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All Non-opioids/OTC Articles

Pain-treating clinicians are constantly searching for medications that improve patient outcomes and/or that can minimize the use of opioids. Perhaps, older treatment modalities just need to be reconsidered.  
Painful muscle spasticity is a chronic complaint among patients with various pain syndromes, particularly those involving upper motor neuron disorders, such as brain and spinal cord injuries, multiple sclerosis, and strokes.
Editors' Note: Psoriatic arthritis (PsA) is a chronic inflammatory disease affecting multiple organs that impacts patients from a pain, quality of life and functional ability standpoint.
Capsaicin Formulation CNTX-4975 Snapshot Product/Class: CNTX-4975 (high-purity synthetic trans-capsaicin), intra-articular injection from Centrexion Therapeutics
Editor’s Note: Two reviews on the migraine pipeline follow, one focusing on ASICs and the other on IGF-1. Acid-sensing Ion Channel Inhibitors May Treat and Prevent Migraine Refractory to Traditional Medications   ASIC Inhibitors in a Snapshot
Calcitonin gene-related peptide (CGRP) antagonists have been a welcome addition to the armamentarium of physicians who treat migraine. At present, there are six CGRP antagonists FDA-approved for migraine therapy. These six medications fall into two groups: monoclonal antibodies (mAbs) and gepants.  
A PPM Brief with Mark Zylka, PhD Peripheral nerve injury can cause an inflammatory response in the spinal cord, leading to chronic neuropathic pain. As pain specialists know, pinpointing the cause of the pain can be difficult.
Vocacapsaicin (CA-008) Snapshot
  • Product/Class: Vocacapsaicin (CA-008, Concentric Analgesics) is a first-in-class non-opioid, water-soluble injectablethat rapidly converts to capsaicin, a potentTRPV1-agonist
  • Features: When injected into surgical sites, vocacapsaicin is rapidly converted to lipophilic capsaicin and can cross the
Topicals are growing in preference given their localized drug delivery and low systemic absorption. Both aspects result in a more favorable side effect profile for patients seeking pain relief.
Pathophysiology and Presentation of RA There is no known specific cause of rheumatoid arthritis (RA), which is believed to result from a mix of both genetic and non-genetic factors combined with a triggering event. Based on epidemiologic studies, genes in the human leukocyte antigen (HLA) system are thought to play a role as are genetics in general based on some familial studies.
With patients increasingly leaning toward alternative and complementary pain-relieving agents, such as marijuana, CBD products, coca tea, ephedra, and kratom, healthcare providers are facing more questions – and more responsibilities – to understand these “natural” products.
Chronic pain is a serious medical condition affecting 1 in 5 people worldwide and up to 40% of the US population.1,2 Currently available medical therapies for treatment of chronic pain may be unsatisfactory, risky, and expensive to employ.3,4 Until very recently, physicians utilized opioid therapy widely in the management of chronic non-cancer pain.
The analgesic effects of highly selective mu-opioid receptor (MOR) agonists have been well established in clinical practice. The adverse effect profile of these medications, however, can limit the use of traditional opioids.
Clonidine may be beneficial for neuropathic pain, but further mechanisms of action are lacking research.
With an increasing demand for non-opioid alternatives, the suicide risk potential for gabapentinoids (gabapentin and pregabalin) is yet to be understood.
Despite their inherent abuse potential, gabapentinoids (gabapentin and pregabalin) may be safer than presumed and offer prescribers an effective opioid-alternative treatment for certain types of neuropathic pain.
A review of the pipeline nerve growth factor (NGF) inhibitors tanezumab (Pfizer, Eli Lilly) and fasinumab (Regeneron, Teva).
For more than two decades, chronic pain was delineated from acute pain if it continued beyond the expected healing period and persisted for 90 days or beyond.
Cyproheptadine may be useful in treating chronic pain conditions such as sleep disorders, sexual dysfunction, refractory headaches, and more.
Sunascen Therapeutics have developed a line of non-habit forming pain relievers that are developed with the patient in mind.
Tanezumab is the first investigational humanized monoclonal immunoglobulin G2 antibody, preventing the binding of NGF to its receptors to block the pain response pathway.
Small doses could help children suffering from various types of inflammation and pain.
Nonopioid Management Just as Impactful as Opioids for Knee/OA Pain
Chronic neuropathy treatment does not offer much pain relief for patients.
Ask the Expert: A discussion of the pain relief potential from Na1.7 Inhibitors for neuropathic pain disorders.
