What is the stepwise approach for acute pain management in an adult patient with no significant comorbidities?

Stepwise Approach for Acute Pain Management

For adults with acute pain and no significant comorbidities, begin with acetaminophen or NSAIDs for mild-to-moderate pain (1-6/10), escalate to short-acting opioids for severe pain (7-10/10), and always consider multimodal therapy combining agents with different mechanisms of action.

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Step 1: Quantify Pain Intensity

• Use a 0-10 numeric rating scale to assess pain severity, asking specifically: "What has been your worst pain in the last 24 hours?" 1, 2
• Categorize pain as:
  • Mild: 1-3/10
  • Moderate: 4-6/10
  • Severe: 7-10/10 1

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Step 2: Mild Pain (1-3/10)

First-Line Treatment

• Start with acetaminophen (up to 3-4g/day) OR a non-selective NSAID (ibuprofen 400-800mg q6-8h, naproxen 500mg q12h) 1, 3, 4
• Choose acetaminophen if: Patient has cardiovascular disease, chronic kidney disease, history of GI bleeding, or is on anticoagulation 4
• Choose NSAIDs if: Pain has inflammatory component (musculoskeletal injury, trauma) and no contraindications exist 3, 4

Important Considerations

• Topical NSAIDs (diclofenac gel, lidocaine patch 5%) are preferred for localized musculoskeletal pain as they minimize systemic effects 5, 4
• Avoid opioids at this pain level unless acetaminophen/NSAIDs are contraindicated or ineffective after adequate trial 1, 3

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Step 3: Moderate Pain (4-6/10)

Escalation Strategy

• Continue scheduled acetaminophen or NSAIDs as baseline therapy 1, 4
• Add short-acting opioids with slower titration if non-opioid agents are insufficient after 30-60 minutes 1
• Consider combination products (acetaminophen/opioid or NSAID/opioid) that target multiple pain pathways simultaneously 3, 4

Opioid-Naïve Dosing

• Oral route (peak effect 60 minutes): Start with morphine 5-10mg PO, oxycodone 5-10mg PO, or hydromorphone 2-4mg PO 1
• Reassess at 60 minutes: If pain unchanged, increase dose by 50% and repeat 1
• IV route (peak effect 15 minutes): Use if oral route not feasible; morphine 2-4mg IV, hydromorphone 0.5-1mg IV 1

Critical Action

• Initiate bowel regimen immediately with stimulant laxative (senna, bisacodyl) when starting opioids to prevent constipation 1

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Step 4: Severe Pain (7-10/10)

Aggressive Management

• Rapidly titrate short-acting opioids for immediate relief 1
• Maintain non-opioid baseline therapy (acetaminophen or NSAIDs) unless contraindicated 1, 4

Opioid-Naïve Rapid Titration Protocol

• Oral: Give morphine 10-15mg PO or oxycodone 10-15mg PO 1

  • Reassess at 60 minutes
  • If pain score unchanged: Increase dose by 50-100% 1
  • If pain score decreased: Repeat same dose as needed 1

• IV (for severe pain crisis): Give morphine 4-6mg IV or hydromorphone 1-2mg IV 1

  • Reassess at 15 minutes
  • If pain score unchanged: Increase dose by 50-100% 1
  • Continue titration every 15 minutes until pain controlled 1

Severe Pain is a Medical Emergency

• Treat severe uncontrolled pain (7-10/10) as urgent requiring prompt response and aggressive management 1

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Step 5: Multimodal Approach (All Pain Levels)

Add Adjuvant Analgesics Based on Pain Type

• Neuropathic pain (burning, shooting, sharp): Add gabapentin 300mg TID (titrate to 900-1800mg/day) or pregabalin 75mg BID (titrate to 150-300mg BID) 1, 2, 5
• Inflammatory/musculoskeletal pain: Prioritize scheduled NSAIDs over PRN dosing 4
• Visceral pain: Consider adding muscle relaxants or antispasmodics as appropriate 4

Non-Pharmacologic Interventions

• Implement immediately alongside medications: Ice/heat application, immobilization of injured areas, physical therapy referral 5
• Cognitive-behavioral techniques: Relaxation techniques, guided imagery, patient education about pain expectations 2, 5

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Step 6: Reassessment and Titration

Monitoring Protocol

• Reassess pain intensity at regular intervals: Every 15 minutes for IV opioids, every 60 minutes for oral opioids 1
• Use the same 0-10 scale consistently for accurate comparison 2
• Evaluate functional goals: Can the patient sleep, move, perform activities of daily living? 2

Dose Adjustment Rules

• If pain unchanged after 2-3 cycles: Increase dose by 50-100% or consider alternative agent 1
• If pain improved but not controlled: Continue same dose and reassess 1
• If pain controlled: Transition to scheduled dosing with breakthrough medication available 1

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Critical Pitfalls to Avoid

Medication-Specific Warnings

• Acetaminophen: Do not exceed 3-4g/day total from all sources; reduce dose in hepatic disease, malnutrition, or alcohol use disorder 4
• NSAIDs: Avoid in patients with cardiovascular disease, chronic kidney disease, or GI bleeding history; use lowest effective dose for shortest duration 5, 4
• Opioids: Always start bowel regimen prophylactically; monitor for respiratory depression; prescribe only 3-7 days for acute pain 1, 4

Common Errors

• Underestimating pain severity: Believe the patient's self-report; pain is subjective 1
• Delaying opioids for severe pain: Severe pain (7-10/10) requires immediate opioid therapy, not stepwise escalation through non-opioids first 1
• Using PRN-only dosing: Scheduled dosing of non-opioids provides better baseline control than as-needed administration 4
• Ignoring psychosocial factors: Fear, anxiety, and lack of education worsen pain perception and outcomes 1, 2

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Special Considerations for Opioid Prescribing

Risk Mitigation

• Prescribe minimum quantity needed: 3-7 days maximum for acute pain 4, 6
• Educate on proper disposal: Advise patients to dispose of unused medications properly 3
• Assess abuse risk: Even for short-term prescriptions, consider patient risk factors 7
• Avoid in patients on medication-assisted therapy unless absolutely necessary and coordinated with addiction specialist 4