decrease cell-mediated immunity and increase risk of infection.

4. May increase appetite. 4. Some patients experience emotional instability or psychoses.

5. May produce euphoria in some patients. 5. May suppress (mask) fevers associated with

6. May decrease pain associated with CNS and spinal cord tumors.

Anticonvulsants 1. Useful for peripheral pain syndromes associated withneuropathic pain, especially lancinating or shooting pain. 1. May increase sedation.

2. Monitoring required to avoid specific toxicities associated with increased serum levels.

3. Idiosyncratic or dose-related bone marrow suppression may limit usefulness.

Antidepressants 1. Useful in pain syndromes associated with neuropathic pain and with pain caused by surgery, chemotherapy, or nerve infiltration. 1. May increase sedation.

2. May promote sleep when taken at bedtime. 2. Anticholinergic side effects of many antidepressants are distressing to many patients.

3. CNS, cardiovascular, and hepatic toxicities may limit usefulness.

Hydroxyzine 1. When given in high dosages (100 mg), some antihistamines may produce additive analgesia with therapeutic doses of opioids. 1. In high doses demonstrates a significant potential for causing respiratory depression which is additive to that of opioids, but not reversible with naloxone.

2. May be beneficial in patients with opioid-induced nausea and vomiting. 2. Can cause significant sedation.

Radiation therapy 1. Directly treats tumor, especially useful for bone metastasis. 1. When multiple fractions are given, it may produce prolonged inconvenience and discomfort for patients.

2. Can provide fast onset of pain relief. 2. Myelosuppression may occur, especially with prior chemotherapy when wide teletherapy or radiopharmaceuticals are used.

3. Single dose is effective for some patients.

4. Widely available mode of treatment.

5. Radiopharmaceuticals and some forms of radiation therapy can treat multiple disease sites.

Relaxation, imagery, biofeedback, distraction, and reframing 1. May decrease pain and anxiety without drug-related side effects. 1. Patient must be motivated to use self-management strategies.

2. Can be used as adjuvant therapy with most other modalities. 2. Requires professional time to teach interventions.

3. Can increase patient's sense of control.

4. Most are inexpensive, require no special equipment, and are easily administered.

Patient education 1. Effective in improving ability to follow medical regimen and in decreasing pain. 1. Requires professional time to teach pain management regimens.

2. Multiple teaching aids available.

3. Promotes self-care in pain treatment and management of side effects.

Psychotherapy, structured support, and hypnosis 1. May decrease pain and anxiety for patients who have pain that is difficult to manage. 1. Requires skilled therapist.

2. May increase patient's coping skills.

Cutaneous stimulation (superficial heat, cold, and massage) 1. May reduce pain, inflammation, and/or muscle spasm. 1. Heat may increase bleeding and edema after acute injury.

2. Can be used as adjuvant therapy with most other modalities. 2. Cold is contraindicated for use over ischemic tissues.

3. Relatively easy to use.

4. Can be administered by patients or families.

5. Relatively low cost.

Transcutaneous electrical nerve stimulation 1. May provide pain relief without drug-related side effects. 1. Requires skilled therapist to initiate therapy.

2. Can be used as adjuvant therapy with most other modalities. 2. Potential risk of infection, bleeding.

3. Gives patient sense of control over pain.

Acupuncture 1. May provide pain relief without side effects. 1. Requires skilled therapist.

2. Can be used as adjuvant with most other therapies.

Peer support groups 1. May increase patient's coping skills. 1. None identified.

