• Inflammation responds to NSAIDs but may need support from a low-efficacy opioid.
• Arthritis: see Chapter 15.
• Minor trauma, e.g. many sports injuries, is commonly treated by local skin cooling (spray of chlorofluoromethanes), counterirritants (see p. 302) and NSAIDs, e.g. diclofenac, systemically or topically.
• Severe trauma including postsurgical pain (p. 347) usually needs narcotic analgesics.
• Peripheral vascular insufficiency should be treated with non-narcotic analgesics but may eventually require low efficacy opioids; vasodilator drugs may, but equally may not, provide benefit.
• Malignant disease requires the full range of analgesics and adjuvant drugs and procedures (see Palliative care, below).
• Bone pain, including cancer metastases, requires NSAIDs alone and with opioids. Bisphosphonates, e.g. sodium pamidronate, sodium clodronate, relieve pain from osteolytic bone metastases from breast cancer and multiple myeloma.
• Nerve compression can be relieved by local corticosteroid (prednisolone) or nerve block (local anaesthetic); nerve destruction can be achieved by alcohol, phenol.
• Dysmenorrhoea, see page 730.
• Mastalgia may benefit from gamolenic acid (in evening primrose oil), danazol and bromocriptine; or from a combined contraceptive pill.
In sickle cell anaemia crises avoid pethidine as the metabolite norpethidine may accumulate; hydroxyurea reduces the frequency (see p. 599).
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