Medications for Acute and Chronic Pain

MedicationsEvidence for UseComments
 Gabapentin, pregabalinNeuropathic pain, peripheral and centralThought to inhibit excitation by binding to the α-2δ subunit of voltage-dependant Ca2+ ion channel in the CNS
Visceral hyperalgesiaSide effects include sedation, nystagmus, tremor, swelling
DysautonomiaSedation can be minimized by increasing the dose gradually and then advancing more rapidly as tolerated
SpasticityNo significant interactions with other drugs
No evidence that 1 is superior to the other for children who have SNI
 Nortriptyline, amitriptylineNeuropathic pain, peripheral and central visceral hyperalgesiaReuptake inhibition or serotonin and norepinephrine in the CNS, both inhibitors of pain transmission (also antagonists of 5HT-2, H-1, and Ach)
Adverse effects include dry mouth, constipation, urinary retention, sedation, agitation, akathisia, and prolonged QTc syndrome (consider baseline ECG)
Limit the use of other anticholinergic medications
Side effects can be lessened by increasing gradually
Caution when using with other medications that result in serotonin syndrome
Serum level not necessary, although can document absorption
Nightly lower dose may have benefit for sleep
 TramadolPainOpioid receptor agonists, including μ-receptors
Tramadol should not be used in children under 12 years or in those 12 to 18 years with altered respiratory status and should be used with caution in older patients with seizures or on drugs that cause serotonin syndrome
 Morphine, other short-acting opioidsPainMorphine and other opioids safe when started with a standard dose, titrated to effect, and adjusted for renal impairment and respiratory depression, as examples
Autonomic storms
 MethadoneNeuropathic painMethadone has benefit of longer duration of action, but requires expertise in use
α2-Adrenergic receptor agonist
 ClonidineDysautonomiaSide effects include hypotension, bradycardia, sedation, although fewer side effects in children than in adults
SpasticitySide effects can be minimized by gradual dose increase
May enhance pain managementClonidine has the option of transdermal patch
Nightly dose may have benefit for sleep
 DronabinolCentral pain in adults with multiple sclerosisCannabinoid receptor agonist (C-1 and C-2)
Appetite stimulantLimited studies in children
Side effects include delayed gastric emptying, dizziness, anxiety, depression, irritability, restlessness, tachycardia, and dry mouth
Benzodiazepines as adjuvants
  ClonazepamAutonomic stormsNot for pain treatment, used as adjuvants to enhance pain treatment
 LorazepamMuscle spasmsIncrease affinity of GABA for GABAA receptors
 MidazolamMyoclonusConsider as-needed use for breakthrough symptoms in children on scheduled analgesics
SeizuresSide effects include prolonged sedation and paradoxical reactions
Use cautiously in combination with opioids
Midazolam has rapid onset and shorter duration
Tolerance develops with scheduled use
  • Ach, acetylcholine; C, cannabinoid; ECG, electrocardiogram; GABA, gamma-aminobutyric acid; H, histamine; 5-HT, serotonin.