Medication Summary
Nonsteroidal anti-inflammatory drugs (NSAIDs) and neuropathic pain medications are most commonly used in the treatment of traumatic brachial plexopathy, depending on the symptoms and the length of time since the injury's occurrence. During the acute phase, narcotic analgesics may also be necessary, but they should not be used for long-term pain management. Narcotic medications are also indicated in the acute postoperative period.
Neuropathic pain medications are useful for the relief of dysesthetic pain in the acute and chronic phases. There is no drug of choice, and medications often must be tried in serial fashion to find one that provides optimal relief for the patient.
Nonsteroidal anti-inflammatory drugs
Class Summary
After acute injury, NSAIDs are particularly helpful in relieving pain related to the injury, including injuries involving soft tissues, such as muscles and ligaments.
Celecoxib (Celebrex)
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek the lowest dose for each patient.
Naproxen (Naprosyn, Aleve)
For relief of mild to moderate pain; naproxen inhibits inflammatory reactions and pain by reducing the activity of cyclooxygenase, which decreases prostaglandin synthesis.
Anticonvulsants
Class Summary
The use of certain antiepileptic drugs, such as the GABA analogue gabapentin (Neurontin), has proven helpful in some cases of neuropathic pain. Anticonvulsants have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin. The multifactorial mechanism of analgesia could include improved sleep, an altered perception of pain, and an increased pain threshold. The efficacy of these drugs can be potentiated with the concomitant use of opiates and NSAIDS. Rarely should these drugs be used in the treatment of acute pain, because they may require a few weeks to become effective.
Gabapentin (Neurontin)
Has anticonvulsant properties and antineuralgic effects; however, the exact mechanism of action is unknown. Gabapentin is structurally related to GABA, but it does not interact with GABA receptors. Titration to effect can take place over several days (300 mg on day 1, 300 mg bid on day 2, and 300 mg tid on day 3).
Tricyclic antidepressants
Class Summary
This is a complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects. They have central effects on pain transmission. Tricyclic antidepressants block the active reuptake of norepinephrine and serotonin.
Nortriptyline (Pamelor)
Has demonstrated effectiveness in the treatment of chronic pain. By inhibiting the reuptake of serotonin and/or norepinephrine by the presynaptic neuronal membrane, this drug increases the synaptic concentration of these neurotransmitters in the central nervous system. Pharmacodynamic effects, such as the desensitization of adenyl cyclase and the down-regulation of beta-adrenergic receptors and serotonin receptors, also appear to play a role in nortriptyline's mechanisms of action.
Doxepin (Sinequan, Adapin)
Inhibits histamine and acetylcholine activity; doxepin has proven useful in the treatment of various forms of depression associated with chronic and neuropathic pain.
Analgesics
Class Summary
Narcotics are indicated in the acute injury period and in the postoperative period should reconstructive surgery be required. In rare cases in which patients require long-term opioid use, these patients should use scheduled, longer-acting medications, such as methadone.
Methadone (Dolophine)
Used in the management of severe pain. Methadone inhibits ascending pain pathways, diminishing the perception of and response to pain.
Oxycodone (OxyContin, Roxicodone, OxyIR)
Indicated for the relief of moderate to severe pain.
Oxycodone and acetaminophen (Percocet)
Drug combination indicated for the relief of moderate to severe pain.
Fentanyl citrate (Duragesic)
Potent narcotic analgesic with much shorter half-life than morphine sulfate. Fentanyl citrate is the DOC for conscious sedation analgesia. It is ideal for analgesic action of short duration during anesthesia and for the immediate postoperative period.
Fentanyl citrate is excellent for pain management and sedation with short duration (30-60 min); it is easy to titrate. The drug is easily and quickly reversed with naloxone.
After the initial dose, subsequent doses should not be titrated more frequently than q3h or q6h thereafter.
When the transdermal dosage form used, controlled with 72-h dosing intervals effective in most patients. However, some patients require 48-h dosing intervals.
Hydrocodone and acetaminophen (Lorcet)
Drug combination indicated for moderate to severe pain.
Tramadol (Ultram)
Inhibits ascending pain pathways, altering perception of and response to pain. Tramadol also inhibits the reuptake of norepinephrine and serotonin.
