Opioid Therapy for Open-Angle Glaucoma and Herniated Disc Pain

First-Line Therapy

• Tramadol is recommended as the first-line opioid with an initial dose of 50 mg 1-2 times daily, with a gradual increase up to a maximum of 400 mg daily, due to its favorable safety profile for glaucoma patients and effectiveness against neuropathic pain 1
• Tramadol shows superior efficacy compared to placebo in pain reduction and improvement of physical function, with a lower risk of dependence compared to other opioids 1

Alternative Options for Inadequate Pain Relief

• Gabapentin and Pregabalin are effective alternatives for neuropathic pain, with Gabapentin starting at 600 mg on the first day and increasing every 3 days up to 1800 mg, and Pregabalin starting at 75 mg in the evening and increasing weekly up to 600 mg daily 1
• Duloxetin and Venlafaxin have both antidepressive and central analgesic properties and are effective for neuropathic pain at doses of 20-120 mg/day 1

Special Considerations for Glaucoma Patients

• NSAIDs should be avoided in glaucoma patients due to the increased risk of renal and gastric toxicity 1

Stepwise Pain Therapy for Herniated Disc

• Start with Tramadol as first-line therapy, and in case of inadequate pain relief, consider adding Gabapentin or Pregabalin for neuropathic pain components 1, 2
• Duloxetin can be considered as an alternative or supplement to first-line treatments for persistent pain 1, 3

Medications to Avoid

• Strong opioids like Morphine, Hydromorphone, and Oxycodone should be avoided due to their higher risk of side effects and dependence 3
• Benzodiazepines show no sufficient evidence for efficacy in acute or subacute radicular pain and may decrease the likelihood of pain improvement 3
• NSAIDs should be avoided in glaucoma patients due to the risk of renal and gastric toxicity 1