Page 198 Guide to Pain Management in Low-Resource Settings

186 Maged El-Ansary

herpes zoster, special ointments of acyclovir should be Th e maximum dose is 150 mg q.i.d., but most patients
used locally, if available. In countries with limited re- will do fi ne with 50–100 mg q.i.d. If slow-release for-
sources, acyclovir will be unavailable or unaff ordable mulations are available, the daily dose has to be divided
for most patients, but this does not necessarily mean a (b.i.d. to t.i.d.). Th e typical side eff ects of nausea and
worse prognosis regarding PHN compared to patients vomiting should be less frequent with the slow-release
taking acyclovir. formulation. Alternatives to tramadol are codeine and
Antibiotic ointments should be used if second- dextropropoxyphene.
ary infections start to appear. Sometimes, potassium
permanganate can be used as topical antiseptic, and cal- If I have coanalgesics available, how do
I choose the right one for my patient
amine lotion for pruritis. A simple and cheap local ther-
with acute herpes zoster?
apy is the topical application of crushed aspirin tablets
mixed either with ether or an antiseptic solution (1000 Generally speaking, for herpes zoster, coanalgesics
mg of aspirin mixed in 20 cc of solution). should be chosen according to the guidelines published
Another local remedy, which may be repeat- on neuropathic pain, since acute herpes zoster causes
ed, is subcutaneous injection of local anesthetics as a mostly neuropathic pain. Th erefore, the drug of fi rst
field block in the painful area. All available local an- choice would be either amitriptyline or gabapentin (or
esthetics maybe used, but daily maximum doses have a comparable alternative such as nortriptyline or prega-
to be observed. balin). Th e decision between a tricyclic antidepressant
and an anticonvulsant should be made according to the
Antiviral, steroids, and topical medications may typical side-eff ect profi le. Patients with liver diseases,
reduce the symptoms of acute herpes zoster but reduced general condition, heart arrhythmias, consti-
are often insuffi cient to control pain. What are pation, or glaucoma should receive gabapentin or pre-
the best analgesics to use?
gabalin. Th ese are presumably weaker analgesics, but
As a general rule in pain management, drugs have to they have the great advantage that no serious side ef-
be titrated gradually against pain until eff ective. Since fects are to be expected. Also, no ECG or blood tests
many of the aff ected patients are old or have a comor- have to be performed. Both drug families have their
bidity, compromising their general condition, it is ad- best effi cacy against constant burning pain, but they
vised to “start low and go slow.” may be insuffi cient for attacks of shooting or electrical
Herpes zoster involves infl ammation of the pain. For other drug options, refer to the appropriate
tissue around the nerve root. Anti-infl ammatory an- chapters in this manual.
algesics such as ibuprofen or diclofenac are indicated
as drugs of fi rst choice. If there are contraindications, I have tried local and systemic therapeutic
such as steroid medication, dehydration, a history of options, but the patient still has excruciating
gastric ulcers, or old age with impaired renal function, pain. Are there any other choices?
paracetamol/acetaminophen (1 g q.i.d.) or dipyrone (at Unfortunately, there is no “wonder drug” available. If
the same dose) is indicated. the above therapeutic strategies fail, it might be worth-
If these drugs prove to be inadequate, guidelines while to send the patient to a referral hospital that has
for the treatment of neuropathic pain nowadays rec- dedicated pain therapists. Otherwise, strong opioids
ommend coanalgesics. If these drugs are not available, would be an alternative, if available. If none of these al-
opioid analgesics (usually recommended as second-line ternatives apply, guiding the patient with tender loving
drugs after the use of coanalgesics) should be used. In care and explaining the usual limited time of intense
herpes zoster pain, it is not necessary to use “strong” pain are suggested. Never tell a patient that you can’t do
opioids, for which there might be governmental restric- anything for him.
tions. Tramadol, a weak opioid analgesics, which due to
its specifi c mode of action is not regarded as an opioid So, what can an experienced pain therapist or
in many countries, and is therefore unrestricted, will be “regular” anesthesiologist off er the patient?
suffi cient for most patients. Tramadol should be started Th e therapy of choice in such incidences is regional
with 50-mg tablets b.i.d. and may be increased in dose anesthesia using epidural catheters. Th is technique
daily by 50–100 mg until suffi cient analgesia is achieved. is usually applied for major surgery or certain surgical