What are the recommended approaches for managing pain?

Pain Management: Recommended Approaches

Pain management should follow a structured biopsychosocial framework with early patient education, risk stratification, and a stepped-care approach that prioritizes non-pharmacological interventions before escalating to pharmacological treatments. 1, 2

Initial Assessment Framework

Core Assessment Components

All patients require systematic pain screening at every clinical encounter using quantified self-report measures 1, 2:

• Pain intensity: Use 0-10 numeric rating scale, categorical scale, or pictorial scale (Wong-Baker FACES) 1
• Pain characteristics: Document severity, type (nociceptive vs neuropathic), spread (localized vs generalized), quality (aching, burning, stabbing), and duration 1
• Functional impact: Assess physical activity, mobility, activities of daily living, social participation, and valued life goals that pain prevents 1
• Treatment history: Previous and ongoing pain treatments with perceived efficacy 1

Biopsychosocial Risk Factors

Beyond pain intensity, identify factors predicting chronicity 1:

• Psychological factors: Pain catastrophizing (rumination, magnification, helplessness), fear of movement, pain self-efficacy, depression, anxiety 1
• Behavioral factors: Pain-related fear and avoidance, activity-rest imbalance, physical deconditioning 1
• Social factors: Family responses to pain behaviors, work status, economic problems, housing 1
• Sleep disturbances: Quality, quantity, feeling refreshed on waking, sleep hygiene habits 1
• Comorbidities: Obesity, substance dependence (tobacco, alcohol, drugs) 1

Common Pitfall: Overreliance on imaging without considering biopsychosocial factors leads to inadequate management 2, 3. Failure to identify psychosocial contributors results in poor treatment outcomes 2, 3.

Stepped-Care Treatment Algorithm

Step 1: Universal First-Line Interventions

All patients receive from initial presentation 1:

• Patient education: Provide educational materials (brochures, online resources) encouraging activity maintenance and sleep hygiene 1
• Self-management support: Psychoeducation by healthcare professional, online or face-to-face self-management programs 1
• Shared decision-making: Establish patient's functional goals, preferences, and priorities; develop agreed management plan 1, 2

Step 2: Specialist Interventions (When Step 1 Insufficient)

Physical Interventions

• Physical activity and exercise: For patients unable to initiate activity independently, refer to physiotherapy for individually tailored graded exercise or strength training 1
• Orthotics and assistive devices: For pain during daily activities impairing function, consider splints, braces, insoles, shoes, daily living aids, or ergonomic adaptations via occupational therapy 1

Psychological Interventions

• Cognitive-behavioral therapy (CBT): When psychosocial factors (fear of movement, catastrophizing) underlie sedentary lifestyle or disability 1, 3
• Sleep-focused CBT: For patients with significant sleep disturbances contributing to pain 1

Pharmacological Interventions

For Mild Pain (WHO Level I):

• Acetaminophen/paracetamol or NSAIDs as first-line 1, 4
• Selective COX-2 inhibitors for gastric intolerance, though efficacy data for cancer pain are limited 1

For Moderate Pain (WHO Level II):

• Weak opioids or low-dose morphine equivalents for pain persisting despite adequate non-opioid doses 1
• May combine with NSAIDs but not with WHO Level III analgesics 1

For Severe Pain (WHO Level III):

• Morphine (oral preferred; parenteral dose = 1/3 oral dose) 1
• Alternatives: hydromorphone, oxycodone (normal or modified release), methadone (complicated by variable half-life), transdermal fentanyl (for stable requirements ≥60 mg/day morphine equivalent) 1
• Around-the-clock dosing with breakthrough doses (≥10% total daily dose) 1
• If >4 breakthrough doses needed, increase baseline opioid 1

Critical Monitoring for Opioids:

• Screen for aberrant use risk before prescribing using SOAPP-R or ORT tools 1
• Monitor using "Four A's": Analgesia, Activities of daily living, Adverse effects, Aberrant drug-taking behaviors 2
• At least six-monthly monitoring for patients on stable strong opioid doses 2
• Discontinue if little or no response 2

Opioid Tapering Protocol (when discontinuing) 5:

• Initiate taper by small increments (no greater than 10-25% total daily dose) to avoid withdrawal 5
• Proceed at intervals of every 2-4 weeks 5
• Reassess frequently for pain and withdrawal symptoms (restlessness, lacrimation, rhinorrhea, myalgia, anxiety, insomnia) 5
• Ensure multimodal pain management and mental health support are in place before tapering 5

Step 3: Multidisciplinary Treatment

For complex or persistent pain unresponsive to Step 2 interventions 1, 3:

• Multiprofessional biopsychosocial assessment and management 3
• Combined physical therapy, psychological interventions, and pharmacological management 1
• Review management plan within 6 months; consider specialist referral if ineffective 3

High-Risk Patient Management

Early identification using validated tools (e.g., STarTBack for back pain) allows intensive intervention and better resource allocation 1, 2, 3:

• More frequent monitoring 2
• Earlier access to multidisciplinary care 2
• Addressing patient beliefs and expectations as fundamental intervention 2

Common Pitfall: Inadequate monitoring of analgesic effectiveness and side effects leads to medication misuse and adverse consequences 2.