What are the recommended opioid adjuncts for managing chronic whole body pain?

Recommended Opioid Adjuncts for Chronic Whole Body Pain

For chronic whole body pain, nonopioid pharmacologic therapies including NSAIDs, acetaminophen, anticonvulsants (gabapentin, pregabalin), and SNRIs (duloxetine) should be used as first-line adjuncts before considering opioid therapy. 1

First-Line Adjunct Therapies

Nonopioid Pharmacologic Options

1. NSAIDs and Acetaminophen

   • NSAIDs: First-line for musculoskeletal pain components 1
     • Topical NSAIDs preferred for localized pain (especially for joints near skin surface)
     • Systemic NSAIDs at lowest effective dose for shortest duration
     • Use with caution in older adults, those with cardiovascular, renal, or GI comorbidities
   • Acetaminophen: Alternative with fewer side effects than NSAIDs 1
     • Lower dosing recommended for patients with liver disease
     • Note: Limited evidence for effectiveness in osteoarthritis 1

2. Anticonvulsants

   • Gabapentin/Pregabalin: Effective for neuropathic pain components 1
     • Pregabalin is FDA-approved for fibromyalgia and certain neuropathic pain conditions
     • When combined with opioids, can provide additive effects at lower doses of both medications 1

3. Antidepressants

   • SNRIs (Duloxetine, Milnacipran): Effective for neuropathic pain, fibromyalgia, and chronic low back pain 1
     • Duloxetine is FDA-approved for diabetic neuropathy and fibromyalgia
     • Milnacipran is FDA-approved for fibromyalgia
   • Tricyclic Antidepressants: Consider for neuropathic pain and fibromyalgia 1
     • Use with caution in older adults (≥65 years) due to anticholinergic effects 1

Second-Line Adjunct Therapies

When First-Line Therapies Are Insufficient

1. Tramadol

   • May decrease pain and improve function in patients with osteoarthritis 1
   • Dosing range: 37.5 mg (with 325 mg acetaminophen) to 400 mg daily in divided doses 1

2. Topical Agents

   • Lidocaine patches: For localized neuropathic pain 1
   • Capsaicin: For localized neuropathic pain 1

Combination Approaches

1. Opioid + Gabapentin Combination

   • When opioids are appropriate, combining with gabapentin may allow for lower doses of both medications while maintaining efficacy for neuropathic pain 1

2. Multiple Adjunct Strategy

   • Combining different classes of adjuncts (e.g., NSAID + anticonvulsant) may provide better pain control through different mechanisms of action

Risk Mitigation Strategies

1. Patient Assessment and Monitoring

   • Screen for risk of opioid misuse before prescribing 1
   • Use opioid patient-provider agreements 1
   • Implement urine drug testing 1
   • Monitor for adverse effects including respiratory depression, especially with benzodiazepine co-prescription 1

2. Naloxone Availability

   • Provide naloxone rescue kits for patients on opioid therapy 1
   • Educate patients and caregivers about overdose signs and naloxone use 1

Important Considerations and Caveats

• Dose-Dependent Risks: Higher opioid doses increase risk of overdose, addiction, fractures, and myocardial infarction 2
• Limited Long-Term Efficacy: Evidence suggests analgesic efficacy may not be sustained during long-term opioid therapy 3
• Common Side Effects: Constipation and nausea are most common and often don't resolve with time; proactive management is essential 4
• Mental Health Screening: Screen all patients for depression and cognitive disorders, as these can impact pain management outcomes 1
• Objective Evidence: Consider objective evidence of severe disease when evaluating long-term opioid therapy 5

Specific Patient Populations

• Older Adults: Use caution with NSAIDs and avoid tricyclic antidepressants; consider lower starting doses 1
• Patients with Liver Disease: Reduce acetaminophen dosing 1
• Patients with Cardiovascular Risk: Use caution with NSAIDs, especially COX-2 inhibitors 1
• Patients with GI Risk: Consider COX-2 inhibitors or add proton pump inhibitors to NSAID therapy 1

By implementing these evidence-based adjunct therapies in a stepwise approach, clinicians can optimize pain management while minimizing opioid requirements and associated risks.