Recommendations concerning liver function tests for Duloxetine, prescribed for neuropathic pain.
Ask the Expert authors examine the role for low-dose ketamine for treatment of CRPS.
Pain expert offers clinical guidance to a commonly asked question about the proper, safe, and effective dose of gabapentin when treating neuropathic pain.
2016 review of current and emerging therapies for opioid-induced constipation, a common side effect of chronic opioid therapy.
To help reduce the need for opioids, IV acetaminophen could be included in the initial and perioperative pain control protocol of burn patients based on its analgesic effect, safety profile, and easy accessibility.
Forest Tennant, MD, DrPH, picks for 2016 Practical Clinical Advances in pain management—oral ketamine and metformin.
Dr. John Claude Krusz describes his protocol for the use of subanesthetic dosages of IV agents—ketamine, lidocaine, propofol—in an outpatient headache clinic.
Canadian researchers discuss 6 common concerns of patients and physicians regarding cannabis use for pain management.
Learn more about the correct dosing of different strains of medicinal cannabis used in Canada for the treatment of various pain conditions.
Skeletal muscle relaxants are commonly prescribed for the management of spasticity and spasm. Learn more about these agents used in pain management.
Guide to topical therapy for acute and chronic sports-related pain, including tendinopathies, bursitis, strains, and sprains.
Marijuana use disorder is common in the United States, is often associated with other substance use disorders, behavioral problems, and disability.
In some cases, tumor necrosis factor inhibitors (TNFi) may be the first-choice agent for patients with psoriatic arthritis. Learn why.
Our experts answer the question about which antidepressant is the least likely to cause cardiac problems, including QT prolongation.
Are corticosteroids safe and effective therapy for complex regional pain syndrome? Read what our experts have to say.
Many experts recommend reclassifying marijuana from a Schedule I to Schedule II substance. Learn more about how reclassification may open the way to more research avenues to study the medicinal role of cannabis.
Marijuana edible products often are mislabeled, leading to calls to reschedule marijuana and install better oversight of this burgeoning industry. Learn more about the call to standardize medical marijuana products.
Q: Please explain the medical marijuana law in Connecticut and the role of pharmacists in dispensing medical marijuana products.
Neuropathic pain, fibromyalgia, spinal cord injury—these are just a few of the chronic pain conditions being treated with medical marijuana. Learn more about who is a good candidate for medical marijuana.
Antibiotics and Microbiome I had a few questions after reading the “Editor’s Memo” in the June issue of Practical Pain Management.1 Dr. Tennant mentions treatment aimed at over-activated glial cells. In the use of tetracyclines, in what time frame do you begin to see results?
The use of marijuana may interfere with the therapeutic effect of pain medications and can increase cognitive dysfunction. Therefore, Dr. Gerald M. Aronoff advises against writing a prescription for a controlled substance (including opioids) to any patients testing positive for illicit drugs, including recreational marijuana.
Evidence has shown that cannabis is associated with an increased risk of motor vehicle accidents, especially when combined with alcohol. Presented here is one clinician’s guide and for screening for marijuana in a chronic pain practice.
Drug safety is always a concern. Our experts answer your questions about NSAID-related sensitivity.
The recent action by the US Food and Drug Administration (FDA) to strengthen the warning label of nonsteroidal anti-inflammatory drugs (NSAIDs) to reflect an increase risk of heart attack or stroke raises questions about how safe are these medications for patients with pre-existing cardiovascular disease (CVD).
Stimulants are a class of compounds that have a sympathomimetic or uplighting action on the central nervous system (CNS). Internal or endogenous stimulants are known as catecholamines because a portion of the molecule is catechol. The best known examples are dopamine, norepinephrine, and epinephrine.
Cancer patients undergoing chemotherapy can develop febrile neutropenia. However, the treatment can also lead to bone pain. Learn how antihistamines may help treat G-CSF–induced bone pain.
Topical analgesics are appealing to clinicians because their lack of systemic absorption results in limited adverse effects (AEs).1 Other benefits of topical analgesics include direct access to target sites, convenience, ease of use, painless administration, and improved patient acceptance and adherence, all of which may reduce overall treatment costs.2-4 Most topical anal
Q: Why is there abuse of gabapentin? A: Gabapentin (Gralise, Neurontin) is a widely prescribed drug used for the management of a number of neuropathic pain syndromes.
Old medications are getting renewed interest in the treatment of pain. They are being investigated because of their ability to inhibit microglia activation, and show promise in the treatment of neuropathic pain.
