What is the recommended approach for managing pain?

Pain Management: A Structured Approach

Begin with a comprehensive biopsychosocial assessment using a 0-10 numerical rating scale for pain intensity, then implement a stepped-care approach prioritizing non-pharmacological interventions (patient education, physical activity, and cognitive behavioral therapy) before advancing to pharmacological management. 1, 2

Initial Assessment Framework

Use the 0-10 numerical rating scale as your primary quantification tool, specifically asking about current pain, worst pain in the past 24 hours, and usual pain. 1 This provides standardized measurement but is only the starting point.

Beyond Pain Scores: Critical Assessment Components

Evaluate these specific domains systematically:

• Pain characteristics: severity, type (nociceptive vs. neuropathic), location, radiation pattern, quality (sharp, burning, aching), and spread 1
• Temporal factors: onset timing, duration, course pattern, and specific exacerbating/relieving factors 1
• Functional impact: identify specific activities the patient cannot currently perform rather than focusing solely on pain intensity 1, 2
• Biological factors: underlying pathology, physical disability level, sleep disturbance patterns, and obesity 1
• Psychological factors: catastrophizing cognitions, pain-related beliefs and emotions, and patient's understanding of their condition 1
• Social factors: cultural considerations, linguistic needs, and social support structures 1

Stepped-Care Management Algorithm

Step 1: Education and Self-Management (First-Line for All Patients)

Provide educational materials and psychoeducation immediately, focusing on pain mechanisms and active coping strategies rather than passive approaches. 1, 2 Self-management interventions should be delivered through online or face-to-face programs. 2

Active coping strategies are associated with lower disability rates compared to passive approaches. 3

Step 2: Non-Pharmacological Specialist Interventions

If Step 1 proves ineffective, advance to these evidence-based interventions:

Physical interventions (strongest evidence base):

• Physical activity and exercise programs show the most uniformly positive effects across systematic reviews for inflammatory arthritis and osteoarthritis 3, 2
• Specific modalities: general exercise for spondyloarthritis and osteoarthritis, aerobic exercise for knee osteoarthritis, strength/resistance training for hip/knee osteoarthritis 3
• Orthotics: orthopedic shoes for rheumatoid arthritis and knee osteoarthritis, splints for hand osteoarthritis, knee sleeves/elastic bandages for knee osteoarthritis 3

Psychological interventions (second strongest evidence):

• Cognitive behavioral therapy demonstrates uniform positive effects in rheumatoid arthritis and osteoarthritis, and is recommended as first-line for chronic non-malignant pain 3, 2
• Psychosocial and coping interventions for osteoarthritis 3
• Biofeedback for rheumatoid arthritis, relaxation interventions for osteoarthritis 3

Additional modalities:

• Weight management shows uniform positive effects in rheumatoid arthritis, spondyloarthritis, and hip/knee osteoarthritis 3
• Sleep interventions (though limited meta-analysis data exists for inflammatory arthritis/osteoarthritis specifically) 3

Step 3: Pharmacological Management

Use medications judiciously only after non-pharmacological approaches:

First-line pharmacological options:

• Acetaminophen: safest first-line for musculoskeletal pain, up to 3 grams daily 2
• Gabapentin: first-line for neuropathic pain, titrate to 2400 mg daily in divided doses (adjust for renal function) 2
• NSAIDs: use with caution; avoid in cirrhosis, kidney disease, or cardiovascular disease 3, 2

Opioid therapy (when other approaches fail):

• For opioid-naive patients: initiate oxycodone 5-15 mg every 4-6 hours as needed 4
• For chronic severe pain: administer on regularly scheduled basis every 4-6 hours at lowest effective dosage 4
• Monitor closely for respiratory depression, especially within first 24-72 hours 4

Monitoring Framework: The "Four A's"

Assess treatment effectiveness using this structured approach:

• Analgesia: pain reduction toward functional goals 3, 2
• Activities of daily living: improvement in specific functional tasks 3, 2
• Adverse effects: systematic evaluation of treatment-related complications 3, 2
• Aberrant drug taking: monitoring for misuse patterns (when opioids prescribed) 3

Monitoring frequency:

• Stable patients on strong opioids: regular scheduled assessments 1
• High-risk patients: more intensive monitoring 1
• Patients with no improvement: reassess and adjust management plan 1

Special Population Considerations

For nonverbal patients: use behavioral observation combining direct observation, family/caregiver input, and evaluation of response to interventions 1

For procedure-related pain: pretreat with analgesic intervention using multimodal approach 1

For pediatric patients: use validated age-appropriate pain scales (NRS, r-FLACC, PIPP-R, FPS-R), combine topical anesthetics with adjuvants for procedures, and employ cognitive behavioral strategies with parental involvement 3

Critical Pitfalls to Avoid

Never rely solely on pain intensity scores—pain is multidimensional and requires assessment of functional impact and patient-centered goals. 1, 2 A patient reporting 7/10 pain who can perform all desired activities may need less intervention than someone reporting 4/10 pain who cannot work.

Expect analgesic failure and individualize response—close monitoring with willingness to stop ineffective treatments is essential rather than continuing ineffective regimens. 1

Identify high-risk patients early—patients at high risk for chronic disability require more intensive management from the outset to reduce long-term disability. 3, 2

Never ignore underlying treatable causes—providing only symptomatic treatment (especially opioids) for conditions like impending spinal cord compression without addressing underlying pathology is inappropriate. 1

Avoid undertreating based on unfounded fears—while opioid caution is warranted, undertreating severe pain (particularly cancer pain) causes unnecessary suffering. 3