What injections are used for severe body pain?

Injections for Severe Body Pain

For severe body pain, strong opioid injections such as morphine are the most effective treatment when non-opioid options have failed, following the WHO three-step analgesic ladder approach. 1

Stepwise Approach to Pain Management

Step 1: Non-Opioid Analgesics (Mild Pain)

• First-line treatment: Acetaminophen/paracetamol (650 mg every 4-6 hours, maximum 3-4g daily) 1
• NSAIDs for inflammatory pain: Ibuprofen (400-600 mg every 6-8 hours) or diclofenac (50 mg four times daily) 2, 1
• Caution with NSAIDs: Monitor for GI, renal, and cardiac toxicities, especially in patients over 60 years, with peptic ulcer disease, or compromised fluid status 2
• Monitoring: Baseline blood pressure, BUN, creatinine, liver function tests, CBC, and fecal occult blood; repeat every 3 months 2

Step 2: Weak Opioids (Moderate Pain)

• Options: Codeine, dihydrocodeine, tramadol, or low-dose strong opioids 2
• Combinations: Often combined with acetaminophen (maximum 4000 mg acetaminophen and 240 mg codeine) 2
• Formulations: Consider controlled-release formulations of codeine, dihydrocodeine, and tramadol for moderate pain 2

Step 3: Strong Opioids (Severe Pain)

• First choice: Morphine (oral route preferred; if parenteral, use 1/3 of oral dose) 2
• Alternatives:
  • Hydromorphone or oxycodone (oral, normal or modified release) 2
  • Transdermal fentanyl (for patients with stable opioid requirements, unable to swallow, poor tolerance to morphine, or poor compliance) 2
  • Methadone (requires expertise due to variable half-life) 2

Interventional Pain Management

Diagnostic Blocks

• Perform diagnostic blocks with local anesthetic to identify specific pain generators 1
• Document pain relief response (percentage and duration) to inform treatment decisions 1

Therapeutic Injections

• Epidural injections:

  • Caudal: Bupivacaine 0.25% (0.5 ml/kg, max 15ml) with/without steroids 1
  • Lumbar interlaminar: Bupivacaine 0.25% (0.2-0.3 ml/kg) with/without steroids 1
  • Indicated when pain persists despite optimal medication management 1
  • Caution: Not recommended for chronic axial spine pain but may be appropriate for radicular pain 1

• Neurolytic procedures:

  • Appropriate for well-localized pain syndromes 1
  • Consider when adequate analgesia not achieved despite appropriate medication trials 1
  • Most effective for pain likely to be relieved with specific nerve blocks 1

Important Safety Considerations

For Opioid Injections

• Have resuscitative equipment, oxygen, and resuscitative drugs immediately available 3
• Use lowest effective dosage to avoid high plasma levels and serious adverse effects 3
• Perform syringe aspirations before and during each injection 3
• Monitor cardiovascular and respiratory vital signs and consciousness after each injection 3
• Be alert for early warning signs of CNS toxicity: restlessness, anxiety, tinnitus, dizziness, blurred vision, tremors 3

For Interventional Procedures

• Monitor for potential complications:
  • Respiratory depression with opioids
  • Hypotension with epidural local anesthetics
  • Temporary bladder voiding disorders
  • Temporary sensory disorders
  • Infection and bleeding 1

Adjunctive Treatments

Coanalgesics for Neuropathic Pain

• Antidepressants (tricyclics, SNRIs like duloxetine) 2, 1
• Anticonvulsants (gabapentin, pregabalin) 2, 1
• Topical agents (lidocaine patch, diclofenac gel) for localized pain 1

Non-Pharmacological Approaches

• Physical therapy focusing on core strengthening, flexibility, and proper body mechanics 1
• Transcutaneous electrical nerve stimulation (TENS) 1
• Cognitive behavioral therapy for pain management 4

Clinical Pearls and Pitfalls

• Avoid using two products of the same pharmacological class simultaneously 1
• Reserve opioids for when non-opioid options are inadequate 1
• Inadequate acute pain management increases risk of developing chronic pain 5
• Regular reassessment of pain control and medication effects is essential 1
• Consider cardiovascular, renal, and gastrointestinal risk factors when prescribing NSAIDs 1
• Acute and chronic pain are different clinical entities requiring different approaches 6

By following this stepwise approach to pain management, clinicians can effectively address severe body pain while minimizing risks and side effects associated with treatment.