What is the recommended pain management regimen for chronic pain?

Chronic Pain Management Regimen

Start with acetaminophen (up to 4g/day for those with normal liver function, lower doses for liver disease) and/or NSAIDs as first-line therapy for musculoskeletal pain, reserving opioids only as second- or third-line treatment after failure of safer alternatives and only for time-limited trials with strict monitoring protocols. 1, 2

First-Line Pharmacological Approach

For Musculoskeletal Pain

• Acetaminophen is the safest initial option with fewer side effects than NSAIDs, typically dosed at 4g/day in patients with normal liver function 1
• Use lower acetaminophen doses in patients with liver disease, malnutrition, or severe alcohol use disorder 1, 3
• NSAIDs are equally first-line and may be more effective than acetaminophen for osteoarthritis pain, but carry gastrointestinal, cardiovascular, and renal risks 1, 3
• COX-2 selective NSAIDs reduce gastrointestinal bleeding risk but increase cardiovascular risk compared to traditional NSAIDs 1

For Neuropathic Pain Components

• Gabapentin is first-line for neuropathic pain, typically titrated to 2400 mg/day in divided doses 2
• Capsaicin 8% dermal patch or cream provides topical relief, with a single 30-minute application effective for up to 12 weeks 2
• Consider combining morphine and gabapentin for additive effects at lower individual doses when opioids become necessary 1

Second-Line Options

When First-Line Agents Fail

• SNRIs (duloxetine or venlafaxine) for inadequate response to first-line treatments, particularly for neuropathic components 2
• Pregabalin as an alternative gabapentinoid, especially useful in patients with liver impairment where duloxetine is contraindicated 4
• Tramadol 37.5-400 mg/day in divided doses for up to 3 months may improve pain, stiffness, and function in osteoarthritis 1, 5
• Tramadol carries lower addiction risk than traditional opioids but monitor for opioid-like side effects 5

Adjuvant Medications

• Tricyclic antidepressants may be considered but have more side effects than SNRIs 2
• Alpha lipoic acid for neuropathic pain components 2

Opioid Therapy: Last Resort Only

When to Consider Opioids

• Only after failure of first-line therapies in patients reporting moderate-to-severe pain with functional impairment 1
• Potential benefits must outweigh risks of adverse events, misuse, diversion, and addiction 1
• Start with the smallest effective dose, combining short- and long-acting formulations 1
• For immediate-release oxycodone: initiate at 5-15 mg every 4-6 hours as needed, with around-the-clock dosing for chronic pain rather than as-needed 6

Mandatory Safety Protocols Before Prescribing Opioids

• Assess all patients for risk of misuse, diversion, and addiction prior to prescribing 1
• Implement an opioid patient-provider agreement (PPA) covering informed consent and plan of care 1
• Routine monitoring is mandatory: opioid treatment agreements, urine drug testing, pill counts, and prescription drug monitoring programs 1
• UDT results should never be used in isolation to discharge patients but combined with clinical data 1

Patient and Family Education Requirements

• Teach patients and caregivers about opioid overdose recognition and naloxone use 1
• Provide naloxone rescue kit to all patients on opioids 1
• Educate on safe storage away from individuals at risk of misuse/overdose 1
• Ensure poison control number is readily visible 1
• Review pharmacological interactions, particularly with benzodiazepines, alcohol, and other CNS depressants 1

Special Considerations for Specific Populations

Elderly Patients

• Exercise extreme caution with NSAIDs if creatinine clearance is low, chronic kidney disease present, or congestive heart failure exists 5
• Monitor renal function, blood pressure, and signs of GI bleeding if NSAIDs prescribed 5
• Avoid benzodiazepines entirely due to fall risk, cognitive impairment, and habituation 5
• Multimodal approach strongly recommended: acetaminophen + gabapentinoids + NSAIDs (if safe) + tramadol, reserving opioids only for breakthrough pain 5

Patients on Methadone Maintenance

• ECG screening for QTc prolongation is mandatory before starting methadone, with interval follow-up with dose changes 1
• Split methadone into 6-8 hour doses for continuous pain control, adding 5-10% of current dose as afternoon/evening doses 1
• If additional methadone cannot be prescribed, add gabapentin for neuropathic pain or NSAIDs for musculoskeletal pain 1

Patients on Buprenorphine Maintenance

• Increase buprenorphine dosage in divided doses (4-16 mg every 8 hours) as initial step 1
• Consider switching from buprenorphine/naloxone to transdermal buprenorphine alone 1
• If maximal buprenorphine reached, add long-acting potent opioid (fentanyl, morphine, or hydromorphone) 1
• Higher doses of additional opioids may be needed due to buprenorphine's high μ-receptor binding affinity 1

Non-Pharmacological Interventions (Essential Adjuncts)

• Cognitive Behavioral Therapy (CBT) strongly recommended for promoting adaptive behaviors and addressing maladaptive pain responses 2
• Physical and occupational therapy to improve muscle strength, function, and reduce pain interference 2
• Yoga specifically for chronic neck/back pain, headache, rheumatoid arthritis, and musculoskeletal pain 2
• Medical exercise programs to improve muscular strength and sensorimotor function 2
• Hypnosis particularly for neuropathic pain components 2
• Acupuncture may be trialed though evidence is limited 2

Medications to Avoid

• Do NOT prescribe opioids as first-line therapy due to risks of pronociception, cognitive impairment, respiratory depression, endocrine/immunological changes, and addiction 2
• Lamotrigine is not recommended for neuropathic pain due to rash risk and limited efficacy 2
• Benzodiazepines should be avoided as evidence for chronic pain efficacy is limited and risks are substantial 2, 5

Monitoring and Reassessment

• Screen all patients for depression using two questions: "During the past 2 weeks have you been bothered by feeling down, depressed, or hopeless?" and "During the past 2 weeks have you been bothered by little interest or pleasure in doing things?" 1
• Review baseline mental health status for modifiable factors: self-esteem, coping skills, recent loss/grief, substance use, violence/safety, mood disorders, suicidal ideation 1
• Regular assessment of pain intensity, functional improvement, and medication side effects 2
• For breakthrough pain in low-risk patients, use small amounts of short-acting opioids with agreed-upon pill counts and duration 1
• For mild-to-moderate breakthrough pain, use adjuvant therapy: nonpharmacologic treatments, steroids, nonopioid analgesics, topical agents 1