What is the treatment for pain management?

Pain Management Treatment

For pain management, begin with non-opioid analgesics (acetaminophen up to 4-6 g/day or NSAIDs with gastroprotection), escalate to weak opioids (tramadol, codeine) for moderate pain, and reserve strong opioids (morphine, oxycodone) for severe pain, while integrating non-pharmacologic therapies (exercise, physical therapy, psychological interventions) throughout all stages of treatment. 1, 2

Pharmacological Approach: WHO Pain Ladder

Mild Pain (Step 1)

• Acetaminophen/Paracetamol: 500-1000 mg every 4-6 hours, maximum 4-6 g daily 1, 2
• NSAIDs with gastroprotection for prolonged use: 1
  • Ibuprofen: 400-800 mg every 6-8 hours, maximum 3200 mg daily 1
  • Naproxen: 250-500 mg twice daily, maximum 1000 mg daily 1
  • Diclofenac: 25-50 mg four times daily or 100 mg sustained-release twice daily 1

Moderate Pain (Step 2)

• Tramadol: 50-100 mg every 4-6 hours, maximum 400 mg daily 2
• Codeine combinations: Up to 240 mg codeine with 4000 mg acetaminophen daily 1
• Dihydrocodeine: 60-120 mg doses, maximum 240 mg daily 2
• Low-dose strong opioids (morphine 20-40 mg oral daily or oxycodone 20 mg daily) are increasingly preferred over traditional weak opioid combinations 1, 2

Severe Pain (Step 3)

• Morphine sulfate: Starting dose 20-40 mg oral daily, no upper limit; parenteral dosing is 1/3 of oral dose 1, 2
• Oxycodone: Starting dose 20 mg oral daily, 1.5-2 times more potent than oral morphine 1, 2
• Hydromorphone: Starting dose 8 mg oral, 7.5 times more potent than oral morphine 1
• Transdermal fentanyl: Starting dose 12 µg/h for stable opioid requirements only, 4 times more potent than oral morphine 1
• Methadone: Starting dose 10 mg oral, but requires experienced prescriber due to variable half-life (4-12 times more potent than morphine depending on dose) 1

Adjuvant Medications for Neuropathic Pain

Neuropathic pain requires specific adjuvants as opioids alone are often insufficient. 1

First-Line Agents

• Gabapentin: Titrate to effective dose for diabetic neuropathy and postherpetic neuralgia 3, 4
• Pregabalin: FDA-approved for diabetic peripheral neuropathy (150-600 mg/day), postherpetic neuralgia (150-600 mg/day), and spinal cord injury pain (150-600 mg/day) 4
• Duloxetine/Venlafaxine (SNRIs): Effective for neuropathic pain 3

Second-Line Agents

• Tricyclic antidepressants (amitriptyline): Use with caution in patients over 65 due to anticholinergic effects 3
• Carbamazepine: For specific neuropathic conditions 2

Topical Options

• Lidocaine 5% patches: For localized neuropathic pain 2, 3
• Capsaicin 8% patch or 0.075% cream: For patients with contraindications to oral therapy 3

Refractory Cases

• Ketamine at subanesthetic doses: Reserved for truly intractable pain unresponsive to other interventions 2

Non-Pharmacologic Interventions

Physical activity and psychological interventions show the most uniform positive effects on pain across conditions. 1

Physical Modalities (Evidence Type 2-3)

• Exercise therapy: Small to moderate improvements in pain and function for chronic low back pain, with benefits appearing as early as week 1 1
• Yoga: Moderate effects on pain at short and intermediate term for chronic low back pain 1
• Massage: Small short-term improvements in pain for chronic low back and neck pain 1
• Acupuncture: Small improvements in short and intermediate-term pain 1
• Low-level laser therapy: Moderate effects for chronic neck pain 1
• Spinal manipulation: Small improvements at intermediate term 1

Psychological Interventions (Evidence Type 2)

• Cognitive behavioral therapy (CBT): Uniform positive effects on pain in rheumatoid arthritis and osteoarthritis 1
• Mindfulness-based stress reduction: Small short-term improvement in pain 1
• Biofeedback and relaxation: Positive effects in specific conditions 1

Multidisciplinary Rehabilitation

• Associated with small improvements in function and pain versus exercise alone at short and intermediate terms 1
• Cautiously recommended due to absence of studies examining added effect over monodisciplinary therapies 1

Special Considerations

Chronic Non-Cancer Pain

• Avoid long-term opioid therapy due to lack of sustained efficacy evidence and significant risks including addiction, overdose, and mortality 1, 5
• Prioritize multimodal non-pharmacological approaches over escalating opioid doses 1
• If opioids are used, implement the "Four A's" monitoring approach: Analgesia, Activities of daily living, Adverse effects, Aberrant drug-taking behaviors 1
• Monitor strong opioids at minimum six-monthly intervals for stable patients, more frequently during dose adjustments 1

Cancer Pain

• More liberal use of strong opioids and interventional techniques is appropriate 2
• Radiotherapy has specific efficacy for bone metastases, neural compression, and cerebral metastases 1, 2
• Consider bisphosphonates for bone pain from metastases 2
• Combination of opioids with adjuvants for neuropathic cancer pain 1

Opioid Tapering

• When discontinuation is necessary, use gradual tapering with support interventions for better functional outcomes 1
• Longer time to discontinuation in patients on high-dose therapy decreases risk of opioid-related emergency visits 1
• Abrupt discontinuation may increase overdose risk 1

Weight Management

• Shows uniform positive effect on pain in rheumatoid arthritis, spondyloarthritis, and hip/knee osteoarthritis 1

Critical Pitfalls to Avoid

• Do not delay analgesia while pursuing diagnosis - pain relief should begin during diagnostic evaluation 1
• Avoid intramuscular injections for urgent pain relief; use intravenous or subcutaneous routes instead 1
• Do not use opioids in conditions where they worsen outcomes (e.g., gastroparesis) 2
• Recognize pseudoaddiction - behaviors suggesting addiction that resolve with adequate pain treatment; the cause is inadequate analgesia, not true addiction 1
• Avoid amitriptyline specifically for phantom limb pain - evidence does not support efficacy 5
• Perioperative ketamine, gabapentin, and locoregional anesthesia do not prevent phantom limb pain despite common practice 5