What medications can be used to reduce pain?

Medications for Pain Management

Multimodal pain management using acetaminophen, NSAIDs, and adjunctive medications like gabapentinoids should be prioritized to reduce pain while minimizing opioid use. 1

First-Line Medications

Non-Opioid Analgesics

• Acetaminophen (Paracetamol)

  • Recommended as first-line therapy for mild pain (NRS: 1-4) 1
  • Dosing: 500-1000mg every 6 hours, maximum 4000mg daily 1
  • Particularly useful in older adults due to better safety profile 2
  • Caution: Reduce dose in patients with hepatic disease 1

• NSAIDs

  • Recommended for mild to moderate pain when not contraindicated 1
  • Options include:
    • Ibuprofen: 400-600mg every 6 hours (max 2400mg daily) 1
    • Naproxen: 250-500mg twice daily (max 1000mg daily) 1
    • Diclofenac: 50mg 3-4 times daily (max 200mg daily) 1
  • Particularly effective for inflammatory pain conditions 1
  • Caution: Risk of GI bleeding, cardiovascular events, and renal toxicity 3
  • Consider gastroprotection when used long-term 1

• Topical Analgesics

  • Topical NSAIDs: First-line for non-low back musculoskeletal injuries 1
  • Topical lidocaine: Useful for localized pain (4% cream/patch) 4
  • Topical capsaicin: Effective for localized chronic pain 5

Second-Line Medications

For Moderate Pain (NRS: 5-7)

• Gabapentinoids

  • Gabapentin and pregabalin recommended for neuropathic pain 1
  • Act by decreasing neurotransmitter release in synapses 1
  • Moderate evidence supports their use in multimodal analgesia 1

• Antidepressants

  • Tricyclic antidepressants and SNRIs (duloxetine) effective for neuropathic pain 1
  • Duloxetine has moderate-quality evidence for chronic low back pain 2

• Alpha-2-Agonists

  • Reduce opioid requirements through sympatholytic effect 1
  • Inhibit norepinephrine release 1

Third-Line Medications (For Severe Pain)

Opioid Medications

• Should be used only when other options have failed for severe, disabling pain 2
• Options include:
  • Tramadol: Lower addiction potential than traditional opioids 1
  • Morphine, oxycodone: For severe pain (NRS: 8-10) 1
• Round-the-clock dosing with "breakthrough" doses (10-15% of total daily dose) 1
• Limit duration to shortest period necessary 1

Pain Management Algorithm

1. For mild pain (NRS 1-4):

   • Start with acetaminophen 1000mg every 6 hours OR
   • NSAID (if no contraindications)
   • Consider topical agents for localized pain

2. For moderate pain (NRS 5-7):

   • Combine acetaminophen AND NSAID (if not contraindicated) 1
   • Add adjunctive therapy based on pain type:
     • Neuropathic: Add gabapentinoid or SNRI
     • Musculoskeletal: Consider muscle relaxant for spasm 6

3. For severe pain (NRS 8-10):

   • Continue acetaminophen and NSAID (if not contraindicated)
   • Add short-term opioid at lowest effective dose 1
   • Consider referral to pain specialist for complex cases

Special Considerations

• Elderly patients: Prefer acetaminophen; use caution with NSAIDs due to increased risk of adverse effects 2
• Renal impairment: Avoid NSAIDs; adjust medication doses appropriately 3
• Cardiovascular disease: Use caution with NSAIDs; consider acetaminophen as primary agent 3
• Gastrointestinal risk: Add gastroprotection if using NSAIDs or consider COX-2 inhibitors 1

Common Pitfalls to Avoid

1. Overreliance on opioids: Opioids should not be first-line therapy for most pain conditions 1
2. Inadequate dosing of non-opioids: Ensure proper dosing of acetaminophen and NSAIDs before escalating to opioids 1
3. Monotherapy approach: Multimodal therapy is more effective than single agents 1
4. Prolonged NSAID use: Increases risk of GI, cardiovascular, and renal complications 3
5. Overlooking non-pharmacological options: Exercise therapy, heat/cold therapy, and cognitive behavioral approaches should complement medication 2

By following this structured approach to pain management, clinicians can effectively address pain while minimizing risks associated with various analgesic medications.