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Alternative And Adjunctive Therapies

In addition to the pharmacologic interventions discussed, there are important alternative therapies for the management of acute pain. These alternative therapies include physical, cognitive, and behavioral interventions, see Table 12. 86 While some of these may seem difficult to execute in the ED, they are important to understand because of the potential application at home or upon admission.

When traditional therapies have failed or are otherwise undesirable, novel approaches need to be considered. Altier et al have reviewed cases of patients up to sixty-six years of age with chronic neuropathic pain who have had initially promising results with methadone. All of the patients had failed to be controlled with conventional analgesics. They only reviewed thirteen cases and recognize that prospective studies are required to determine its efficacy in this patient population. 87 Topical opioids have been used for the management of painassociated with open wounds. Methadone powder for longer relief of wound pain has been described in case reports. Pain was better controlled in patients who had open, exudative wounds while those patients with eschars showed less response. 88 Intraarticular (IA) injection of opioids has been used after arthroscopic knee surgery with relief of pain. 89 IA injection of opioids has also been studied prospectively for pain control in osteoarthritis. Patients had relief up to seven days without any short-term or long-term side effects. 90 Case reports  have noted up to two weeks of relief with IA opioid injections in patients with chronic pain. 91

Topical tricyclic anti-depressants have shown promising results for the control of neuropathic pain in case reports and open label studies. 92, 93 However, two randomized, blinded, placebo-controlled studies have been done, one with topical doxepin and the other with topical amitriptyline. These studies have demonstrated mixed findings; one study found significant analgesia and the other found no difference compared to placebo. 94, 95

Acupressure and acupuncture are beyond the scope of this article. Literature on the benefit of these interventions continues to provide conflicting results. Consequently, considerable controversy continues to exist and there is a need for definitive studies. Arecent systematic review on acupuncture, analyzed 162 publications and concluded that "some findings are encouraging but others suggest that its (acupuncture) clinical effects mainly depend on a placebo effect". 96, 97

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