Managing an Arachnoiditis Flare: What to Do When Pain Escalates

If you have Adhesive Arachnoiditis, flares are not a possibility — they are a reality. Pain that was manageable yesterday can become unbearable today, and without a plan in place, a flare can spiral into an emergency room visit, a cycle of uncontrolled pain, and further progression.

This article covers how to manage an acute AA pain flare at home, based on Dr. Forest Tennant's Bulletin 5 (February 2026) on at-home injections for acute pain flares and Bulletin 57 (November 2025) on ongoing pain relief. Both are available to download below.

Understanding What Happens During a Flare

A flare is not just pain getting worse. It is a physiological cascade. When pain spikes, the body responds by elevating blood pressure, adrenalin, glucose, and cortisol levels. Those elevations then feed back into the pain — making it worse. It becomes a vicious cycle that is very difficult to break once it takes hold.

This is why the goal of flare management is speed. The faster you can interrupt the cycle, the less severe the flare becomes and the faster you recover.

Dr. Tennant is direct on this point: every person with AA must have a short-acting opioid or other medication available that will relieve their pain flare within one hour. Not eventually. Within one hour.

Building Your Flare Kit Before You Need It

The most important thing you can do for flare management happens before a flare starts. Work with your physician now to have the following in place:

• A short-acting oral opioid or non-opioid for immediate pain relief

• Injectable medications if your case is moderate to severe

• A written flare plan your family or caregiver understands

• Your physician's after-hours contact or an agreed escalation plan

Do not wait until you are in a flare to have this conversation with your doctor. A flare is not the time to be calling pharmacies or explaining your condition to an unfamiliar provider.

Non-Opioid Options for Flare Management

Dr. Tennant's most current guidance includes several non-opioid options for acute flares:

• Journavx® (suzetrigine) 50mg every 12 hours as needed — a new non-opioid pain medication recently approved by the FDA that works through a different mechanism than traditional pain drugs

• Palmitoylethanolamide (PEA) with luteolin (Mirica or other) 600 to 1200mg every 4 to 6 hours

• Ketamine troche or buccal tablet 5 to 20mg every 4 to 6 hours

Oral Opioid Options

For flares and baseline pain where non-opioid options are insufficient:

• Tramadol

• Codeine

• Hydrocodone with acetaminophen (Norco, Vicodin)

• Oxycodone with acetaminophen (Percocet)

If low dose opioids fail to control pain, Dr. Tennant recommends switching to a potent long-acting opioid — fentanyl patch or a long-acting morphine or oxycodone preparation.

Injectable Options for Moderate to Severe Flares

For moderate to severe AA cases, oral medications alone may not be sufficient to break a flare within the critical one-hour window. Dr. Tennant recommends that all but the mildest AA cases be trained and supplied with one or more injectable medications for home use.

Recommended injectable options — patient and physician choice:

1. Ketorolac (Toradol®) 30 to 60mg

2. Methylprednisolone 10 to 20mg

3. Hydromorphone 5mg — for optimal relief, use ultra potent hydromorphone injectable at 50mg/ml. Five mg is only 0.1cc injected subcutaneously under the skin. Available through Anazao Laboratories, Tampa, Florida.

Subcutaneous or intramuscular: Either route can be used. Subcutaneous injections can be administered using a standard insulin or allergy syringe.

Safety: Patients and families can be trained in proper sanitary administration and safe storage. There is no evidence that injectable opioids prescribed for pain flares lead to addiction in this population.

Recognizing Central Pain

Some AA patients experience a specific pattern that Dr. Tennant calls central pain or centralization. If your pain is constant and accompanied by any of these symptoms, you may be experiencing centralization:

• Episodes of rapid heartbeat (tachycardia)

• Elevated blood pressure

• Sweating

• Cold hands and feet (vasoconstriction)

Central pain requires a different approach — adding a descending pain medicinal such as tizanidine, clonidine, methylphenidate, or amphetamine salts (Adderall). PEA is also specifically useful for central pain at 600mg BID in the first month, increasing to 1200mg BID in the second month.

If you recognize this pattern, bring it to your physician's attention specifically — it is often undertreated because it is not recognized.

A Note on Injectable Opioids and Stigma

Dr. Tennant addressed this directly. The practice of training severe chronic pain patients to use injectable opioids at home for flare control has existed since the 1840s. It is humane. It is sometimes lifesaving. And it has been increasingly shunned based on misinformed assumptions about addiction risk.

There is no evidence that injectable opioids prescribed for severe pain flares lead to addiction. If your physician is hesitant, bring them a copy of Bulletin 5 and ask them to engage with the evidence directly.

You deserve adequate flare management. Advocate for it.

When to Go to the Emergency Room

Home management is the goal, but there are situations that require emergency care:

• Pain that does not respond to your full flare protocol within a reasonable timeframe

• New neurological symptoms — sudden weakness, loss of bladder or bowel control, sudden numbness

• Symptoms that feel significantly different from a typical flare

• Any concern that something has changed neurologically

If you go to the emergency room, bring documentation of your diagnosis, your current medications, and if possible a copy of the relevant Tennant Foundation bulletins. Many emergency physicians are unfamiliar with AA and having documentation helps establish the legitimacy and severity of your condition.

After the Flare

Once a flare is controlled, review what triggered it if possible. Common triggers include:

• Physical overexertion

• Prolonged sitting or standing

• Stress

• Illness or infection

• Weather changes

• Missed medications

Identifying patterns helps you anticipate and potentially prevent future flares. Keep a simple log — date, duration, severity, what helped, what preceded it. That information is also valuable for your physician.

If flares are becoming more frequent or more severe, that is a sign of potential deterioration that needs to be evaluated. See our article on If Your Arachnoiditis Is Getting Worse for the next steps.

📄 Download Bulletin 5 — At Home Injections for Acute Pain Flares📄 Download Bulletin 57 — Protocol for Ongoing Pain Relief 📄 Find an AA-aware physician

This article is for educational purposes only and does not constitute medical advice. Always consult a qualified physician before making changes to your treatment plan. See our Disclaimer.