What are the treatment options for managing pain?

Treatment Options for Managing Pain

Begin with nonopioid analgesics (acetaminophen up to 4000 mg/day or NSAIDs like ibuprofen 400 mg every 4-6 hours) for mild pain (≤4/10 on numerical rating scale), escalate to weak opioids or low-dose strong opioids for moderate pain (5-6/10), and use strong opioids like morphine for severe pain (≥7/10), following the WHO analgesic ladder approach. 1, 2, 3

Pain Assessment Framework

Before initiating treatment, quantify pain intensity using a 0-10 numerical rating scale, categoric scale, or pictorial scale (Wong-Baker FACES) 4, 1, 3. Self-report is the gold standard for pain assessment 4, 5. Document pain characteristics (aching, burning, stabbing), location, duration, and functional impact 4, 6.

• Mild pain: Score ≤4/10 on numerical rating scale 1
• Moderate pain: Score 5-6/10 2, 3
• Severe pain: Score ≥7/10 2, 3

For patients with cognitive impairment, observe pain-related behaviors including facial expressions, body movements, and vocalizations 3.

Algorithmic Treatment Approach by Pain Severity

Step 1: Mild Pain (≤4/10)

First-line: Acetaminophen 1000 mg every 6 hours (maximum 4000 mg/day) OR ibuprofen 400 mg every 4-6 hours (maximum 2400 mg/day) 1, 2, 3

• Acetaminophen provides effective analgesia without opioid risks including dependence and respiratory depression 1
• Ibuprofen is the first-choice NSAID with favorable safety profile 1
• NSAIDs are superior when inflammatory components are present 1
• Key contraindications for NSAIDs: Renal impairment, heart failure, history of gastrointestinal bleeding 1
• Consider gastroprotection when using NSAIDs for prolonged periods 2

Common pitfall: Starting with opioids for mild pain exposes patients to unnecessary risks when nonopioids suffice 1. Using subtherapeutic doses may lead to perceived treatment failure and inappropriate escalation 1.

Step 2: Moderate Pain (5-6/10)

Add weak opioids OR low-dose strong opioids to nonopioids: 2, 3

• Codeine, dihydrocodeine, or tramadol (weak opioids) 2, 3
• Low-dose morphine or oxycodone (strong opioids at lower doses) 2, 3
• Continue first-line nonopioids for multimodal analgesia 2
• Combination products containing acetaminophen plus opioid are commonly used 2

Step 3: Severe Pain (≥7/10)

Strong opioids with continued nonopioids: 2, 3

• Morphine (preferred agent): Oral route preferred when possible 2, 3
• Alternatives: Hydromorphone, oxycodone, or fentanyl 3
• Transdermal fentanyl for stable pain requiring ≥60 mg/day oral morphine equivalent 2
• Continue first-line agents for multimodal pain control 2

Opioid Administration Principles

Schedule analgesics around-the-clock rather than "as needed" for persistent pain to maintain consistent serum levels 4, 2, 3. This provides superior analgesia compared to PRN dosing 1.

• Provide breakthrough doses (10-15% of total daily dose) for transient pain exacerbations 2, 3
• If more than 4 breakthrough doses needed daily, increase baseline opioid regimen 2, 3
• Titrate doses rapidly to achieve effective pain control 3

Manage opioid side effects proactively: 3

• Constipation: Prophylactic laxatives
• Nausea/vomiting: Antiemetics
• CNS toxicity: Dose reduction or opioid rotation

Adjuvant Analgesics for Specific Pain Types

Neuropathic Pain

Pregabalin or gabapentin for diabetic peripheral neuropathy, postherpetic neuralgia, or spinal cord injury-related neuropathic pain 3, 7:

• Pregabalin 75-300 mg twice daily (maximum 600 mg/day) 7
• Demonstrated efficacy in reducing pain scores by ≥50% in clinical trials 7
• Alternative: Tricyclic antidepressants or SNRIs 3

Bone Pain

Bone-modifying agents: Bisphosphonates or denosumab 3

Inflammatory Pain

Corticosteroids for inflammatory components 3

Non-Pharmacological Interventions

Integrate as part of multimodal approach 4:

• Physical therapy and exercise 4
• Psychosocial and behavioral interventions 4
• Patient education on pain neurophysiology 4
• Radiation therapy for localized bone pain 3

Interventional Procedures

Consider when pain inadequately controlled despite optimal pharmacologic therapy or when opioid side effects are intolerable 3:

• Regional infusion of analgesics 3
• Nerve blocks 3
• Vertebral augmentation 3

Reassessment and Monitoring

Conduct pain assessments at every clinical visit using standardized tools 3. Document pain ratings in medical records 3.

New pain in patients on chronic pain treatment requires immediate reevaluation 4:

• Determine if related to worsening current pathology or new pathology (opportunistic infection, medication adverse event, new comorbidity) 4
• Assess for "end-of-dose failure" or opioid tolerance requiring dose increase 4
• Evaluate if current treatment is ineffective and requires different approach 4
• Common misconception: Existing chronic pain treatment will ameliorate new pain symptoms 4

Interdisciplinary Team Approach

For complex chronic pain, especially with co-occurring substance use or psychiatric disorders, utilize interdisciplinary teams including pain specialists, physical therapists, occupational therapists, and behavioral health providers 4.

Treatment goal: Restore function, decrease pain severity, and improve quality of life 4.