What are the treatment options for managing pain?

Pain Management Treatment Options

The most effective approach to pain management follows the World Health Organization's stepwise "pain ladder," starting with non-opioid analgesics for mild pain, adding weak opioids for moderate pain, and using strong opioids for severe pain, with each step incorporating appropriate adjuvant therapies as needed. 1

Assessment of Pain

• All patients should be evaluated for pain at every clinical visit using standardized self-reporting tools such as visual analog scales (VAS), numerical rating scales (NRS), or verbal rating scales (VRS) 1
• Pain assessment should include characterization of type, location, intensity, duration, temporal patterns, and relieving/exacerbating factors 1
• For patients with cognitive impairment, observe pain-related behaviors such as facial expressions, body movements, and vocalizations 1

Treatment Based on Pain Intensity

Mild Pain (WHO Level I)

• Use non-opioid analgesics such as acetaminophen/paracetamol (maximum 4000 mg/day) or NSAIDs 2, 1
• When using NSAIDs for prolonged periods, provide gastroprotection to prevent GI toxicity 2, 1
• Common NSAIDs include ibuprofen (max 2400 mg/day), diclofenac (max 200 mg/day), and ketoprofen (max 300 mg/day) 2

Moderate Pain (WHO Level II)

• Add weak opioids such as codeine, dihydrocodeine, or tramadol to non-opioid analgesics 2, 1
• Alternatively, use low doses of strong opioids such as morphine or oxycodone 2, 1
• Combination products (e.g., acetaminophen 4000 mg + codeine 240 mg) can be effective but monitor maximum doses 2
• Consider controlled-release formulations of codeine, dihydrocodeine, or tramadol for improved convenience 2

Severe Pain (WHO Level III)

• Use strong opioids such as morphine (preferred), hydromorphone, or oxycodone 2, 1
• Oral administration is the preferred route; if given parenterally, the equivalent dose is 1/3 of the oral medication 2
• For patients with stable pain requirements, consider transdermal fentanyl, especially for those unable to swallow or with poor tolerance to morphine 2
• Strong opioids may be combined with ongoing use of level I agents for multimodal analgesia 2

Principles of Opioid Administration

• Provide around-the-clock dosing for persistent pain rather than "as needed" administration 1
• Include "breakthrough" doses (typically 10-15% of total daily dose) for transient pain exacerbations 1
• Titrate doses rapidly to achieve effective pain control 1
• Adjust the baseline opioid regimen if more than four breakthrough doses are needed daily 1
• For opioid tapering, reduce by no more than 10-25% of the total daily dose at intervals of 2-4 weeks to avoid withdrawal symptoms 3

Management of Opioid Side Effects

• Anticipate and proactively manage common side effects, including constipation, nausea/vomiting, and central nervous system toxicity 1
• Use prophylactic laxatives, antiemetics, and consider dose reduction or opioid rotation as needed 1
• Monitor for signs of withdrawal during dose reduction, including restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, and mydriasis 3

Adjuvant Analgesics

• Consider anticonvulsants (gabapentin, pregabalin) and antidepressants (tricyclics, SNRIs) for neuropathic pain 1
• Use corticosteroids for inflammatory pain and bone-modifying agents (bisphosphonates, denosumab) for bone pain 1
• For cancer pain, incorporate primary anti-tumor treatments and non-invasive techniques such as psychological or rehabilitative interventions 2

Non-Pharmacological Approaches

• Consider radiation therapy for localized bone pain 1
• Evaluate for surgical stabilization for impending fractures 1
• Implement psychological interventions to address anxiety and depression 1
• Provide patient education about pain management options 1

Special Considerations

• Ensure a multimodal approach to pain management, especially for chronic pain patients 3
• When discontinuing opioids, provide mental health support if needed 3
• For cancer pain, recognize that over 80% of patients with advanced metastatic disease experience pain, primarily from direct tumor infiltration 2
• Approximately 20% of pain in cancer patients may be attributed to effects of surgery, radiotherapy, or chemotherapy 2

Monitoring and Follow-up

• Obtain regular pain ratings and document them in medical records 1
• Adjust treatment based on changes in pain intensity, side effects, and disease progression 1
• Provide patients with written follow-up plans and instructions on medication adherence 1
• Continually reevaluate patients to assess maintenance of pain control and monitor for development of addiction, abuse, or misuse 3