What can I take for pain management?

Pain Management Recommendations

Start with acetaminophen (paracetamol) 1000 mg every 6 hours (maximum 4000 mg daily) as your first-line treatment for mild to moderate pain, and add ibuprofen 400-600 mg every 6 hours if acetaminophen alone provides insufficient relief. 1, 2

First-Line Approach: Non-Opioid Analgesics

Acetaminophen (Paracetamol)

• Acetaminophen should be your initial choice because it is effective, well-tolerated, and safer than other options when used appropriately 1
• Dose: 500-1000 mg every 4-6 hours, maximum 4000 mg per day 1, 2
• Acetaminophen is particularly advantageous when started early in pain management and works synergistically when combined with other analgesics 1
• Reduce doses in patients with liver disease, malnutrition, or severe alcohol use disorder 2, 3
• Monitor for hepatotoxicity, especially at maximum doses 2

NSAIDs (If Acetaminophen Insufficient)

• Ibuprofen 400 mg every 6 hours is the safest NSAID option and should be your first NSAID choice 1, 3, 4
• Higher ibuprofen doses (600-800 mg) offer modest additional analgesia but increase adverse effects 1
• NSAIDs reduce both pain intensity and opioid requirements when used in multimodal regimens 1
• Use NSAIDs with caution in patients with gastrointestinal bleeding history, cardiovascular disease, or chronic kidney disease 1, 3
• Prescribe gastroprotection when NSAIDs are used long-term 1

Multimodal Analgesia Strategy

Combining acetaminophen with NSAIDs provides superior pain relief compared to either agent alone through additive or synergistic mechanisms 1, 5

• The combination of acetaminophen 500 mg every 6 hours plus ibuprofen 600 mg every 6 hours provides adequate postoperative pain control with opioids reserved for breakthrough pain 1
• This multimodal approach reduces opioid-related side effects and improves outcomes 1

When to Escalate Treatment

For Moderate Pain (Inadequate Response to Non-Opioids)

• Add tramadol as a second-line option if acetaminophen and NSAIDs are insufficient 1, 2
• Tramadol is approximately one-tenth as potent as morphine 2
• Avoid tramadol with SSRIs, TCAs, or MAOIs due to serotonin syndrome risk 2
• Tramadol effectiveness may plateau after 30-40 days for chronic pain 2
• Alternative: Consider low-dose strong opioids (morphine, oxycodone) instead of weak opioids 1

For Severe Pain

• Oral morphine is the opioid of first choice for moderate to severe pain 1
• Start with immediate-release morphine every 4 hours plus rescue doses for breakthrough pain 1
• The oral to IV morphine potency ratio is 1:2 to 1:3 1
• Always prescribe laxatives prophylactically when initiating opioids to prevent constipation 1
• Use metoclopramide or antidopaminergic drugs for opioid-related nausea/vomiting 1

Special Considerations for Specific Pain Types

Neuropathic Pain

• Gabapentin or pregabalin should be added to the multimodal regimen for neuropathic pain 1, 6
• Pregabalin is effective for diabetic peripheral neuropathy and postherpetic neuralgia 6
• Tricyclic antidepressants (nortriptyline, desipramine) or SNRIs (duloxetine, venlafaxine) are first-line alternatives 1
• Topical lidocaine is effective for localized peripheral neuropathic pain 1

Renal Impairment

• Use all opioids with caution and at reduced doses in renal impairment 1
• Fentanyl and buprenorphine (transdermal or IV) are the safest opioids in chronic kidney disease stages 4-5 (eGFR <30 mL/min) 1

Critical Pitfalls to Avoid

• Never exceed 4000 mg acetaminophen daily due to hepatotoxicity risk 1, 2
• Do not use NSAIDs long-term without gastroprotection 1
• Avoid prescribing opioids on an "as needed" basis for chronic pain; use scheduled dosing with rescue doses for breakthrough pain 1
• Codeine and propoxyphene have poor efficacy and should be avoided 4
• COX-2 selective inhibitors (coxibs) may increase cardiovascular thrombotic risk 1

Practical Algorithm

1. Start with acetaminophen 1000 mg every 6 hours 1, 2
2. If inadequate relief after 24-48 hours, add ibuprofen 400-600 mg every 6 hours 1
3. If still inadequate, add tramadol or switch to low-dose morphine 1, 2
4. For severe pain from the outset, start with morphine plus acetaminophen/NSAID combination 1
5. Always use scheduled dosing, not "as needed" for chronic pain 1