What are the pain management options for patients with acute or chronic pain?

Pain Management Options for Patients

First-Line Treatment: Nonpharmacologic Therapy

For chronic pain (≥3 months), begin with nonpharmacologic interventions before considering medications. 1, 2

Strongly Recommended Nonpharmacologic Options

• Exercise therapy provides moderate pain relief (approximately 10 points on a 100-point scale) and should be individualized, supervised, and incorporate both stretching and strengthening components 1, 2
• Supervised jaw exercise and stretching (for temporomandibular disorders) 1
• Cognitive behavioral therapy (CBT) is strongly recommended for chronic pain, as it promotes adaptive behaviors and addresses maladaptive pain responses 1
• Yoga (Viniyoga or Iyengar styles) demonstrates sustained benefits at 26 weeks with decreased medication use 1, 2
• Spinal manipulation for acute low back pain and chronic/subacute low back pain 1
• Physical and occupational therapy for chronic pain conditions 1

Conditionally Recommended Nonpharmacologic Options

• Acupuncture for chronic or subacute low back pain and chronic pain conditions 1
• Massage therapy for chronic or subacute low back pain 1
• Tai chi for chronic low back pain 1, 2
• Hypnosis specifically for neuropathic pain 1
• Relaxation training and mindfulness-based stress reduction to address autonomic arousal and pain catastrophizing 1

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Second-Line Treatment: Pharmacologic Therapy

Medications should only be initiated after nonpharmacologic approaches have been attempted, and the choice depends on pain type, severity, and duration. 1

For Acute Pain (< 3 months)

Mild to Moderate Acute Pain

• Acetaminophen (up to 1,000 mg per dose, maximum 4,000 mg/day) is the safest first-line option due to favorable safety profile and low cost, though it provides slightly weaker analgesia than NSAIDs 1, 3, 4
• NSAIDs (ibuprofen 400 mg or naproxen) provide superior pain relief compared to acetaminophen but carry gastrointestinal, renovascular, and cardiovascular risks 1, 3, 4
  • Assess cardiovascular and gastrointestinal risk factors before prescribing 1
  • Use lowest effective dose for shortest duration 1
  • Consider proton-pump inhibitor co-administration in higher-risk patients 1

Severe Acute Pain

• Opioid analgesics (hydrocodone, morphine, oxycodone) or tramadol for severe, disabling pain not controlled by acetaminophen and NSAIDs 1, 5, 6, 3
• Skeletal muscle relaxants (excluding baclofen and dantrolene) provide short-term relief for acute low back pain but cause central nervous system sedation 1

What NOT to Use for Acute Pain

• Systemic corticosteroids are ineffective for acute low back pain 1
• Antidepressants, benzodiazepines, and antiseizure medications have insufficient evidence for acute pain 1

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For Chronic Pain (≥ 3 months)

First-Line Pharmacologic Options

• NSAIDs (ibuprofen 400 mg or naproxen) provide moderate pain relief and are the most effective oral medication option 1, 2
  • Assess cardiovascular and gastrointestinal risks before prescribing 1
  • Use lowest effective dose for shortest duration 1

Second-Line Pharmacologic Options

• Duloxetine (30-60 mg daily) is specifically recommended for chronic pain, particularly with neuropathic components 1, 2
• Tramadol provides moderate short-term pain relief and small functional improvement 1
• Tricyclic antidepressants (low-dose) provide small to moderate pain relief independent of mood effects, particularly for chronic low back pain and neuropathic pain 1
  • Typical regimen: start low and titrate over 1-3 weeks 1
  • Adverse effects occur before therapeutic benefit 1

For Neuropathic Pain Specifically

• Gabapentin (titrate to 2,400 mg/day in divided doses) is first-line for HIV-associated neuropathic pain and improves sleep 1
• Pregabalin for post-herpetic neuralgia if inadequate response to gabapentin 1
• Capsaicin 8% dermal patch (single 30-minute application) for HIV-associated peripheral neuropathic pain 1
• Lidocaine 5% patch applied daily to painful site with minimal systemic absorption 1

Opioids for Chronic Pain (Use with Extreme Caution)

• Strong opioids (morphine, oxycodone, hydromorphone) provide small short-term improvement (approximately 1 point on 0-10 scale) 1
• Only consider after documented failure of all nonpharmacologic and non-opioid pharmacologic treatments 1, 2
• Benefits must clearly outweigh risks including addiction, aberrant drug-related behaviors, and paradoxical pain amplification 1, 5, 6
• Initiate at 5-15 mg oxycodone every 4-6 hours as needed, titrating based on response 5
• For chronic pain, administer on around-the-clock basis rather than as-needed 5

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Critical Pitfalls to Avoid

Strongly Recommended AGAINST

• Irreversible oral splints and discectomy for temporomandibular disorders 1
• NSAIDs combined with opioids for temporomandibular disorders 1
• Reversible occlusal splints, arthrocentesis, botulinum toxin injection, corticosteroid injection, benzodiazepines, and β-blockers for temporomandibular disorders 1
• Interventional procedures (epidural injections, facet joint injections, radiofrequency ablation) for axial non-radicular low back pain 2
• Routine imaging unless red flags present (progressive neurological deficits, cauda equina symptoms, suspected infection/malignancy, significant trauma) 1, 2
• Long-term opioids for chronic abdominal pain due to addiction risk and narcotic bowel syndrome 1

Medications with Poor Efficacy

• Codeine and propoxyphene have poor efficacy and significant side effects for acute pain 4
• Acetaminophen shows no difference from placebo for acute low back pain 1

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Special Populations

Cancer Pain

• WHO three-step ladder approach: 1
  1. Mild pain: Acetaminophen, aspirin, or NSAIDs
  2. Moderate pain (NRS 5-7): Combination products with weak opioids (codeine, tramadol) or low-dose strong opioids (morphine, oxycodone), maximum acetaminophen 4,000 mg/day with codeine 240 mg/day 1
  3. Severe pain: Strong opioids (morphine, oxycodone, hydromorphone) 1
• Gabapentin or pregabalin for neuropathic cancer pain, titrating to 2,400 mg/day or 600 mg/day respectively 1
• Topical agents (lidocaine 5% patch, diclofenac gel) as coanalgesics 1

HIV-Associated Pain

• Early antiretroviral therapy for prevention and treatment of HIV-associated distal symmetric polyneuropathy 1
• Gabapentin as first-line for HIV-associated neuropathic pain 1
• Capsaicin 8% patch for HIV-associated peripheral neuropathic pain 1

Inflammatory Bowel Disease

• Low-dose tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors for neuromodulation of chronic abdominal pain 1
• Avoid opioids due to risk of narcotic bowel syndrome 1
• Brain-gut behavior therapies targeting pain catastrophizing 1

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When to Refer

• Refer to multidisciplinary pain management if pain persists despite optimized nonpharmacologic and pharmacologic therapy over 3-6 months 2
• Immediate specialist consultation for red flags: progressive neurological deficits, cauda equina syndrome, suspected infection, or malignancy 1, 2
• Palliative care consultation for advanced illness to assist with pain management and goals of care 1

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Opioid Tapering (When Discontinuing)

• Taper by small increments (no greater than 10-25% of total daily dose) every 2-4 weeks to avoid withdrawal symptoms 6
• Monitor for withdrawal symptoms: restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, mydriasis, irritability, anxiety, insomnia, nausea, vomiting, diarrhea 6
• Ensure multimodal pain management approach including mental health support is in place before initiating taper 6
• Pause taper or raise dose if withdrawal symptoms arise, then proceed more slowly 6