What medications are recommended for pain relief?

Medications for Pain Relief

For acute mild to moderate pain, start with acetaminophen 1000 mg every 6-8 hours combined with ibuprofen 400-600 mg every 6 hours, as this combination provides superior pain relief with minimal side effects compared to either agent alone. 1, 2

First-Line Therapy: Non-Opioid Analgesics

Acetaminophen should serve as the foundation of your pain management regimen 1, 2:

• Dose: 1000 mg every 4-6 hours (maximum 4 grams daily) 2, 3
• Administer on a scheduled basis, not as-needed, to maintain consistent analgesia 1, 4
• Reduce doses in patients with hepatic disease, malnutrition, or severe alcohol use disorder 3
• In severe hepatic impairment, avoid or significantly reduce dosing 1

NSAIDs should be added to acetaminophen for enhanced pain control 1, 2:

• Ibuprofen 400-800 mg every 6 hours is the safest and most effective NSAID option 1, 3, 5
• Naproxen 250-500 mg every 12 hours is an alternative with longer duration of action 1, 2
• Diclofenac 50 mg provides excellent efficacy (NNT 2.1) 6
• Administer on a scheduled basis for optimal effect 1

Critical contraindications and cautions for NSAIDs 7, 3:

• Avoid in patients with history of gastrointestinal bleeding, cardiovascular disease, or chronic kidney disease 3
• Never use immediately before or after coronary artery bypass graft surgery 7
• In patients with bleeding risk, consider COX-2 selective inhibitors (celecoxib) instead 1
• Avoid ibuprofen in post-MI patients as it blocks aspirin's antiplatelet effects 8
• Use proton pump inhibitors concurrently to reduce GI complications in high-risk patients 8

Neuropathic Pain: Add Adjuvant Medications

For neuropathic pain components that don't respond adequately to NSAIDs and acetaminophen, add gabapentinoids as first-line adjuvants 8, 1:

Gabapentin 8, 1:

• Starting dose: 100-300 mg at bedtime
• Target dose: 900-3600 mg daily in 2-3 divided doses
• Titrate by 50-100% every few days
• Requires dose adjustment in renal insufficiency 8

Pregabalin 8, 1:

• Starting dose: 50 mg three times daily
• Target dose: 100 mg three times daily (maximum 600 mg daily)
• More efficiently absorbed than gabapentin 8
• Requires dose adjustment in renal insufficiency 8

Antidepressants for neuropathic pain 8, 2:

• Duloxetine: Start 30-60 mg daily, increase to 60-120 mg daily 8
• Nortriptyline or desipramine: Start 10-25 mg nightly, increase to 50-150 mg nightly (better tolerated than amitriptyline) 8
• Avoid strong CYP2D6 inhibitors (paroxetine, fluoxetine, duloxetine) in patients on tamoxifen 8

Moderate to Severe Pain: Opioid Considerations

For severe pain unresponsive to non-opioid regimens, add opioids at the lowest effective dose for the shortest duration 1, 2:

Weak opioids for moderate pain 2:

• Tramadol: effective but use cautiously in patients with seizure risk or on antidepressants 2
• Codeine combined with acetaminophen: monitor for constipation 2

Strong opioids for severe pain 2:

• Morphine is first-line for moderate to severe pain 2
• Oxycodone is 1.5-2 times as potent as oral morphine 2
• Hydromorphone is an effective alternative 2
• Limit to breakthrough pain only at approximately 10% of total daily dose 2
• Always prescribe prophylactic laxatives and antiemetics when initiating opioids 1

Topical Therapies for Localized Pain

Lidocaine 5% patch 8:

• Apply daily to painful site
• Minimal systemic absorption
• Effective for postherpetic neuralgia and localized cancer-related pain 8

Topical NSAIDs 8, 3:

• Diclofenac gel applied 3 times daily or patch once to twice daily 8
• Recommended for non-low back musculoskeletal injuries 3

Specific Pain Syndromes

For bone pain 8, 2:

• NSAIDs are particularly effective 2
• Consider bisphosphonates for cancer-related bone pain 8

For muscle spasm/musculoskeletal pain 8:

• Add muscle relaxants to NSAIDs for acute low back pain 8
• Physical therapy with range of motion exercises 8

For chronic low back pain 8:

• Tricyclic antidepressants have small to moderate benefit (effect size 0.5-0.8) 8
• Skeletal muscle relaxants are effective for acute episodes 8

Critical Implementation Strategy

Multimodal analgesia is superior to monotherapy 1, 2:

• Combining acetaminophen + NSAID + gabapentinoid reduces opioid requirements by 30-50% 1
• Scheduled dosing is more effective than as-needed administration 1, 4
• Oral route should be preferred when possible 2
• Regular pain assessments should guide regimen adjustments 1

Common pitfalls to avoid 1:

• Monotherapy with opioids leads to higher doses and increased side effects 1
• As-needed dosing results in fluctuating analgesia and higher overall medication use 1
• Failure to provide prophylactic treatment for opioid side effects (constipation, nausea) 1
• Using higher NSAID doses than necessary increases adverse effects without proportional benefit 3, 5