2. Increases sense of control.

3. Provides support for families and patients.

Pastoral counseling 1. May increase patient's coping skills. 1. None identified

2. May provide spiritual and emotional comfort

Intervention	Advantages	Disadvantages
Oral analgesics Acetaminophen Aspirin NSAIDs	1. Useful for a wide variety of mild to moderate pains.	1. Ceiling effect to analgesia.
2. Widely available, some over the counter.	2. Side effects, especially gastritis and renal toxicity, can be serious.
3. Additive analgesia when combined with opioids and other modalities.	3. May risk bleeding in severely thrombocytopenic patients.
4. Can be administered by patient or family.	4. Only one NSAID (ketorolac) is available now for parenteral administration
5. Some are inexpensive.	5. Many are expensive.
Oral opioids	1. Effective for both localized and generalized pain.	1. Side effects may limit analgesic effectiveness.
2. Ceiling to analgesic effectiveness imposed only by side effects.	2. Prescription of these substances is regulated.
3. Multiple drugs choices in this class.	3. Stigma or fears associated with use.
4. Sedative and anxiolytic properties useful in some acute treatment settings.
5. Can be administered by patient or family.
6. Some are inexpensive.
7. Long acting, controlled-release forms available.
Transdermal opioids(fentanyl)	1. Long duration of action (48 - 72 hours) from single patch.	1. Side effects may not be as quickly as in oral opioid administration.
2. Allows use of a strong opioid (fentanyl) in outpatient settings for some patients who have not tolerated morphin and related drugs.	2. Difficult to modify dosage rapidly.
3. Many patients find them easy to use.	3. Relatively slow onset of action.
4. Provides continuous administration of an opioid without use of needles or pumps.	4. Requires additional short-acting medicine for breakthrough pain.
5. Can be administered by patient or family.	5. Expensive.
Rectal opioids	1. Relatively easy-to-use alternative route when the oral route is unavailable.	1. Not widely accepted by patients or families.
2. Other opioid suppositories available for morphine intolerant patients.	2. Side effects may limit analgesic effectiveness.
3. Can be administered by patient or family.	3. Relatively slow onset of action.
4. Less expensive than subcutaneous or intravenous infusions.	4. Contraindicated if low white blood cell or platelet count (risks of infection, bleeding).
Subcutaneous infusion	1. Can provide rapid pain relief without intravenous access.	1. Only a limited volume infusate can be administered (e.g. 2 to 4 ml/hour).
2. Morphine or hydromorphone are the preferred drugs for this route when administered in the home.	2. Induration, irritation at infusion site may be a complication.
3. When used in PCA mode, allows for rapid individual dose titration and provides sense of control for patient.	3. Requires skilled nursing and pharmacy support.
	4. Often requires expensive drug infusion pump and recurring charges for disposables.
Intravenous infusion	1. Can provide rapid pain relief.	1. Infection and infiltration of intravenous lines are potential complications.
2. Almost all opioids can be given by this route.	2. Requires skilled nursing and pharmacy support.
3. Not limited by infusate volumes.	3. Often requires expensive drug infusion pump and recurring charges for disposables.
4. When used in PCA mode, allows for rapid individual dose titration and provides sense of control for patient.
Epidural, intrathecal, and intracerebral ventricular routes	1. Useful for pain that has not responded to less invasive measures.	1. Tolerance may occur sooner than with oral or rectal administration.
2. Local anesthetics may be added to spinal opioids and may produce additive analgesia.	2. Infection at catheter site can produce meningitis and/or epidural abscess.
	3. Pruritus and urinary retention are more common than with oral or parenteral opioid administration.
	4. Contraindicated in presence of acute spinal cord compression.
	5. Requires special expertise.
	6. Requires careful monitoring, especially when therapy begins and when doses are increased.
	7. May require expensive drug infusion pump, intervention fees, and recurring charges for disposables.
Regional neurolytic blocks	1. Effective for pain relief with certain diagnoses (e.g pancreatic cancer).	1. Risk of postural hypotension, bowel and bladder incontinence, and leg weakness.
2. May be useful for movement-related and abdominal visceral pain that is refractory to drug therapy.	2. Procedure is irreversible.
3. Can allow dosage (and side effect) reduction of systemic drugs for localized pain.	3. Requires special expertise.
	4. Expenses for specialized care and operating room costs.
