What are the recommended medications for pain management?

Pain Management Recommendations

Multimodal pain management should be the standard approach for pain control, with acetaminophen and NSAIDs as first-line agents, and opioids reserved for moderate to severe pain that doesn't respond to initial therapy. 1

Pain Management Algorithm Based on Pain Severity

Mild Pain (Pain Score 1-3)

• First-line: Acetaminophen 500-1000 mg every 4-6 hours (maximum 3-4g/day) 1
  • Safest initial choice with fewer side effects than NSAIDs
  • Effective for short-term pain relief
  • Reduce dosing in patients with liver disease

Moderate Pain (Pain Score 4-6)

• First-line: Acetaminophen plus NSAIDs 1
  • Ibuprofen 400-600 mg every 6 hours (safest NSAID option) 2
  • COX-2 inhibitors (e.g., celecoxib) if traditional NSAIDs are contraindicated 1
• Second-line: Add weak opioid if inadequate response
  • Tramadol 50-100 mg every 4-6 hours (maximum 400 mg/day) 1, 3

Severe Pain (Pain Score 7-10)

• First-line: Continue acetaminophen and NSAIDs 1
• Add strong opioid: 1, 4
  • Morphine 5-10 mg IV/SC or 20-40 mg oral
  • Oxycodone 5-15 mg oral every 4-6 hours
  • Hydromorphone (7.5 times more potent than oral morphine)
• Consider: Patient-controlled analgesia (PCA) for acute severe pain 3

Specific Pain Types

Neuropathic Pain

• First-line: Gabapentinoids (gabapentin or pregabalin) 1
• Second-line: Alpha lipoic acid (ALA) 1
• Third-line: Consider time-limited opioid trial if no response to first-line agents 1
  • When opioids are appropriate for neuropathic pain, consider combining morphine with gabapentin for additive effects and lower individual doses 1

Musculoskeletal Pain

• First-line: Acetaminophen and NSAIDs 1
• Second-line: Consider time-limited opioid trial for moderate-severe pain with functional impairment 1

Important Considerations

Opioid Management

• Start with the smallest effective dose 4
• For chronic pain, administer on a regular schedule rather than "as needed" 1
• Provide rescue doses for breakthrough pain 1
• Monitor for side effects: constipation (use prophylactic laxatives), nausea/vomiting, respiratory depression 1
• Assess risk for misuse, addiction, and diversion before prescribing 1
• Implement monitoring tools: opioid treatment agreements, urine drug testing, pill counts 1

NSAID Cautions

• Avoid in patients with renal impairment, GI bleeding risk, or cardiovascular disease 1
• COX-2 inhibitors have decreased GI toxicity but increased cardiovascular risk 1

Special Populations

• Elderly: Use caution with NSAIDs due to increased risk of renal and GI complications 3
• Renal Impairment: Use all opioids with caution; fentanyl and buprenorphine are safest in severe renal impairment 1

Adjunctive Treatments

• Radiotherapy: Effective for pain from bone metastases, neural compression, cerebral metastases 1
• Surgery: Consider for pain from impending/evident fractures or obstruction of hollow organs 1

Common Pitfalls to Avoid

1. Relying on monotherapy for moderate to severe pain
2. Underdosing analgesics, leading to inadequate pain control
3. Overusing opioids as first-line therapy
4. Failing to address constipation prophylactically when prescribing opioids
5. Not adjusting therapy based on patient response and side effects

By following this evidence-based, stepwise approach to pain management, clinicians can effectively control pain while minimizing adverse effects and the risk of opioid misuse.