What are the alternative pain management options for patients?

Alternative Pain Management Options

For patients requiring pain management, use a stepwise approach following the WHO pain ladder: start with acetaminophen or NSAIDs for mild pain, add weak opioids (tramadol, codeine) or low-dose strong opioids for moderate pain, and escalate to full-dose strong opioids (morphine, oxycodone, hydromorphone) for severe pain, while incorporating non-pharmacologic interventions (psychological support, rehabilitative therapies) and interventional procedures (nerve blocks, radiotherapy) when indicated. 1

Pharmacologic Approach by Pain Severity

Mild Pain (WHO Level I)

• Acetaminophen/Paracetamol: 500-1000 mg every 4-6 hours, maximum 4000-6000 mg daily 1

  • Onset of action: 15-30 minutes 1
  • Primary caution: hepatotoxicity at excessive doses 1
  • Preferred first-line agent for mild to moderate acute pain 2, 3

• NSAIDs (when acetaminophen insufficient):

  • Ibuprofen: 400-600 mg every 6 hours (maximum 2400 mg daily) - safest NSAID option 1, 3
  • Naproxen: 250-500 mg twice daily (maximum 1000 mg daily) 1
  • Diclofenac: 25-50 mg four times daily or 100 mg controlled-release twice daily 1
  • All NSAIDs require gastroprotection when used long-term 1
  • Caution: GI toxicity, renal toxicity, cardiovascular effects 1, 2

Moderate Pain (WHO Level II)

• Combination therapy: Acetaminophen/NSAID PLUS weak opioid 1

  • Acetaminophen up to 4000 mg + codeine up to 240 mg daily 1
  • Tramadol: 50-100 mg every 4-6 hours (maximum 400 mg daily) 1
    • Controlled-release formulations: 100-200 mg every 12 hours 1
    • Critical warning: Increased seizure risk, especially with SSRIs, TCAs, MAOIs, other opioids 4
    • Contraindicated in suicidal/addiction-prone patients 4
  • Codeine/Dihydrocodeine: Controlled-release 60-120 mg every 12 hours (maximum 240 mg daily) 1

• Alternative: Low-dose strong opioids (morphine 20-40 mg oral, oxycodone 20 mg oral) 1

Severe Pain (WHO Level III)

• Morphine (first-line strong opioid):

  • Oral: 20-40 mg starting dose, no upper limit with titration 1
  • Parenteral: 5-10 mg (equivalent to 1/3 oral dose) 1
  • Oral route preferred 1

• Alternative strong opioids:

  • Oxycodone: 20 mg oral starting dose, 1.5-2x potency of oral morphine 1
  • Hydromorphone: 8 mg oral starting dose, 7.5x potency of oral morphine 1
  • Transdermal fentanyl: Reserved for stable opioid requirements ≥60 mg/day morphine equivalent 1
    • Starting dose: 25 mcg/hour 1
    • Preferred for patients unable to swallow, poor morphine tolerance, or compliance issues 1
  • Methadone: Requires experienced prescriber due to variable half-life (4-12x morphine potency depending on dose) 1

• Dosing principles:

  • Around-the-clock scheduled dosing PLUS breakthrough doses 1
  • Breakthrough dose = 10% of total daily dose 1
  • If >4 breakthrough doses needed daily, increase baseline long-acting formulation 1

Non-Pharmacologic Interventions

Psychological and Rehabilitative Approaches

• Psychological interventions for pain management 1
• Rehabilitative therapies 1
• These should be incorporated alongside pharmacologic therapy, not as replacements 1

Interventional Procedures

• Radiotherapy: Critical efficacy for bone metastases, neural compression, cerebral metastases, radicular pain 1
• Surgery: Specific indication for impending/evident fractures, hollow organ obstruction 1
• Nerve blocks: For refractory pain unresponsive to systemic therapy 1
• Invasive anesthetic/neurosurgical treatments: For inadequately controlled pain 1

Neuropathic Pain Management

• Co-analgesics (combine with opioids):
  • Antidepressants (TCAs, SNRIs) 1
  • Anticonvulsants 1
  • Neuroleptics 1
• Ketamine: Subanesthetic doses for intractable pain (NMDA antagonist) 1
• Neuropathic pain often responds poorly to opioids alone 1

Critical Safety Considerations

Opioid Side Effect Management

• Constipation: Prophylactic laxatives for all patients 1
• Nausea/vomiting: Continued anti-emetics 1
• CNS toxicity (drowsiness, confusion, hallucinations): Consider opioid rotation or dose reduction 1
• Naloxone: Short-acting IV antagonist for severe overdose (caution: may precipitate seizures with tramadol) 1, 4

Patient-Specific Precautions

• Renal impairment: Fentanyl preferred (no active metabolites) 5
• Cardiovascular instability: Fentanyl causes less hypotension 5
• Respiratory depression risk: Use caution with CNS depressants, alcohol, head trauma 4
• Tramadol contraindications: Epilepsy, seizure history, concurrent serotonergic drugs, suicidal ideation 4

NSAID-Specific Warnings

• Acetaminophen safer than NSAIDs for patients with liver disease (when used at recommended doses), kidney disease, cardiovascular disease, GI disorders, asthma, or elderly 6
• No routine dose reduction needed for elderly with acetaminophen 6
• COX-2 inhibitors show no safety advantage for acute pain and require cardiovascular caution 2, 3

Hemodynamic Considerations

• Fentanyl preferred over other opioids in hemodynamically unstable patients (cardiac/trauma) 5
• Slowing IV fentanyl administration rate limits histamine-mediated hypotension 5
• Both fentanyl and hydromorphone effective in cardiovascularly stable patients 5