What are the recommended treatments for managing pain?

Pain Management: Evidence-Based Treatment Recommendations

For most pain conditions, begin with nonopioid analgesics (acetaminophen or NSAIDs) combined with nonpharmacologic interventions, escalating systematically only when lower-intensity treatments fail to provide adequate relief. 1, 2

Initial Assessment Requirements

Before initiating treatment, assess these specific elements:

• Pain severity using validated scales: Use numerical rating scale (NRS 0-10), visual analog scale (VAS), or verbal rating scale (VRS) to quantify intensity 1
• Pain type classification: Differentiate between nociceptive (tissue damage), neuropathic (nerve injury), inflammatory, or mixed pain mechanisms 1
• Functional impact: Measure interference with physical activity, sleep quality, social participation, and activities of daily living using the PEG tool (Pain intensity, Enjoyment of life, General activity) 3
• Psychological factors: Screen for depression, anxiety, pain catastrophizing, fear of movement, and self-efficacy beliefs 1, 3
• Social determinants: Evaluate work status, family support, economic barriers, and substance use history 1

Treatment Algorithm by Pain Severity

Mild Pain (NRS 1-4)

First-line pharmacologic treatment:

• Acetaminophen 1000 mg every 6 hours (maximum 4000 mg/day) 1, 2, 4
• OR Ibuprofen 400 mg every 4-6 hours (maximum 2400 mg/day) 1, 2, 4
• Prescribe on a regular schedule, not "as needed," for chronic pain 1, 2

Contraindications to monitor:

• NSAIDs: Avoid in renal impairment, heart failure, history of gastrointestinal bleeding, or concurrent anticoagulation 1, 2, 4
• Consider topical NSAIDs as alternative with fewer systemic effects 2, 4

Moderate Pain (NRS 5-7)

Combination therapy approach:

• Continue acetaminophen (up to 4000 mg/day) PLUS ibuprofen (1200 mg/day) 4
• Add weak opioid (codeine 240 mg/day maximum, tramadol, or low-dose strong opioid like morphine 5-15 mg every 4-6 hours) 1, 5
• For musculoskeletal pain with spasm: Add cyclobenzaprine 5 mg three times daily 4

Severe Pain (NRS 8-10)

Strong opioid initiation:

• Oral morphine is the first-choice strong opioid for moderate-to-severe cancer pain 1
• Oxycodone 5-15 mg every 4-6 hours for immediate-release formulation, titrated based on response 5
• Critical: Reserve opioids only when nonopioid alternatives have failed or are contraindicated 5
• Prescribe laxatives prophylactically for all patients on opioids 1
• Prescribe antiemetics (metoclopramide) for opioid-related nausea 1

Neuropathic Pain-Specific Algorithm

Step 1 - First-line agents (choose one):

• Gabapentin: Start 300 mg at bedtime, titrate to 2400 mg/day in divided doses over 2-4 weeks 1, 3
• OR Pregabalin: Start 75 mg twice daily, titrate to 300-600 mg/day 1
• OR Duloxetine: 30 mg daily for 1 week, then 60 mg daily (proven for diabetic peripheral neuropathy) 1, 3
• OR Nortriptyline/desipramine: Start 10-25 mg at bedtime, titrate slowly to 75-100 mg/day (obtain ECG if age >40 years) 1

Step 2 - For localized peripheral neuropathic pain:

• Add topical lidocaine 5% patch to affected area, up to 3 patches for 12 hours daily 1
• OR Capsaicin cream applied to painful area 1, 3

Step 3 - If partial response after 6-8 weeks:

• Combine two first-line agents from different classes (e.g., gabapentin + duloxetine) 1

Step 4 - If inadequate response to combination therapy:

• Refer to pain specialist for interventional procedures (nerve blocks, spinal drug delivery) 1

Inflammatory Arthritis and Osteoarthritis Pain

Mandatory nonpharmacologic interventions (not optional):

