Initial Treatment Recommendations for Managing Pain and Other Symptoms
The initial treatment approach for pain management should follow a multimodal strategy that combines appropriate pharmacological agents with non-pharmacological interventions, tailored to the specific type and severity of pain. 1
Pain Assessment and Classification
Before initiating treatment, properly assess:
- Pain intensity (using visual analog scales)
- Pain characteristics (neuropathic, inflammatory, musculoskeletal)
- Temporal patterns (acute vs. persistent)
- Impact on function and quality of life
Pharmacological Management
For Mild Pain (WHO Level I)
- First-line: Acetaminophen/paracetamol or NSAIDs 1
- Ibuprofen: Start with 400mg every 4-6 hours as needed (maximum 3200mg daily) 2
- Use the lowest effective dose for shortest duration to minimize side effects
- Caution with NSAIDs in patients with gastrointestinal, cardiovascular, or renal risk factors
For Moderate Pain (WHO Level II)
- First-line: Low-dose morphine or equivalent opioid 1
- Alternative: Weak opioids combined with non-opioid analgesics
- Do not combine weak opioids with strong opioids 1
For Severe Pain (WHO Level III)
- First-line: Morphine or equivalent strong opioid 1
- Oral administration preferred
- Provide "breakthrough" doses (typically 10% of total daily dose)
- Titrate dose based on response
For Neuropathic Pain
- First-line: Gabapentin 1
- Starting dose: 100-300mg nightly
- Gradually increase to 900-3600mg daily in divided doses
- Slower titration for elderly or medically frail patients
- Dose adjustment required for renal insufficiency 1
- Alternative: Pregabalin
- Starting dose: 50mg three times daily
- Increase to 100mg three times daily as needed
- Maximum dose: 600mg daily in divided doses 1
For Bone Pain
- Consider bisphosphonates for metastatic bone pain 1
- Evaluate for potential surgical intervention or radiation therapy for localized bone pain 1
Non-Pharmacological Interventions
Physical Interventions
- Topical agents for localized pain 1
- Lidocaine patch 5%: Apply daily to painful site
- Diclofenac gel: Apply three times daily
- Physical therapy and occupational therapy 1
- Heat or cold application
- Massage therapy
Psychological Support and Interventions
- Cognitive behavioral therapy (CBT) 1
- Relaxation techniques and guided imagery
- Breathing exercises and distraction techniques
- Hypnosis for neuropathic pain 1
Educational Interventions
- Inform patients that emotional reactions to pain are normal 1
- Provide clear explanation of pain management plan
- Set realistic expectations about pain control
- Emphasize that pain management is a team effort 1
Special Considerations
Cancer Pain
- Treat the underlying cause when possible
- Consider disease-modifying treatments (chemotherapy, radiation, surgery)
- For bowel obstruction pain: bowel rest, nasogastric suction, corticosteroids, and/or octreotide 1
Neuropathic Pain in HIV
- Early initiation of antiretroviral therapy is recommended 1
- Gabapentin is first-line treatment 1
- Consider serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants if inadequate response to gabapentin 1
Monitoring and Follow-up
- Regularly reassess pain control and adjust treatment as needed
- Monitor for side effects of medications
- Review patient management plan within 6 months 1
- Consider referral to pain specialist if inadequate response to initial management
Common Pitfalls to Avoid
- Overreliance on opioids for chronic non-cancer pain
- Undertreatment of pain due to fear of medication side effects
- Failure to address psychosocial aspects of pain
- Not providing adequate breakthrough pain medication
- Neglecting to reassess pain control regularly
- Dismissing pain reports when physical findings don't correlate with reported intensity
By implementing this comprehensive approach to pain management, clinicians can effectively address both the physical and psychological aspects of pain, leading to improved quality of life and functional outcomes for patients.