What are the options for pain management?

Pain Management Options

For mild pain, start with acetaminophen (up to 4000 mg/day) or ibuprofen 400 mg every 4-6 hours as first-line therapy; for moderate pain, add or switch to combination acetaminophen/opioid products; for severe pain, use strong opioids like morphine or hydromorphone, always integrating non-pharmacological approaches regardless of pain severity. 1, 2

Systematic Approach Based on Pain Severity

Mild Pain (≤4/10 on numerical rating scale)

• Acetaminophen is the initial choice, dosed up to 1000 mg per dose with a maximum daily dose of 4000 mg, providing effective analgesia without opioid-related risks 1, 2, 3
• Ibuprofen 400 mg is the preferred NSAID when inflammatory components are present, dosed every 4-6 hours (maximum 2400 mg/day), offering superior efficacy to other NSAIDs with a favorable safety profile 1, 2
• Avoid starting with opioids for mild pain—this exposes patients to unnecessary risks of dependence, respiratory depression, and addiction when nonopioids provide adequate relief 2

Critical pitfall: Using subtherapeutic doses of nonopioids may lead to perceived treatment failure and inappropriate escalation to opioids; ensure maximum recommended doses are reached before declaring treatment failure 2

Moderate Pain (5-7/10)

• Combination products containing acetaminophen plus weak opioids (hydrocodone or oxycodone) are appropriate when nonopioids alone fail 4, 5
• These combinations target separate pain pathways simultaneously, demonstrating additive analgesic effects with a pharmacologic sparing effect 5
• Opioid-containing products should be reserved for patients in whom non-opioid analgesics have not been tolerated or have not provided adequate analgesia 6

Severe Pain (≥8/10)

• Morphine is the most commonly used strong opioid, with oral administration preferred when possible 1
• Hydromorphone serves as a first-line alternative to morphine when morphine is not tolerated or contraindicated, with relative potency approximately 5-7.5 times that of oral morphine 7
• For breakthrough pain, rescue doses should be calculated as 10-15% of the total daily dose 7
• Start with immediate-release formulations for dose titration, then transition to modified-release formulations for maintenance therapy 7

Non-Pharmacological Approaches (Essential at All Pain Levels)

• Physical activity and exercise therapy are first-line treatments for chronic pain, particularly inflammatory arthritis and osteoarthritis 1
• Cognitive behavioral therapy (CBT) is strongly recommended for chronic pain management with high-quality evidence 1
• Yoga is recommended for neck/back pain, headache, rheumatoid arthritis, and musculoskeletal pain with moderate-quality evidence 1

Neuropathic Pain (Special Consideration)

• Gabapentin is first-line treatment for neuropathic pain, typically dosed up to 2400 mg/day with moderate-quality evidence 1

Essential Clinical Practices

Assessment Requirements

• Evaluate pain at every clinical encounter using validated tools (VAS, NRS, or VRS) 1
• Assessment must include pain characteristics, previous treatments, underlying causes, and patient preferences 1
• Screen all chronic pain patients for depression, history of sexual abuse, trauma, and PTSD, as these exacerbate pain and require treatment for comprehensive pain management success 8

Prescribing Principles

• For chronic pain, prescribe analgesics on a regular schedule, not "as needed", to provide consistent serum levels and improved analgesia 2
• Document specific pain syndromes to guide future management and discuss the full strategy with patients 8
• Build therapeutic partnerships using reflective listening, believing patient expressions of pain, and regularly recording detailed assessments 8

NSAID Safety Monitoring

• Key contraindications include renal impairment, heart failure, and history of gastrointestinal bleeding 2
• Monitor for gastrointestinal, cardiovascular, and renal adverse effects, especially in high-risk patients 2
• Consider topical NSAIDs as alternatives with fewer systemic side effects 2

Multimodal and Multidisciplinary Management

• When monotherapy fails or for complex pain conditions, implement multidisciplinary pain management involving primary care providers, nurses, physical/occupational therapists, psychologists, psychiatrists, and case managers 8, 1
• Multimodal treatments combine analgesics, physical therapy, and behavioral/psychological therapy to increase self-management, improve coping resources, reduce disability, and reduce emotional stress 8
• For advanced illness, palliative care consultation assists with pain management and addresses goals of care 1
• For cancer pain, incorporate primary anti-tumor treatments alongside analgesic therapy 1

Opioid Tapering and Discontinuation (When Necessary)

• Never abruptly discontinue opioids in physically dependent patients—rapid discontinuation causes serious withdrawal symptoms, uncontrolled pain, and has been associated with suicide 9
• Initiate tapers by small increments (no greater than 10-25% of total daily dose) to avoid withdrawal symptoms, proceeding at intervals of every 2-4 weeks 9
• Ensure a multimodal approach to pain management, including mental health support, is in place prior to initiating an opioid taper 9
• Common withdrawal symptoms include restlessness, lacrimation, rhinorrhea, perspiration, chills, myalgia, irritability, anxiety, insomnia, nausea, and increased vital signs 9