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Pharmacotherapy of Pain: Adjuvant Analgesics. Adjuvant Analgesics. Defined as drugs with other indications that may be analgesic in specific circumstances Numerous drugs in diverse classes Sequential trials are often needed. Adjuvant Analgesics. Multipurpose analgesics

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adjuvant analgesics
Adjuvant Analgesics
  • Defined as drugs with other indications that may be analgesic in specific circumstances
  • Numerous drugs in diverse classes
  • Sequential trials are often needed
adjuvant analgesics3
Adjuvant Analgesics
  • Multipurpose analgesics
  • Drugs used for neuropathic pain
  • Drugs used for musculoskeletal pain
  • Drugs used for cancer pain
  • Drugs used for headache
multipurpose adjuvant analgesics
Class Examples

Antidepressants amitriptyline, desipramine, nortriptyline, duloxetine,

venlafaxine, paroxetine, others

Alpha-2 adrenergic tizanidine, clonidine


Corticosteroids prednisone, dexamethasone

Multipurpose Adjuvant Analgesics
multipurpose adjuvant analgesics5
Multipurpose Adjuvant Analgesics


  • Best evidence: 30 amine TCAs (e.g., amitriptyline)
  • 20 amine TCAs (desipramine, nortriptyline) better tolerated and also analgesic
  • Evidence for the SSNRIs, e.g., duloxetine, and little evidence in favor of SSRIs/atypical antidepressants (e.g., paroxetine, bupropion, others); these are better tolerated yet
multipurpose adjuvant analgesics6
Multipurpose Adjuvant Analgesics

Alpha-2 adrenergic agonists

  • Clonidine and tizanidine used for chronic pain of any type
  • Tizanidine usually better tolerated
  • Tizanidine starting dose 1–2 mg/d; usual maximum dose up to 40 mg/d
adjuvant analgesics for neuropathic pain
Adjuvant Analgesics for Neuropathic Pain

Class Examples

Anticonvulsants gabapentin, pregabalin, valproate, lamotrigine

phenytoin, carbamazepine,

clonazepam, topiramate,

tiagabine, levetiracetam

oxcarbazepine, zonisamide

Local anesthetics mexiletine, tocainide

adjuvant analgesics for neuropathic pain8
Adjuvant Analgesics for Neuropathic Pain

Class Examples

NMDA receptor dextromethorphan, Antagonists ketamine,


Miscellaneous baclofen, calcitonin

Topical lidocaine,


capsaicin, NSAIDs

adjuvant analgesics for neuropathic pain9
Adjuvant Analgesics for Neuropathic Pain


  • Gabapentin or pregabalin commonly used
    • Favorable safety profile and positive RCTs in PHN/diabetic neuropathy
  • Analgesic effects supported for phenytoin, carbamazepine, valproate, clonazepam, and lamotrigine
  • Limited experience with other drugs
adjuvant analgesics for neuropathic pain10
Adjuvant Analgesics for Neuropathic Pain
  • Local anesthetics
  • Oral therapy with mexiletine, tocainide, flecainide
  • IV/SQ lidocaine also useful
  • Useful for any type of neuropathic pain
adjuvant analgesics for neuropathic pain11
Adjuvant Analgesics for Neuropathic Pain

Miscellaneous drugs

  • Calcitonin
    • RCTs in CRPS and phantom pain
    • Limited experience
  • Baclofen
    • RCT in trigeminal neuralgia
    • 30–200 mg/d or higher
    • Taper before discontinuation
adjuvant analgesics for neuropathic pain12
Adjuvant Analgesics for Neuropathic Pain

NMDA-receptor antagonists

  • N-methyl-D-aspartate receptor involved in neuropathic pain
  • Commercially-available drugs are analgesic: ketamine, dextromethorpan, amantadine
topical adjuvant analgesics
Topical Adjuvant Analgesics
  • Used for neuropathic pain
    • Local anesthetics
      • Lidocaine patch
      • Cream, eg, lidocaine 5%, EMLA
      • Capsaicin
  • Used for musculoskeletal pains
      • NSAIDs
adjuvant analgesics for musculoskeletal pain
Adjuvant Analgesics for Musculoskeletal Pain

“Muscle relaxants”

  • Refers to numerous drugs, eg, cyclobenzaprine, carisoprodol, orphenadrine, methocarbamol, chlorzoxazone, metaxalone
  • Centrally-acting analgesics
  • Do not relax skeletal muscle
adjuvant analgesics for chronic headache
Adjuvant Analgesics for Chronic Headache
  • Beta blockers
  • Anticonvulsants
  • Calcium channel blockers
  • Alpha-2 adrenergic agonists
  • Antidepressants
  • Vasoactive drugs
  • ACE inhibitors
adjuvant analgesics for cancer pain
Adjuvant Analgesics for Cancer Pain
  • For bone pain
    • Bisphosphonates (eg, pamidronate, clodronate), calcitonin, radiopharmaceuticals (eg, Sr89, Sm153)
  • For bowel obstruction pain
    • Anticholinergics, octreotide
adjuvant analgesics with opioid interactions
Adjuvant Analgesics With Opioid Interactions
  • NMDA antagonists (eg, dextromethorphan, ketamine, amantadine)
  • Cholecystokinin-B antagonists (eg, proglumide)
  • Ultra-low doses of opioid antagonists