What are the options for pain management?

Comprehensive Pain Management Options

Pain management should follow a stepped-care approach that includes non-pharmacological interventions, pharmacological treatments, and when necessary, multidisciplinary management based on pain severity and underlying conditions. 1

Assessment of Pain

• Pain should be evaluated at every clinical encounter using validated tools such as visual analog scales (VAS), numerical rating scales (NRS), or verbal rating scales (VRS) 1
• Assessment should include:
  • Patient's needs, preferences, and priorities regarding pain management 1
  • Pain characteristics (severity, type, spread, quality) 1
  • Previous treatments and their perceived efficacy 1
  • Underlying causes of pain (inflammation, tissue damage, neuropathic components) 1
  • Pain-related factors including disability, beliefs/emotions about pain, social influences, sleep problems, and obesity 1

Non-Pharmacological Approaches

Physical Interventions

• Physical activity and exercise therapy are recommended first-line treatments for chronic pain, particularly for inflammatory arthritis and osteoarthritis 1
• Physical and occupational therapy are recommended for chronic pain conditions 1
• Weight-bearing exercises and stabilization exercises for chronic vertebral compression 1
• Progressive resistance training with compression garments and manual lymphatic drainage for lymphedema-related pain 1

Psychological Interventions

• Cognitive behavioral therapy (CBT) is strongly recommended for chronic pain management 1
• Patient education about pain mechanisms, self-management strategies, and sleep hygiene 1
• Hypnosis is recommended for neuropathic pain 1

Complementary Approaches

• Yoga is recommended for neck/back pain, headache, rheumatoid arthritis, and general musculoskeletal pain 1
• Acupuncture may be considered for myofascial pain and chronic pain conditions 1

Assistive Devices and Adaptations

• Orthotics (splints, braces, gloves, insoles) and assistive devices can reduce pain during activities of daily living 1
• Ergonomic adaptations at home and workplace can improve function and reduce pain 1

Pharmacological Management

Mild Pain (WHO Level I)

• Acetaminophen/paracetamol (up to 4000 mg/day) is recommended as first-line treatment for mild pain 1
• NSAIDs (with gastroprotection for prolonged use) are effective for inflammatory pain 1
• Topical agents like lidocaine and capsaicin are recommended for localized neuropathic pain 1

Moderate Pain (WHO Level II)

• Combination products containing acetaminophen plus an opioid for moderate pain (codeine, dihydrocodeine, tramadol) 1
• Low doses of strong opioids (morphine, oxycodone) may be considered when other options are inadequate 1
• Controlled-release formulations of codeine, dihydrocodeine, and tramadol can improve convenience 1

Severe Pain (WHO Level III)

• Morphine is most commonly used, with oral administration preferred 1
• Hydromorphone or oxycodone (normal and modified release) are effective alternatives 1
• Transdermal fentanyl is best for patients with stable opioid requirements who cannot swallow or have poor tolerance to morphine 1
• Methadone is an alternative but requires expertise due to variable pharmacokinetics 1

Neuropathic Pain

• Gabapentin is recommended as first-line treatment for neuropathic pain (typical dose up to 2400 mg/day) 1
• If gabapentin response is inadequate, consider serotonin-norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants 1
• Pregabalin may be considered for post-herpetic neuralgia 1

Special Considerations

Opioid Management

• Reserve opioids for pain severe enough to require opioid treatment when alternative treatments are inadequate 2, 3
• Use the lowest effective dose and regularly reassess the need for continued opioid therapy 2
• When discontinuing opioids, taper gradually (10-25% reduction every 2-4 weeks) to avoid withdrawal symptoms 2
• Monitor for side effects, misuse, and addiction risk 2, 3

Multidisciplinary Approaches

• Consider multidisciplinary pain management when monotherapy fails or for complex pain conditions 1
• Palliative care consultation is recommended for advanced illness to assist with pain management and address goals of care 1
• For refractory pain, consider referral to pain management services for interventional procedures such as TENS, nerve blocks, or dorsal column stimulation 1

Disease-Specific Considerations

• For cancer pain, incorporate primary anti-tumor treatments alongside analgesic therapy 1
• For inflammatory arthritis and osteoarthritis, address both inflammation and pain components 1
• For HIV-associated neuropathic pain, early initiation of antiretroviral therapy is recommended 1

Common Pitfalls to Avoid

• Relying solely on pharmacological approaches without addressing psychological and functional aspects of pain 1
• Inadequate assessment of pain characteristics leading to inappropriate treatment selection 1
• Overuse of opioids for chronic non-cancer pain without exploring non-opioid alternatives 2, 3
• Failing to address sleep disturbances, which can exacerbate pain perception 1
• Not providing adequate breakthrough pain medication for patients on around-the-clock opioid regimens 1