What prescription is recommended for pain management?

Pain Management Prescription Recommendations

For mild to moderate pain, start with acetaminophen (paracetamol) as first-line therapy, or combine it with an oral NSAID such as ibuprofen 400-800 mg every 4-6 hours (maximum 3200 mg/day) for additive analgesia. 1, 2

Initial Approach Based on Pain Severity

Mild Pain (WHO Level I)

• Acetaminophen is the preferred first-line agent, particularly in older adults, providing comparable pain relief to NSAIDs without gastrointestinal toxicity 1
• NSAIDs such as ibuprofen are equally effective for mild pain and can be used if acetaminophen is insufficient 3
• For acute musculoskeletal pain, topical NSAIDs (diclofenac gel) show superior treatment satisfaction and symptom relief compared to oral options 1

Moderate Pain (WHO Level II)

• Combine acetaminophen with oral NSAIDs for additive analgesia and reduced need for stronger medications 1
• Ibuprofen 400 mg every 4-6 hours is appropriate; doses above 400 mg show no additional benefit in controlled trials 2
• Use NSAIDs at the lowest effective dose for the shortest duration, particularly in older adults and those with cardiovascular disease, renal impairment, or prior GI bleeding 3
• Weak opioids (codeine, tramadol) combined with non-opioid analgesics are alternatives if NSAIDs are contraindicated 3

Severe Pain (WHO Level III)

• Oral morphine is the opioid of first choice for moderate to severe pain 3
• Strong opioids should be titrated rapidly using immediate-release formulations every 4 hours, with rescue doses (10% of total daily dose) for breakthrough pain 3
• Laxatives must be routinely prescribed when initiating opioid therapy to prevent constipation 3

Specific Pain Conditions

Osteoarthritis

• Start with acetaminophen or topical NSAIDs for single/few joints 3
• For multiple joints or inadequate response, use duloxetine or systemic NSAIDs 3
• In patients ≥75 years, strongly prefer topical over oral NSAIDs 4

Chronic Low Back Pain

• After insufficient response to non-pharmacologic approaches (exercise), consider NSAIDs or duloxetine 3

Neuropathic Pain

• First-line options include duloxetine, pregabalin, gabapentin, or tricyclic antidepressants 3
• Duloxetine 30 mg daily for one week, then increase to 60 mg daily 5
• Topical lidocaine 5% patches can be added for localized pain 5
• In older adults, use tricyclic antidepressants judiciously due to confusion and fall risks 3

Fibromyalgia

• Duloxetine, milnacipran, or pregabalin are FDA-approved options 3
• Combine with NSAIDs and specific anticonvulsants as needed 3

Critical Safety Considerations

NSAID Precautions

• Add a proton-pump inhibitor in patients with history of GI ulcers 4
• Assess cardiovascular risk factors before prescribing; NSAIDs increase CV risk in those with pre-existing heart disease 4
• In chronic kidney disease stages 4-5 (eGFR <30 ml/min), avoid NSAIDs; use fentanyl or buprenorphine instead 3

Opioid Management

• Opioids should not be first-line therapy for chronic pain; expected benefits must outweigh risks 3
• When prescribed, use scheduled dosing rather than "as needed" for chronic pain 4
• Monitor for adverse effects: constipation (prophylactic laxatives mandatory), nausea (metoclopramide), drowsiness 3
• In renal impairment, reduce all opioid doses and frequency 3

Multimodal Strategy

Always employ multimodal pain management combining acetaminophen, NSAIDs, and adjuvants to reduce opioid requirements and minimize class-specific adverse effects 1. This approach provides superior pain control while reducing medication-related risks.

Monitoring Requirements

• Assess pain severity at every visit using standardized scales (VAS, NRS, or VRS) 3
• Reassess after each intervention at appropriate intervals based on anticipated effect 1
• For chronic pain, review and adjust doses based on total rescue medication use 3
• Treatment is successful if pain reduces by ≥30% from baseline after 2-4 weeks at target dose 5