What are the recommendations for immediate pain management?

Immediate Pain Management Recommendations

For immediate pain management, acetaminophen and/or NSAIDs (such as ibuprofen) are the first-line treatments for mild to moderate pain, with opioids reserved for moderate to severe pain that doesn't respond to first-line agents. 1

First-Line Analgesics

Mild Pain

• Acetaminophen: 975 mg every 8 hours or 650 mg every 6 hours orally 1

  • Well-tolerated in most patients 2
  • Preferred for patients with gastrointestinal issues, cardiovascular disease, or renal disease 2
  • Maximum daily dose: 4000 mg 1

• Ibuprofen: 400-600 mg every 6 hours orally 1, 3

  • Effective for inflammatory pain 4
  • Maximum daily dose: 3200 mg 3
  • Caution in patients with GI bleeding risk, cardiovascular disease, or renal disease 5

• Combination therapy: Acetaminophen plus ibuprofen provides superior pain relief compared to either medication alone 6

  • This multimodal approach targets different pain pathways simultaneously

Moderate Pain

• Continue acetaminophen and/or NSAIDs at optimal dosing 1
• Add weak opioids if needed:
  • Codeine, tramadol, or dihydrocodeine in combination with non-opioid analgesics 1
  • Alternatively, low doses of strong opioids with non-opioid analgesics 1

Severe Pain

• Morphine is the first-choice opioid for moderate to severe pain 1

  • Oral administration preferred when possible
  • Parenteral route (IV/SC) if rapid relief needed, with potency ratio of oral:parenteral approximately 1:3 1
  • Individual titration using immediate-release formulations 1

• Alternative strong opioids:

  • Hydromorphone (0.015 mg/kg IV) may be superior to morphine (0.1 mg/kg IV) 1
  • Oxycodone or hydromorphone in both immediate and modified-release formulations 1
  • Fentanyl (transdermal) for stable pain, especially in patients with poor swallowing or morphine intolerance 1

Special Considerations

Post-Vaginal Delivery Pain Management

For opioid-naïve women after vaginal delivery 1:

1. Non-pharmacologic approaches: ice packs, heating pads, local anesthetic application
2. Acetaminophen: 975 mg every 8 hours or 650 mg every 6 hours
3. Ibuprofen: 600 mg every 6 hours
4. Consider ketorolac (15-30 mg IV/IM every 6 hours for 48 hours) if oral NSAIDs not tolerated

Post-Cesarean Delivery Pain Management

For opioid-naïve women after cesarean delivery 1:

1. Acetaminophen and NSAIDs as baseline therapy
2. Limited opioid prescriptions if needed
3. Monitor for signs of persistent opioid use

Pediatric Pain Management

• Topical anesthetics should be considered for procedures on intact skin (IV placement, lumbar puncture) 1
• Pain assessment should occur routinely at triage and be reassessed during ED stay 1
• Protocols should facilitate appropriate medication delivery for less acute conditions 1

Managing Opioid Side Effects

• Constipation: Prophylactic laxatives should be routinely prescribed 1
• Nausea/vomiting: Metoclopramide and antidopaminergic drugs recommended 1
• Breakthrough pain: Use immediate-release formulations of opioids 1
• Respiratory depression: Monitor closely, especially with parenteral administration 1

Common Pitfalls to Avoid

1. Undertreatment of pain due to fear of opioid addiction
2. Overreliance on opioids without maximizing non-opioid analgesics
3. Failure to anticipate and prevent opioid side effects
4. Not reassessing pain after treatment to determine efficacy
5. Premature escalation to opioids before optimizing first-line agents 4

Algorithm for Pain Management

1. Assess pain severity using validated tools
2. For mild pain: Start with acetaminophen and/or NSAIDs
3. For moderate pain: Optimize acetaminophen/NSAIDs and add weak opioid if needed
4. For severe pain: Consider strong opioids while continuing non-opioid analgesics
5. Reassess pain regularly and adjust treatment accordingly
6. Always prescribe preventive medications for anticipated side effects

This stepwise approach following the WHO analgesic ladder ensures appropriate pain management while minimizing risks of adverse effects and potential for opioid dependence.