What is the best approach for pain management?

Best Approach for Pain Management

The optimal approach to pain management follows a structured, multimodal strategy beginning with comprehensive pain assessment using standardized tools (NRS, VAS), followed by stepwise pharmacologic treatment matched to pain intensity, combined with non-pharmacologic interventions including patient education, physical therapy, and psychological support when indicated. 1

Initial Pain Assessment

Every patient requires systematic pain evaluation at each clinical encounter using validated self-reporting scales (numerical rating scale 0-10, visual analog scale, or verbal rating scale). 1, 2, 3 Specifically ask: "What has been your worst pain in the last 24 hours on a scale of 0-10?" 4

Characterize the pain by:

• Type (nociceptive vs neuropathic) 2, 3
• Location, intensity, duration, and temporal patterns 2, 3
• Factors that relieve or exacerbate symptoms 2, 3
• Impact on daily function, sleep, mood, and quality of life 1, 4

For patients with cognitive impairment, observe behavioral indicators including facial expressions, body movements, and vocalizations. 2, 4

Stepwise Pharmacologic Management

Mild Pain (NRS 1-4)

Start with non-opioid analgesics: acetaminophen up to 1,000 mg per dose (maximum 4,000 mg/day) or ibuprofen 400 mg. 2, 5 Ibuprofen demonstrates superior efficacy compared to acetaminophen across multiple pain conditions in direct comparisons. 6

• When using NSAIDs beyond short-term, provide gastroprotection to prevent GI toxicity 1, 2
• Use NSAIDs cautiously in patients with renal impairment, heart failure, hypertension, or bleeding risk 1, 2, 3

Moderate Pain (NRS 5-7)

Add weak opioids or low-dose strong opioids: Consider tramadol, codeine, or low-dose morphine/oxycodone in combination with non-opioid analgesics. 2, 4

For tramadol specifically, initiate with dose titration: start 50 mg every 4-6 hours, increasing by 50 mg every 3 days as tolerated to reach 200 mg/day, with maximum 400 mg/day. 7 However, note that tramadol shows poor efficacy and increased side effects compared to other options in acute pain. 5

Severe Pain (NRS 8-10)

Use strong opioids: Morphine (preferred first-line), hydromorphone, oxycodone, or fentanyl. 2, 4

Critical opioid administration principles:

• Provide around-the-clock dosing for persistent pain rather than "as needed" 2, 3
• Include breakthrough doses (10-15% of total daily dose) for pain exacerbations 2, 3
• Titrate rapidly to achieve effective control 2, 3
• Adjust baseline regimen if more than 4 breakthrough doses needed daily 2, 4

Adjuvant Analgesics for Specific Pain Types

For neuropathic pain: Add anticonvulsants (gabapentin, pregabalin), tricyclic antidepressants, or SNRIs (duloxetine, venlafaxine). 1, 2, 4 These should be part of a multimodal strategy, not monotherapy. 1

For bone pain: Consider bisphosphonates or denosumab. 2, 3

Topical agents (lidocaine, capsaicin, ketamine) are appropriate for peripheral neuropathic pain. 1

Essential Non-Pharmacologic Interventions

Patient Education

All patients require access to educational materials about staying active, sleep hygiene, and self-management strategies. 1 Provide psychoeducation and encourage participation in self-management programs. 1

Physical Activity and Exercise

When patients cannot initiate activity independently, refer to physiotherapy for individually tailored graded exercise or strength training. 1 Physical therapy demonstrates effective pain relief for low back pain lasting 2-18 months. 1

Psychological Interventions

When psychological factors interfere with pain management: Provide basic psychological support or refer for cognitive behavioral therapy, biofeedback, or relaxation training. 1 These interventions show evidence for back pain relief lasting 4 weeks to 2 years. 1

If psychopathology (depression, anxiety) is present, coordinate treatment with the patient's primary care physician. 1

Sleep Management

For sleep disturbance, inquire about causes (pain, worrying, poor habits) and provide sleep hygiene education. 1 If severely disturbed, refer to specialized sleep therapy. 1

Weight Management

For obese patients, explain that obesity contributes to pain and disability, then discuss accessible weight management options including dietitian referral or bariatric services. 1

Monitoring and Adjustment

Establish a therapeutic partnership through reflective listening, believing the patient's pain report, and documenting detailed assessments. 1 Regular pain ratings must be obtained and documented in medical records. 2, 3

Reassess regularly for changes in pain intensity, medication side effects, and functional status. 2, 3 Adjust treatment when side effects occur or pain persists. 4

Before prescribing long-term pharmacologic therapy, implement a strategy for monitoring side effects, adverse effects, and compliance. 1

Critical Pitfalls to Avoid

• Never underestimate pain severity in cognitively impaired patients 2, 4
• Avoid inadequate opioid titration leading to poor control 2
• Don't neglect prophylactic management of opioid side effects 2
• Recognize that most patients have multiple pain types requiring different approaches 2
• Address opiophobia in patients and families through education 2
• Don't overlook psychosocial impact on pain experience 2

Special Considerations

For elderly patients over 75 years, limit total tramadol dose to 300 mg/day. 7 In patients with creatinine clearance <30 mL/min, increase tramadol dosing interval to 12 hours with maximum 200 mg/day. 7

Avoid tramadol with MAO inhibitors or SSRIs due to increased seizure and serotonin syndrome risk. 7 Use cautiously with CNS depressants including alcohol. 7

When discontinuing opioids, taper gradually to avoid withdrawal symptoms (anxiety, sweating, insomnia, tremors). 7