• Patient education materials on staying active and sleep hygiene 1
• Supervised physical exercise or strength training if patient cannot self-initiate activity 1
• Orthotics (splints, braces, insoles) for pain during daily activities 1
• Weight management if BMI >30 kg/m² (obesity directly contributes to pain and disability) 1

Pharmacologic escalation:

• Start with NSAIDs or acetaminophen as per mild pain protocol 1
• Optimize disease-modifying therapy for inflammatory arthritis before escalating analgesics 1
• Consider intra-articular corticosteroid injections for localized joint pain 1

Cancer Pain Management

Breakthrough pain protocol:

• Prescribe immediate-release opioid (morphine, oxycodone) at 10-15% of total daily opioid dose for rescue 1
• For predictable pain (movement, swallowing): Give rescue dose 20 minutes before trigger 1
• For unpredictable breakthrough pain: Use rapid-onset formulations (buccal/sublingual/intranasal fentanyl) 1

Interventional procedures for specific cancer pain:

• Pancreatic/upper abdominal cancer: Celiac plexus block 1
• Pelvic cancer: Superior hypogastric plexus block 1
• Bone metastases: Radiofrequency ablation or vertebroplasty/kyphoplasty 1

Nonpharmacologic Interventions (Evidence-Based)

Strongly recommended first-line treatments:

• Cognitive Behavioral Therapy (CBT): Reduces pain intensity and disability in chronic pain with comorbid depression 3, 6, 7
• Physical therapy and graded exercise: Effective for low back pain, arthritis, and general musculoskeletal pain 1, 3
• Yoga: Specifically for chronic neck/back pain, headache, and rheumatoid arthritis 3
• Acupuncture: Effective for multiple pain conditions including musculoskeletal and neuropathic pain 1, 8, 9

Adjunctive psychological interventions:

• Acceptance and Commitment Therapy (ACT) combined with mindfulness reduces pain interference and psychiatric symptoms at 6 months 3, 7
• Hypnosis for neuropathic pain components 3
• Biofeedback and relaxation training for chronic low back pain 1

When to mandate psychological referral:

• Pain catastrophizing scores indicating rumination, magnification, or helplessness 1, 3
• Comorbid depression or anxiety requiring treatment 1, 3
• Fear of movement preventing physical rehabilitation 1

Interdisciplinary Team Approach

Required team members for complex chronic pain:

• Primary care provider (coordinates care) 3
• Psychologist or psychiatrist (addresses behavioral health) 3
• Physical and occupational therapists (functional restoration) 3
• Pain specialist (interventional procedures, complex medication management) 3
• Social worker (addresses social determinants and barriers) 3

Schedule longer appointments (30-45 minutes) to establish treatment goals and assess multiple pain dimensions 3

Critical Monitoring Parameters

At every visit, reassess:

• Pain intensity using same scale (NRS/VAS/VRS) 1, 3
• Functional improvements in daily activities 1, 3
• Medication adherence and side effects 1
• For opioid therapy: Signs of aberrant behavior, oversedation, or respiratory depression 5

Treatment success criteria:

• Pain reduced to ≤3/10 on NRS with tolerable side effects = continue current regimen 1
• Pain remains ≥4/10 after adequate trial = add second agent or switch to alternative 1
• <30% pain reduction at target dose = treatment failure, escalate to next step 1

Common Pitfalls to Avoid

• Starting opioids for mild pain: Exposes patients to addiction risk when nonopioids would suffice; always exhaust nonopioid options first 2, 5
• Subtherapeutic nonopioid dosing: Ensure maximum recommended doses (acetaminophen 4000 mg/day, ibuprofen 2400 mg/day) before declaring failure 2
• Ignoring psychological factors: Pain catastrophizing and depression predict poor treatment response; address early 1, 3
• Monotherapy for neuropathic pain: Combination therapy (e.g., gabapentin + duloxetine) more effective than single agents 1, 3
• Inadequate trial duration: TCAs require 6-8 weeks including 2 weeks at maximum tolerated dose before assessing efficacy 1
• Forgetting opioid side effect prophylaxis: Always prescribe stimulant laxatives with opioid initiation 1