New directions in pain management

Pain medicine is one of the most rapidly developing medical specialties of today. While there are many modalities that can be used in managing the patient in pain, drug treatment remains, for the most part, the cornerstone of treatment. Opioids retain their position as the foundation of most analgesic strategies, although they tend to be used nowadays in combination with adjuvant analgesics such as paracetamol and nonsteroidal antiinflammatory drugs. The range of available opioids has also been expanded with drugs such as hydromorphone and oxycodone, originally developed almost a century ago. This expanded choice has resulted in the concept of opioid rotation in chronic pain states, an approach that is aimed at maintaining pain control while minimizing adverse effects. Nonsteroidal antiinflammatory drugs continue to play an important role, especially as adjuvants, and the development of drugs such as celecoxib and refecoxib, highly specific for the inhibition of cyclooxygenase 2 pathway has been a further advance. The treatment of neuropathic pain continues to be a challenge to the clinician. While this has traditionally been treated with drugs from the anticonvulsant, antiarrhythmic and anti-depressant groups, results from these treatments have often been less than satisfactory. This has led to the development of completely new drug classes that modulate neuronal transmission in pain pathways, some of which are derived from exotic animal sources, such as the conotoxins from the marine snail family and epibatidine from a species of frog. The role of cannabinoids remains controversial.