What is the stepped approach to analgesia for pain management?

Stepped Approach to Analgesia for Pain Management

Pain management should follow the WHO three-step analgesic ladder, escalating from non-opioids to weak opioids to strong opioids based on pain intensity, with around-the-clock dosing for persistent pain and rescue doses for breakthrough episodes. 1, 2

Step 1: Mild Pain (NRS 1-4)

• Start with non-opioid analgesics as first-line therapy for mild pain 1, 2
• Acetaminophen/paracetamol: Maximum 4000 mg/day in divided doses 1, 2
• NSAIDs: Ibuprofen (up to 2400 mg/day), naproxen (up to 1000 mg/day), or diclofenac (up to 150 mg/day) 1
• Add gastroprotection when using NSAIDs for prolonged periods to prevent GI toxicity 1, 2
• Monitor closely for renal impairment, heart failure, hypertension, bleeding risk, and platelet dysfunction with NSAID use 1

Step 2: Moderate Pain (NRS 5-7)

• Add weak opioids to non-opioid analgesics when Step 1 fails 1, 2
• Weak opioid options: Codeine (up to 240 mg/day), dihydrocodeine (up to 240 mg/day), or tramadol (up to 400 mg/day) 1
• Alternative approach: Use low doses of strong opioids (morphine or oxycodone) instead of weak opioids 1, 2
• Consider controlled-release formulations of codeine, dihydrocodeine, tramadol, morphine, or oxycodone for convenience 1, 2
• Continue non-opioid analgesics in combination with opioids for synergistic effect 1

Step 3: Severe Pain (NRS 8-10)

• Use strong opioids as the mainstay for severe pain 1, 2
• First-line strong opioid: Morphine is preferred initially 2
• Alternative strong opioids: Hydromorphone, oxycodone, or fentanyl 2
• Oral route preferred when tolerated, as it is the first choice for administration 1
• Continue non-opioid analgesics as part of multimodal approach unless contraindicated 1

Critical Dosing Principles

• Around-the-clock dosing: Schedule regular doses for persistent pain rather than "as needed" administration 1, 2, 3
• Breakthrough doses: Provide rescue medication equivalent to 10-15% of total daily dose for transient pain exacerbations 1, 2, 3
• Rapid titration: Adjust doses quickly to achieve effective pain control, monitoring within first 24-72 hours 4
• Dose escalation trigger: If more than four breakthrough doses are needed daily, increase the baseline opioid regimen 1, 2
• Starting dose for opioid-naive patients: Oxycodone 5-15 mg every 4-6 hours as needed 4

Adjuvant Analgesics for Specific Pain Types

• Neuropathic pain: Add anticonvulsants (gabapentin, pregabalin), antidepressants (tricyclics, SNRIs), or corticosteroids 1, 2, 5, 6
• Bone pain: Consider bone-modifying agents (bisphosphonates, denosumab) 2
• Inflammatory pain: Trial of NSAIDs or glucocorticoids 1

Route Selection Algorithm

• First choice: Oral administration when patient can swallow and tolerate 1
• Alternative routes indicated when: Severe vomiting, bowel obstruction, severe dysphagia, severe confusion, poor pain control requiring rapid escalation, or intolerable oral opioid side effects 1
• Alternative routes: Transdermal, subcutaneous, intravenous, or intrathecal 1

Interventional Strategies

Refer for interventional pain management when: Pharmacologic therapy fails to provide adequate analgesia without intolerable side effects, or pain is likely to respond to nerve blocks 1, 3

• Nerve blocks: Celiac plexus block for pancreatic/upper abdominal pain, superior hypogastric plexus block for lower abdominal pain, intercostal or peripheral nerve blocks 1
• Regional infusion: Epidural, intrathecal, or regional plexus analgesia minimizes systemic side effects 1
• Vertebral procedures: Vertebroplasty/kyphoplasty for vertebral compression fractures or spinal metastases 1
• Radiofrequency ablation: For bone lesions causing localized pain 1
• Contraindications: Unwilling patients, infections, coagulopathy, very short life expectancy, or lack of technical expertise 1

Multimodal Approach

• Combine pharmacologic and non-pharmacologic interventions to target multiple pain pathways and reduce opioid requirements 1, 7, 8
• Non-pharmacologic options: Physical therapy, cognitive-behavioral therapy, relaxation techniques, acupuncture, transcutaneous electrical nerve stimulation (TENS), and patient education 1, 7, 8, 6

Monitoring Requirements

• Assess pain at every clinical visit using standardized self-reporting tools (VAS, NRS, or VRS) 2, 5
• Monitor for respiratory depression especially within first 24-72 hours of initiating or escalating opioids 4
• Anticipate and manage opioid side effects: Constipation (prophylactic laxatives mandatory), nausea, sedation, confusion, pruritus 1, 3, 4
• Document pain ratings and treatment response in medical records 2
• Adjust treatment based on changes in pain intensity, side effects, and disease progression 2, 3

Common Pitfalls to Avoid

• Underestimating pain severity in patients with cognitive impairment—use behavioral observation tools 1, 2, 5
• Inadequate opioid titration leading to persistent uncontrolled pain 2, 5
• Failing to provide prophylactic laxatives with opioid therapy 1
• Not addressing opioidophobia in patients and families through education 1, 2
• Overlooking multiple concurrent pain types in the same patient requiring different treatment strategies 2, 5
• Exceeding maximum acetaminophen dose when using combination opioid-acetaminophen products 3