What should I prioritize for pain management?

Pain Management Prioritization

For pain management, you should follow the WHO analgesic ladder approach, starting with non-opioid analgesics for mild pain, adding weak opioids for moderate pain, and using strong opioids for severe pain. 1

Assessment of Pain

• Pain severity should be assessed using validated tools such as visual analogue scales (VAS), numerical rating scales (NRS), or verbal rating scales (VRS) to determine appropriate treatment 1
• Pain intensity should be categorized as:
  • Mild pain (1-3 on a 0-10 scale)
  • Moderate pain (4-7 on a 0-10 scale)
  • Severe pain (8-10 on a 0-10 scale) 1

Stepwise Approach to Pain Management

Step 1: Mild Pain (1-3/10)

• Begin with non-opioid analgesics:
  • Acetaminophen/paracetamol (up to 1000 mg per dose, maximum 4000 mg daily) 1, 2
  • NSAIDs such as ibuprofen (400-600 mg every 6-8 hours) or naproxen (500 mg initially, then 250-500 mg every 12 hours) 3, 4
• Consider gastroprotection when using NSAIDs for prolonged periods 1
• For patients with liver disease, cardiovascular risk, or gastrointestinal concerns, acetaminophen is generally safer than NSAIDs 2

Step 2: Moderate Pain (4-7/10)

• If pain persists despite Step 1 medications, add a weak opioid:
  • Codeine, dihydrocodeine, or tramadol 1
  • Alternatively, use low doses of strong opioids such as morphine or oxycodone 1
• Continue non-opioid analgesics from Step 1 for additive effects 1
• For opioid-tolerant patients, continue non-opioid and adjuvant therapies with short-acting opioids as needed 1

Step 3: Severe Pain (8-10/10)

• For severe pain, use strong opioids:
  • Morphine is the standard first-line strong opioid 1
  • Alternatives include hydromorphone, oxycodone, or fentanyl 1
• Oral administration is preferred when possible 1
• For parenteral administration, the equivalent dose is approximately 1/3 of the oral dose 1
• For patients with acute severe pain needing urgent relief, use parenteral opioids via intravenous or subcutaneous routes 1

Important Considerations

• Always provide "rescue doses" for breakthrough pain (typically 10-20% of the total daily opioid dose) 1
• For persistent pain, schedule analgesics around-the-clock rather than "as needed" 1
• Always initiate prophylactic bowel regimens when starting opioid therapy to prevent constipation 1
• For opioid-tolerant patients experiencing inadequate pain relief, consider increasing the dose by 30-50% 1
• Transdermal fentanyl should be reserved for patients with stable opioid requirements 1

Special Situations

• For patients with renal impairment, use opioids with caution at reduced doses and frequency 1
• In patients with chronic kidney disease (stages 4-5), fentanyl and buprenorphine are safer options 1
• For neuropathic pain components, consider adjuvant medications such as anticonvulsants or antidepressants 1
• In elderly patients, start with lower doses but do not routinely reduce doses without clinical indication 2

Common Pitfalls to Avoid

• Failing to regularly reassess pain intensity and adjust treatment accordingly 1
• Not providing breakthrough pain medication when prescribing around-the-clock opioids 1
• Neglecting to start prophylactic treatment for opioid-induced constipation 1
• Using transdermal fentanyl for unstable pain or rapid titration 1
• Overlooking the potential benefits of continuing non-opioid analgesics when escalating to opioids 1

By following this structured approach to pain management, you can optimize pain control while minimizing adverse effects and improving quality of life for patients experiencing pain.