What is the first-line treatment for a patient not on any medication yet who requires pain management or is at risk of opioid dependence?

First-Line Pain Management for Opioid-Naïve Patients

For patients not currently on any medications who require pain management, treatment should be stratified by pain intensity: mild pain (1-3/10) should be treated with NSAIDs or acetaminophen, moderate pain (4-6/10) requires slower titration of short-acting opioids, and severe pain (7-10/10) necessitates rapid titration of short-acting opioids. 1

Pain Intensity-Based Treatment Algorithm

Mild Pain (1-3/10)

• Start with NSAIDs or acetaminophen as first-line therapy 1
• Consider slower titration of short-acting opioids only if non-opioid analgesics fail to provide adequate relief 1

Moderate Pain (4-6/10)

• Initiate slower titration of short-acting opioids 1
• Begin with 5-15 mg oral morphine sulfate or 1-5 mg IV morphine sulfate (or equivalent) 1
• Reassess efficacy and side effects every 60 minutes for oral administration, every 15 minutes for IV administration 1
• If pain score unchanged or increased: administer 50-100% of previous rescue dose 1
• If pain score decreases to 4-6: repeat same dose and reassess 1
• If pain score decreases to 0-3: continue current effective dose as needed 1

Severe Pain (7-10/10)

• Initiate rapid titration of short-acting opioids immediately 1
• Use same dosing strategy as moderate pain but with more aggressive titration 1
• Short-acting formulations provide rapid onset of analgesic effect 1
• Route selection (oral vs. IV) should be based on patient's ongoing analgesic needs 1

Essential Concurrent Interventions

Mandatory Bowel Regimen

• Prophylactic bowel regimen must be started simultaneously with opioid initiation 1
• Use stimulating laxative (e.g., sennosides) with or without stool softener 1
• Evidence shows that adding docusate to sennosides is less effective than sennosides alone 1
• Constipation is nearly universal with opioid therapy and tolerance rarely develops 2

Antiemetic Prophylaxis

• Nausea management should be initiated concurrently with opioid therapy 1
• Nausea is common and may not resolve with continued use 2

Adjuvant Analgesics

• Consider coanalgesics for specific pain syndromes in all patient groups 1
• Coanalgesics enhance effects of opioids or NSAIDs 1

Risk Assessment and Monitoring

Pre-Treatment Screening

• Assess for risk factors including past or current substance abuse, untreated psychiatric disorders, younger age, and social/family environments that encourage misuse 3
• Middle-aged patients with substance abuse and psychiatric comorbidities have higher opioid mortality prevalence 3
• Suicide risk is frequently undercounted in opioid-related deaths and requires specific assessment 3

Ongoing Monitoring

• Reassess all patients on long-term opioid therapy at least every 3 months 1
• Evaluate whether opioids continue to meet treatment goals with sustained improvement in pain and function 1
• Monitor for common adverse effects (sedation, dizziness, nausea, vomiting, constipation) and serious adverse events (respiratory depression, overdose) 1, 2
• Screen for early warning signs of opioid use disorder (difficulty controlling use, craving, work/family problems) 1
• Patients at greater risk (depression, mental health conditions, history of substance use disorder, ≥50 MME/day, concurrent CNS depressants) require more frequent evaluation than every 3 months 1

Critical Pitfalls to Avoid

Avoid Mixed Agonist-Antagonist Opioids

• Never use pentazocine, nalbuphine, or butorphanol in opioid-dependent patients 1
• These agents can precipitate acute withdrawal syndrome 1

Avoid Underdosing

• Write continuous scheduled dosing orders rather than as-needed orders 1
• Inadequate pain control can lead to pseudoaddiction (drug-seeking behaviors secondary to uncontrolled pain) 1
• Undertreating pain decreases responsiveness to subsequent opioid analgesics 4

Patient Education and Support

• Provide psychosocial support to address barriers to pain control (fear of addiction, side effects, inability to purchase medications) 1
• Educate patients and families regarding pain management expectations and adverse effects 1
• Reassure patients that pain will be treated and they will not be abandoned 1

When Opioids Are Inadequate

If clinically meaningful improvements in pain and function are not sustained, or if patients experience high-risk regimens without benefit, work with patients to reduce opioid dosage or discontinue opioids 1. Maximize nonpharmacologic and nonopioid pharmacologic treatments 1. Consider consulting a pain specialist to assist with pain management 1.