Many people with migraines have lower than normal levels of magnesium. Treatment with magnesium supplements may help manage acute migrain attacks.
For patients at risk of developing an NSAID-induced ulcer who require chronic NSAID therapy, a COX-2 selective agent (Celebrex) may be considered in patients without cardiovascular risk. If a preventive therapy is required, misoprostol and proton pump inhibitors have been found to be more effective than histamine 2 receptor antagonists.
Q: Can NSAIDs be used to treat chronic pain in a patient who has had bariatric surgery?
A patient requested refills for 2 benzodiazepine agents at the same time (alprazolam and clonazepam).  Is this ever appropriate?  
I have yet to find a pain practitioner who really likes prescribing benzodiazepines. In just about every guideline or protocol that involves prescribing opioids, there’s always an admonition to not mix opioids and benzodiazepines. No wonder. Practically every opioid overdose involves the addition of one or more benzodiazepines.
Question: What is better for treating rebound headaches—long-acting or short-acting NSAIDs?
Thank you for your responses to my letter about a patient whose back pain was “cured” after a dental procedure where he received meperidine (Demerol) and nitrous oxide.1 I suspected that these two drugs would in some way “realign the stars” but I have not seen much published data regarding the effect on N-methyl-D-aspartate (NMDA) receptors or oth-er mechanisms of changing centr
Question: Can misoprostol be used for refractory chronic constipation?
Nonprescription, or over-the-counter (OTC), analgesics accounted for 11% of all nonprescription drug sales in 2011.1 Benefits of OTC analgesic medication use include direct, rapid access to medications for pain relief, decreased health care utilization resulting in lower costs, and increased engagement of the patient with their own health care.
Question: Are antibiotics a treatment option for low back pain?
Acetaminophen (Tylenol) is widely used due to its analgesic and antipyretic effects and its inclusion in myriad over-the-counter and prescription products.1 Although acetaminophen’s mechanism of action is unknown, it is theorized to involve inhibition of cyclooxygenase enzymes in the central nervous system.2 The most concerning adverse effect of acetaminophen has long been
PPM Editorial Board answers letters from readers. Can nitrous oxide potentiate pain management or eliminate pain altogether?
Discontinuing NSAIDs prior to surgery can be confusing to both patients and physicians. Stopping medications before surgery should be based on pharmacokinetics of individual NSAIDs.
Pain experts answer the question "What is the evidence for the use of long-term skeletal muscle relaxants in the treatment of chronic low back pain"?
Navigating the Dos and Don'ts of common analgesics in pain patients with chronic liver disease.
Insomnia is a profound problem in patients with severe, intractable pain that is poorly controlled.
QUESTION: Which NSAIDs Are Most Selective For COX-1 and COX-2?
Ask the Expert question and answer: Pharmacists answer a question about when it's safe to restart an NSAID after a confirmed GI bleed.
December 2012 Ask the Expert looks at conflicting evidence regarding clinically significant renal effects of sulindac.
When a patient’s urine drug screen tests positive for methamphetamine by mass spectrometry, the result has serious implications for the patient and the provider. Determining the source of the methamphetamine is an important next step and is not always as straightforward as it appears.
What should prescribing physicians do when insurers refuse to pay for patients' fentanyl products?
Part 2 of a two-part series on adverse drug effects in pain management examines muscle relaxants.
Educational review from Practical Pain Management of managing adverse drug effects of triptans and NSAIDs. Written by pharmacists; full of useful management tips.
Nonopioid analgesics are preferred treatments in a multitude of practice guidelines; a brief overview of specific guidelines for low back pain, osteoarthritis, and migraine is presented here because these are the most common types of pain identified by adults.
Article discusses the emerging use of ziconotide for chronic severe pain, which shows potential of becoming a powerful non-opioid analgesic in the pain physician's armamentarium.
Antidepressants have become a routine adjunctive therapy for most forms of chronic pain. Review your options to help you choose the best for your chronic pain patients.
There are 4 points upon which there is broad consensus in the field and that we should discuss immediately:
The potential loss of brain tissue should motivate all pain clinicians to look for undiagnosed mood disorders. Treating both pain and mood disorders aggressively will increase the likelihood of a better outcome. Not treating, or undertreating either, will most likely result in treatment failures for both conditions.
When used as an adjunct in severe chronic pain patients who take systemic opioids, topical morphine enhances pain relief, decreases pain flares, promotes stretching and walking, and reduces overall cost of treatment.
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