Ablative neurosurgery	1. May be useful for movement-related lower body pain that is refractory to drug therapy.	1. Six-month duration of pain relief for cordotomy is only 50%.
2. Fast onset of pain relief.	2. Procedure is irreversible.
3. Percutaneous cordotomy can be done under local anesthesia.	3. Requires special expertise.
4. Can allow dosage (and side effect) reduction of systemic drugs for localized pain.	4. Expensive because of specialized care and operating room costs.
Corticosteroids	1. Effective in pain associated with inflammatory component (e.g., bone pain).	1. Prolonged use associated with adrenal suppression, fluid and electrolyte disturbance.
2. Can produce cytotoxic effect against some tumors.	2. Increases risk of gastritis.
3. May be given orally or intravenously.	3. Prolonged use may decrease cell-mediated immunity and increase risk of infection.
4. May increase appetite.	4. Some patients experience emotional instability or psychoses.
5. May produce euphoria in some patients.	5. May suppress (mask) fevers associated with
6. May decrease pain associated with CNS and spinal cord tumors.
Anticonvulsants	1. Useful for peripheral pain syndromes associated withneuropathic pain, especially lancinating or shooting pain.	1. May increase sedation.
	2. Monitoring required to avoid specific toxicities associated with increased serum levels.
	3. Idiosyncratic or dose-related bone marrow suppression may limit usefulness.
Antidepressants	1. Useful in pain syndromes associated with neuropathic pain and with pain caused by surgery, chemotherapy, or nerve infiltration.	1. May increase sedation.
2. May promote sleep when taken at bedtime.	2. Anticholinergic side effects of many antidepressants are distressing to many patients.
	3. CNS, cardiovascular, and hepatic toxicities may limit usefulness.
Hydroxyzine	1. When given in high dosages (100 mg), some antihistamines may produce additive analgesia with therapeutic doses of opioids.	1. In high doses demonstrates a significant potential for causing respiratory depression which is additive to that of opioids, but not reversible with naloxone.
2. May be beneficial in patients with opioid-induced nausea and vomiting.	2. Can cause significant sedation.
Radiation therapy	1. Directly treats tumor, especially useful for bone metastasis.	1. When multiple fractions are given, it may produce prolonged inconvenience and discomfort for patients.
2. Can provide fast onset of pain relief.	2. Myelosuppression may occur, especially with prior chemotherapy when wide teletherapy or radiopharmaceuticals are used.
3. Single dose is effective for some patients.
4. Widely available mode of treatment.
5. Radiopharmaceuticals and some forms of radiation therapy can treat multiple disease sites.
Relaxation, imagery, biofeedback, distraction, and reframing	1. May decrease pain and anxiety without drug-related side effects.	1. Patient must be motivated to use self-management strategies.
2. Can be used as adjuvant therapy with most other modalities.	2. Requires professional time to teach interventions.
3. Can increase patient's sense of control.
4. Most are inexpensive, require no special equipment, and are easily administered.
Patient education	1. Effective in improving ability to follow medical regimen and in decreasing pain.	1. Requires professional time to teach pain management regimens.
2. Multiple teaching aids available.
3. Promotes self-care in pain treatment and management of side effects.
Psychotherapy, structured support, and hypnosis	1. May decrease pain and anxiety for patients who have pain that is difficult to manage.	1. Requires skilled therapist.
2. May increase patient's coping skills.
Cutaneous stimulation (superficial heat, cold, and massage)	1. May reduce pain, inflammation, and/or muscle spasm.	1. Heat may increase bleeding and edema after acute injury.
2. Can be used as adjuvant therapy with most other modalities.	2. Cold is contraindicated for use over ischemic tissues.
3. Relatively easy to use.
4. Can be administered by patients or families.
5. Relatively low cost.
Transcutaneous electrical nerve stimulation	1. May provide pain relief without drug-related side effects.	1. Requires skilled therapist to initiate therapy.
2. Can be used as adjuvant therapy with most other modalities.	2. Potential risk of infection, bleeding.
3. Gives patient sense of control over pain.
Acupuncture	1. May provide pain relief without side effects.	1. Requires skilled therapist.
2. Can be used as adjuvant with most other therapies.
Peer support groups	1. May increase patient's coping skills.	1. None identified.
2. Increases sense of control.
3. Provides support for families and patients.
Pastoral counseling	1. May increase patient's coping skills.	1. None identified
2. May provide spiritual and emotional comfort

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