What are the options for non-narcotic (non-opioid) pain management?

Non-Opioid Pain Management Options

Start with acetaminophen (paracetamol) 1000 mg every 4-6 hours (maximum 4000 mg/day) as first-line therapy for mild to moderate pain, or use NSAIDs like ibuprofen 400-600 mg every 6-8 hours for inflammatory or bone pain. 1, 2

First-Line Non-Opioid Analgesics (WHO Step I)

Acetaminophen/Paracetamol

• Acetaminophen is the recommended first-line treatment for mild to moderate pain (pain intensity 1-4 on numerical rating scale) 2, 1
• Dose: 500-1000 mg every 4-6 hours, with a maximum daily dose of 4000 mg 2, 1
• Onset of action occurs within 15-30 minutes 2
• Critical caution: Hepatotoxicity occurs if daily recommended dose is exceeded—use cautiously in patients with liver failure and avoid in severe liver disease 2

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)

• NSAIDs are specifically recommended for inflammatory pain, particularly bone pain 2
• Common options include:
  • Ibuprofen: 200-600 mg every 6-8 hours (maximum 2400 mg/day) 2, 1
  • Naproxen: 250-500 mg twice daily (maximum 1000 mg/day) 2, 1
  • Diclofenac: 25-50 mg every 6-8 hours 2
  • Ketoprofen: 25-75 mg every 6 hours 2

Critical NSAID Safety Considerations

• Gastric protection with proton pump inhibitors is recommended for prolonged NSAID use 2
• NSAIDs should not be used with methotrexate 2
• Exercise caution with nephrotoxic chemotherapy (particularly cisplatin) or myelotoxic agents 2
• COX-2 selective inhibitors increase risk of thrombotic cardiovascular adverse reactions 2, 3
• Monitor for gastrointestinal bleeding, platelet dysfunction, and renal failure with long-term use 2, 3
• In elderly patients (over 65 years), use lower starting doses due to increased risk of GI bleeding 1, 4
• In renal impairment, use NSAIDs with extreme caution or avoid completely 1

Second-Line and Adjuvant Options

Tramadol (Weak Opioid Alternative)

• Tramadol is approximately one-tenth as potent as morphine and suitable for moderate pain (WHO Step II) 5
• Dose: 50-100 mg every 4-6 hours, or modified-release 100-200 mg every 12 hours (maximum 400 mg/day) 2
• Critical warning: Avoid or use extreme caution with SSRIs, TCAs, MAOIs, or other serotonergic medications due to risk of serotonin syndrome 5
• Tramadol effectiveness may plateau after 30-40 days for chronic pain 5
• Common adverse effects include nausea, vomiting, vertigo, anorexia, and asthenia 2

Gabapentinoids (Adjuvant for Neuropathic Pain)

• Gabapentin and pregabalin should be considered as components in multimodal analgesia, particularly for neuropathic pain 1
• Pregabalin has demonstrated efficacy in diabetic peripheral neuropathy, postherpetic neuralgia, and spinal cord injury-related neuropathic pain 6
• Use when standard non-opioid medications provide insufficient relief for neuropathic pain 1

Pain Management Algorithm Based on Intensity

Mild Pain (NRS 1-4)

• Start with acetaminophen 1000 mg every 4-6 hours OR an NSAID 2, 1
• Choose acetaminophen if patient has GI risk factors, renal impairment, or cardiovascular disease 1, 7
• Choose NSAIDs for inflammatory or bone pain 2

Moderate Pain (NRS 5-7)

• Optimize acetaminophen and/or NSAID dosing to maximum safe doses 1
• Consider combination therapy: acetaminophen PLUS an NSAID for additive/synergistic effects 1
• Add tramadol 50-100 mg if non-opioids insufficient 2
• Consider gabapentinoids if neuropathic component present 1

Severe Pain (NRS 8-10)

• Maximize non-opioid options first before escalating to strong opioids 1
• Add appropriate adjuvant medications based on pain type (gabapentinoids for neuropathic pain) 1
• Strong opioids may be considered as first-line in patients with very severe pain 2

Combination Therapy Principles

• Non-opioid analgesics (WHO level 1) can be combined with opioid analgesics (WHO levels 2 and 3) 2
• Combining acetaminophen with NSAIDs may provide additive or synergistic effects 1
• Do not prescribe two products of the same pharmacological class with the same kinetics together (e.g., two sustained-release opioids) 2
• Coanalgesics can be used concurrently at each level in the WHO analgesic ladder 2

Administration Principles

• Analgesics for chronic pain should be prescribed on a regular "around-the-clock" schedule, not "as required" 2
• The oral route should be advocated as the first choice when tolerated 2
• Drug administration should conform to timing based on half-life and duration of action 2
• Provide rescue doses (10-15% of total daily dose) for breakthrough pain 2

Common Pitfalls to Avoid

• Never exceed maximum daily doses: acetaminophen 4000 mg/day, ibuprofen 2400 mg/day, naproxen 1000 mg/day 1, 5
• Do not use opioid-containing combinations as first-line therapy when non-opioid alternatives would be effective 1
• Do not ignore cardiovascular risks of NSAIDs, especially COX-2 inhibitors, in patients with cardiovascular disease 1, 3
• Avoid NSAIDs in patients with active ulcerative disease or history of GI bleeding 2, 4
• Do not combine multiple NSAIDs or use with corticosteroids without gastric protection 2, 4
• In patients with liver disease, reduce paracetamol doses or avoid completely in severe disease 5, 2