What are the recommended approaches for pain management?

Pain Management: Evidence-Based Approach

Start with acetaminophen (up to 4000 mg/day) or NSAIDs as first-line therapy for mild to moderate pain, escalating through the WHO pain ladder to opioids only for severe pain, while integrating non-pharmacological interventions throughout. 1, 2

Initial Assessment

Evaluate pain at every clinical encounter using validated scales (VAS, NRS, or verbal rating scales) to quantify severity and guide treatment selection. 1, 2 Document pain characteristics, previous treatments, underlying causes, and any red flags suggesting complications requiring immediate investigation. 1

Stepwise Pharmacological Approach (WHO Pain Ladder)

Mild Pain (WHO Level I)

• Acetaminophen/paracetamol 500-1000 mg every 4-6 hours (maximum 4000 mg/day) is the safest first-line option 1, 2
• NSAIDs (ibuprofen 200-600 mg, maximum 2400 mg/day; naproxen 250-500 mg, maximum 1000 mg/day) are equally effective but carry GI, renal, and cardiovascular risks 1, 3, 4
• Selective COX-2 inhibitors may reduce GI toxicity but have unsettled safety concerns and lack solid efficacy data for some pain types 1

Moderate Pain (WHO Level II)

• Add weak opioids (tramadol 50-100 mg every 4-6 hours, maximum 400 mg/day) or low-dose morphine equivalents when Level I agents fail 1
• Continue Level I agents alongside weak opioids for additive effect 1
• Never combine weak opioids with strong opioids 1

Severe Pain (WHO Level III)

• Morphine is the gold standard, with oral administration preferred 1, 2
• Starting dose: 20-40 mg oral morphine every 4-6 hours for opioid-naive patients 1, 5
• Parenteral morphine is 3 times more potent than oral (use 1/3 the oral dose) 1
• Alternatives: oxycodone (2x potency of oral morphine, start 20 mg), hydromorphone, or transdermal fentanyl (reserved for stable requirements ≥60 mg/day morphine equivalent) 1, 5

Opioid Management Principles

• Prescribe around-the-clock dosing with breakthrough doses (10% of total daily dose) for transient pain exacerbations 1
• If more than 4 breakthrough doses needed daily, increase baseline long-acting formulation 1
• Titrate rapidly to effect while monitoring for respiratory depression, especially in first 24-72 hours 5, 6
• Always prescribe prophylactic laxatives to prevent constipation 1
• Manage nausea with antiemetics, drowsiness with psychostimulants, and consider opioid rotation if side effects are refractory 1

Neuropathic Pain Specific Approach

Gabapentin is first-line for neuropathic pain, titrating to 2400 mg/day in divided doses 1, 2 If inadequate response, consider serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants as second-line options. 1 Topical capsaicin 8% patch provides 12+ weeks of relief for localized neuropathic pain with single 30-minute application. 1

Non-Pharmacological Interventions (Integrate Early)

• Cognitive behavioral therapy (CBT) is strongly recommended for chronic pain with high-quality evidence 1, 2
• Yoga for neck/back pain, headache, rheumatoid arthritis, and musculoskeletal pain 1, 2
• Physical and occupational therapy for functional restoration 1, 2
• Hypnosis specifically for neuropathic pain 1
• Radiotherapy has critical efficacy for bone metastases, neural compression, and radicular pain 1

Multimodal Analgesia Strategy

Combine medications from different classes to achieve additive/synergistic effects while reducing individual drug doses and side effects. 1, 2 Effective combinations include:

• Acetaminophen + NSAID for moderate pain 1, 3
• Acetaminophen or NSAID + gabapentinoid for neuropathic components 1, 2
• Non-opioid baseline + opioid for severe pain 1

Special Populations and Monitoring

• Reduce opioid use in OSAS patients due to cardiopulmonary complication risk 1
• Younger age and female gender are risk factors for inadequate postoperative pain control 1
• Reassess pain within 24 hours and at regular intervals (every 4-6 hours initially), adjusting therapy based on response and adverse effects 1, 2
• Any new pain in controlled patients requires investigation for complications or disease progression 1

Critical Pitfalls to Avoid

• Never use NSAIDs in patients with cirrhosis (GI bleeding, ascites decompensation risk), advanced kidney disease, or active cardiovascular disease 7, 4
• Do not prescribe transdermal fentanyl for opioid-naive patients or unstable pain 1
• Avoid combining weak and strong opioids simultaneously 1
• Never delay pain management while awaiting diagnostic workup 1
• Do not use methadone without expertise due to unpredictable pharmacokinetics 1

When to Escalate Care

Consult palliative care or pain specialists when monotherapy fails, for complex pain syndromes, or in advanced illness to address goals of care. 1, 2 Maintain multidisciplinary team communication including patient, family, and all providers throughout treatment. 1