What is the best pain management strategy for this patient?

Pain Management Recommendation

Start with acetaminophen 1000 mg every 6 hours (maximum 4000 mg/day) as first-line therapy for mild to moderate pain, and add ibuprofen 400-600 mg every 6 hours if acetaminophen alone provides inadequate relief. 1, 2

Initial Assessment Required

Before prescribing, evaluate:

• Pain intensity using a 0-10 numerical rating scale: "What has been your worst pain in the last 24 hours?" 3, 4
• Pain characteristics: onset, location, quality (aching/throbbing suggests somatic; shooting/stabbing suggests neuropathic), duration, and what makes it better or worse 1
• Impact on function: sleep, daily activities, mood, and quality of life 1
• Contraindications: hepatic disease, renal impairment, cardiovascular disease, gastrointestinal bleeding history, or NSAID allergy 1

Stepwise Pharmacologic Approach

For Mild Pain (NRS 1-4)

First choice: Acetaminophen 1, 3, 2

• Dose: 500-1000 mg every 6 hours (maximum 4000 mg/day) 1
• Acetaminophen is safer than NSAIDs and should be the initial analgesic, particularly in patients with cardiovascular disease, renal impairment, or gastrointestinal disorders 1, 5
• Reduce dose in patients with advanced hepatic disease, malnutrition, or severe alcohol use disorder 2, 5

Add or switch to NSAIDs if inadequate relief: 1, 2

• Ibuprofen 400-600 mg every 6 hours is the safest NSAID option 1, 6
• Alternative: Naproxen 250-500 mg twice daily 1
• Always provide gastroprotection (proton pump inhibitor) when using NSAIDs for more than a few days 1
• Avoid NSAIDs in patients with history of GI bleeding, cardiovascular disease, chronic kidney disease, or hypertension 1, 2

For Moderate Pain (NRS 5-7)

Multimodal approach combining acetaminophen + NSAID: 1, 3

• Acetaminophen 1000 mg every 6 hours PLUS
• Ibuprofen 600 mg every 6 hours 1

If still inadequate, add weak opioid: 1, 3

• Tramadol 50-100 mg every 6 hours, OR
• Codeine 30-60 mg every 4-6 hours (combined with acetaminophen), OR
• Low-dose oxycodone 5 mg every 4-6 hours 7

Important caveat: Codeine has shown poor efficacy and significant side effects in multiple studies and should be avoided when other options are available 6, 8

For Severe Pain (NRS 8-10)

Strong opioids are indicated: 1, 3

• Morphine is the preferred first-line strong opioid 1, 3
• Alternative: Oxycodone 5-15 mg every 4-6 hours 1, 3, 7
• Alternative: Hydromorphone at equivalent doses 1

Continue acetaminophen and/or NSAIDs as adjuncts to reduce total opioid requirements 1

Opioid Administration Principles (When Required)

Dosing schedule: 1, 3, 4

• Provide around-the-clock dosing for persistent pain, not "as needed" 1, 3, 4
• Prescribe breakthrough doses (10-15% of total daily dose) for transient pain exacerbations 3, 4
• If patient requires more than 4 breakthrough doses daily, increase the baseline scheduled dose 3, 4

Titration: 7

• Start conservatively, especially in opioid-naive patients 7
• For oxycodone: initiate at 5-15 mg every 4-6 hours and titrate based on response 7
• Monitor closely for respiratory depression, especially in first 24-72 hours 7

Duration: 1, 2

• Use the lowest effective dose for the shortest duration possible 1, 7
• For acute pain, limit opioid prescriptions to less than 14 days 2

Special Considerations for Neuropathic Pain

If pain has neuropathic characteristics (shooting, stabbing, burning, tingling): 1, 3

• Add gabapentin starting at 300 mg at bedtime, titrate to 300-600 mg three times daily 1
• Alternative: Pregabalin 75-150 mg twice daily (better absorption than gabapentin) 1
• Consider low-dose tricyclic antidepressants (amitriptyline 10-25 mg at bedtime) or SNRIs (duloxetine 30-60 mg daily) 1

Common Pitfalls to Avoid

• Don't underdose acetaminophen: Use full 1000 mg doses (not 500 mg) for adequate analgesia 1, 6
• Don't use codeine as first-line opioid: It has poor efficacy and high side effect burden compared to alternatives 6, 8
• Don't prescribe NSAIDs without gastroprotection for prolonged use 1
• Don't use opioids alone: Always combine with non-opioid analgesics to reduce opioid requirements 1
• Don't forget to reassess: Pain should be evaluated at every clinical encounter and medications adjusted accordingly 1, 3, 4
• Don't abruptly discontinue opioids in patients taking them regularly: taper by 25-50% every 2-4 days 7

Monitoring and Follow-up

• Reassess pain intensity at every visit using the same numerical scale 1, 3
• Monitor for side effects: constipation, nausea, sedation with opioids; GI bleeding, renal dysfunction with NSAIDs 1, 2
• Adjust regimen if pain persists or side effects develop 1, 4
• Provide written instructions including medication names, doses, timing, and when to seek help 4