What are the treatment options for acute pain in a patient?

Acute Pain Management

For acute pain, start with topical NSAIDs (with or without menthol gel) for musculoskeletal injuries, or oral NSAIDs (ibuprofen 400-600 mg every 4-6 hours or naproxen) for most other acute pain conditions, as these provide superior pain relief with better safety profiles than opioids. 1, 2

First-Line Treatment Algorithm by Pain Severity

Mild Pain (Pain Score 1-3/10)

• Topical NSAIDs are the preferred first-line option for musculoskeletal injuries (sprains, strains, whiplash) due to superior benefit-harm ratio 1
• Acetaminophen 650-1000 mg every 6 hours (maximum 4000 mg/day) is effective for mild pain and well-tolerated 1, 3
• Acetaminophen alone has NOT been shown effective for migraine but works for other mild pain conditions 4

Moderate Pain (Pain Score 4-6/10)

• Oral NSAIDs are the cornerstone: ibuprofen 400-600 mg every 4-6 hours or naproxen 500 mg twice daily 2, 3
• Combination therapy: Add acetaminophen to NSAIDs for additive analgesic effects 1
• For low back pain: NSAIDs or skeletal muscle relaxants plus heat therapy 1, 4
• For dental pain: NSAIDs are MORE effective than opioids and should be first-line 1, 4
• For kidney stone pain: NSAIDs are at least as effective as opioids and decrease ureteral spasm 1

Severe Pain (Pain Score 7-10/10)

Oral route:

• Maximize non-opioid combinations first before considering opioids 1, 2
• If opioids are necessary: prescribe ≤3 days supply (rarely >7 days needed) at lowest effective dose 4
• Never use long-acting/extended-release opioids for acute pain 2, 4
• Prescribe opioids as needed (PRN) rather than scheduled dosing 4

IV route for severe pain:

• Hydromorphone 0.015 mg/kg IV is preferred over morphine due to quicker onset, lower risk of toxic metabolite accumulation in renal failure, and reduced dose-stacking risk 2
• Fentanyl 1 mcg/kg IV initially, then ~30 mcg every 5 minutes, is preferred over morphine for moderate-to-severe pain 2
• Ketorolac (Toradol) IV/IM for severe pain: relatively rapid onset, 6-hour duration, reserved for severe migraines or when opioids need to be avoided; maximum 5 days total use 4, 5

Pain Type-Specific Recommendations

Migraine Headache

• Mild-moderate migraine: NSAIDs (oral), combination analgesics with caffeine (aspirin + acetaminophen + caffeine), or isometheptene combinations 4
• Moderate-severe migraine: Triptans (sumatriptan, rizatriptan, zolmitriptan), dihydroergotamine, or calcitonin gene-related peptide antagonists 4, 1
• With nausea/vomiting: Use non-oral routes; add metoclopramide or prochlorperazine 4
• Remote electrical neuromodulation has moderate evidence for acute migraine 4

Neuropathic Pain

• Gabapentin or carbamazepine in addition to analgesics provide superior relief 1
• Standard analgesics alone are insufficient for neuropathic conditions 4

Low Back Pain (Acute/Subacute)

• Heat therapy is highly effective as non-pharmacologic approach 4, 1
• NSAIDs or skeletal muscle relaxants if pharmacologic treatment desired 4, 1
• Spinal manipulation shows small benefit for function 4
• Massage moderately improves short-term pain and function 4
• Acetaminophen showed NO difference vs placebo in trials 4

Postoperative Pain

• Multimodal approach: IV acetaminophen 1000 mg every 6 hours + NSAIDs + gabapentinoids + lidocaine patches, with opioids reserved for breakthrough pain at lowest dose for shortest duration 2
• Massage and transcutaneous electrical nerve stimulation are effective 4, 1

Critical Pitfalls to Avoid

Medication-Specific Dangers

• AVOID codeine-containing products due to genetic variability in CYP2D6 metabolism causing either inadequate analgesia or toxicity 2
• AVOID morphine in renal failure due to toxic metabolite accumulation and respiratory depression risk 2
• NEVER exceed acetaminophen 4000 mg/day to prevent hepatotoxicity; use caution in liver disease, malnutrition, or severe alcohol use disorder 1, 3, 6
• AVOID NSAIDs in patients with history of GI bleeding, cardiovascular disease, or chronic renal disease 3
• NEVER use ER/LA opioids (methadone, fentanyl patches, extended-release formulations) for acute pain 4

Prescribing Errors

• Do NOT prescribe opioids "just in case" pain continues longer than expected 4
• Do NOT prescribe >3 days of opioids for most acute pain (rarely >7 days needed) 4
• Do NOT use scheduled opioid dosing for acute pain; prescribe PRN only 4
• Limit acetaminophen in combination products when large opioid doses needed; prescribe separately if necessary 2

Clinical Decision Errors

• Do NOT use opioids for pain adequately managed with non-opioid alternatives 1
• Do NOT fail to consider topical NSAIDs first for musculoskeletal injuries 1
• Do NOT use acetaminophen alone for migraine (ineffective) 4

Evidence Quality Considerations

The 2022 CDC guideline 4 represents the most current high-quality evidence, superseding the 2016 version 4. The CDC systematic review found opioids were less effective or equally effective compared to NSAIDs for surgical dental pain, kidney stones, and low back pain, while causing significantly more adverse events (nausea, dizziness, somnolence) 4. The Praxis Medical Insights summaries 1, 2 synthesize multiple high-quality guidelines and should guide clinical decision-making, particularly the recommendation for topical NSAIDs as first-line therapy for musculoskeletal injuries.