From the Guidelines
Opioids should not be the first-line treatment for pain associated with ischemic stroke due to the significant risk of physical dependency and potential to complicate stroke recovery. The management of pain following an ischemic stroke is complex and requires a tailored approach. According to the Canadian Stroke Best Practice Recommendations [ 1 ], patients with persistent Central Post Stroke Pain (CPSP) should initially receive a trial of low-dose, centrally acting analgesics.
Some key considerations for managing stroke-related pain include:
- Using anticonvulsants such as gabapentin or pregabalin as first-line treatment [ 1 ]
- Utilizing tricyclic antidepressants (e.g., amitriptyline) or SNRIs (particularly duloxetine) as second-line treatment [ 1 ]
- Considering opioids or tramadol only for patients resistant to first and second-line treatments, with caution due to the risk of dependency [ 1 ]
It is crucial to adopt an individualized patient-centered approach for managing central pain syndromes, involving an interdisciplinary team with expertise in mental health and central pain management [ 1 ]. This approach allows for the optimization of pain control while minimizing the risks associated with opioid therapy, such as respiratory depression, sedation, and constipation, which can hinder stroke recovery and rehabilitation efforts.
From the Research
Opioids in Post-Stroke Pain Management
- The use of opioids in post-stroke pain management is still debated, with some studies suggesting a slight analgesic effect, while others show inconclusive results 2.
- A systematic review and meta-analysis found that seven out of eight included studies showed an overall slight analgesic effect of opioids, but the results were inconclusive due to the small number of studies and patients 2.
- Another study found that the most frequently prescribed pain medications for stroke survivors were other analgesics, followed by narcotic analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), anticonvulsants, and tricyclic antidepressants 3.
Opioid Antagonists in Ischemic Stroke Treatment
- A systematic review investigated the effectiveness of anti-opioid medication in treating ischemic stroke and found that only one of the naloxone and nalmefene clinical trials showed statistically favorable results 4.
- The review suggested that additional research should be conducted with new clinical trials of both drugs with larger samples in patients less than 70 years old and moderate to severe infarcts 4.
- Another study discussed the neuroprotective role of the brain opioid system in stroke injury and the potential of targeting opioid receptors for neuroprotection during ischemic stroke 5.
Alternative Treatments for Post-Stroke Pain
- A study evaluated the efficacy and safety of pregabalin in patients with central post-stroke pain and found that although pain reductions at endpoint did not differ significantly between pregabalin and placebo, improvements in sleep, anxiety, and clinician global impression of change suggest some utility of pregabalin in the management of central post-stroke pain 6.
- The study suggests that pregabalin may be a useful treatment option for patients with central post-stroke pain, particularly for those who experience sleep disturbances and anxiety 6.