What is the appropriate approach to managing pain in a patient, considering various treatment options and potential medical history factors such as substance abuse or respiratory disease?

Pain Management Approach

Pain management should begin with a 0-10 numerical rating scale assessment asking specifically "What has been your worst pain in the last 24 hours?", followed by scheduled (not PRN) multimodal analgesia combining non-opioid medications (acetaminophen and NSAIDs) with opioids when indicated, using around-the-clock dosing rather than as-needed administration for persistent pain. 1

Initial Assessment Framework

Pain Quantification

• Use a 0-10 numerical rating scale to assess three specific parameters: current pain, worst pain in past 24 hours, and usual pain 2, 1
• If worst pain scores ≥3 or the patient reports distress, proceed to comprehensive evaluation 2
• For patients scoring <3, continue monitoring 2

Comprehensive Pain Characterization

Document the following specific elements:

• Pain characteristics: severity, type (nociceptive vs neuropathic), location, radiation pattern, quality descriptors 2, 1
• Temporal factors: onset, duration, course, exacerbating and relieving factors 2, 1
• Functional impact: identify specific activities the patient cannot currently perform rather than focusing solely on pain scores 2, 1

Biopsychosocial Assessment

Evaluate three domains systematically:

Physical/Biological factors 2, 1:

• Underlying pathology requiring treatment
• Current inflammation or joint damage
• Physical disability and mobility limitations
• Sleep disturbance patterns
• Obesity and general fitness level
• Comorbidities (renal/hepatic disease, respiratory conditions)

Psychological factors 2:

• Pain-related beliefs and catastrophizing cognitions
• Fear of movement or activity avoidance
• Psychological distress or psychiatric comorbidity
• Patient's understanding of pain and treatment expectations

Social factors 2:

• Impact on work, family relationships, and social participation
• Economic concerns and housing situation
• Cultural and linguistic considerations
• Substance use history (tobacco, alcohol, illicit drugs)

Treatment Algorithm

Step 1: First-Line Interventions

Initiate multimodal non-opioid therapy as the foundation 1:

Scheduled medications (not PRN):

• Acetaminophen: 1000 mg every 6-8 hours, given regularly from treatment initiation 3
• NSAIDs: Ibuprofen 400-600 mg every 6-8 hours or naproxen 250-500 mg twice daily if no contraindications 3, 4
• Start NSAIDs at lowest effective dose; for naproxen, initial dose should not exceed 1250 mg/day, with maintenance not exceeding 1000 mg/day 4

Nonpharmacologic interventions 2, 1:

• Physical therapy and exercise programs
• Cognitive behavioral therapy for chronic pain
• Relaxation techniques, guided imagery, breathing exercises
• Heat, ice, elevation, compression as appropriate

Step 2: Opioid Initiation (When Non-Opioids Insufficient)

Critical principle: Use around-the-clock scheduled dosing, not PRN, for persistent pain 3

For opioid-naïve patients 5:

• Start with short-acting opioids: morphine 5-15 mg oral or 2-5 mg IV
• Provide rescue doses at 10-20% of 24-hour total, available every 1-2 hours 5
• If patient requires ≥4 rescue doses in 24 hours, increase scheduled baseline dose 5

Dose titration strategy 5, 3:

• Calculate total 24-hour opioid consumption (scheduled + all PRN doses)
• Increase both around-the-clock and PRN doses by 25-50% based on this total
• Reassess within 24-48 hours after any dose adjustment

Step 3: Special Population Considerations

Patients with substance abuse history 2:

• Do NOT withhold opioids for legitimate pain—addiction is rarely a problem when treating cancer or acute pain 2
• Reassure patient that addiction history will not prevent adequate pain management 2
• Use higher doses at shorter intervals due to cross-tolerance 2
• Avoid mixed agonist-antagonist opioids (may precipitate withdrawal) 2
• Notify addiction treatment program of hospitalization and medications given 2

Patients on methadone maintenance 2:

• Continue usual methadone maintenance dose (verify with clinic)
• Add separate short-acting opioids for acute pain
• Do not use maintenance methadone dose for analgesia

Patients on buprenorphine maintenance 2: For acute pain, choose one of four options:

1. Continue buprenorphine and titrate short-acting opioids (short-duration pain only)
2. Divide buprenorphine to every 6-8 hours
3. Discontinue buprenorphine, use opioid analgesics, convert back when pain resolves
4. (Inpatients only) Switch to methadone 20-40 mg with short-acting opioids, convert back before discharge

Patients with respiratory disease 4:

• NSAIDs contraindicated if history of aspirin-induced asthma or bronchospasm 4
• Use lowest effective opioid doses with close respiratory monitoring
• Consider non-opioid adjuvants (gabapentin for neuropathic components)

Monitoring and Reassessment

Regular Assessment Schedule

• Daily assessment during initial titration phase 5
• Within 24-48 hours after any dose adjustment 3
• Stable patients: ongoing monitoring using "Four A's" framework 1

Four A's Monitoring Framework 1:

1. Analgesia: Is pain adequately controlled?
2. Activities of daily living: Is function improving?
3. Adverse effects: Monitor sedation, constipation, nausea, respiratory depression
4. Aberrant drug taking: Watch for concerning behaviors

Patient Education Requirements

Provide written instructions including 2, 3:

• Exact dosing schedule for each medication
• List of potential side effects and management strategies
• Medications to discontinue
• Expected timeline for pain improvement
• Contact numbers and specific callback criteria

Critical callback criteria 2, 3:

• New or worsening pain despite medications
• Nausea/vomiting preventing eating for >24 hours
• No bowel movement for 3 days
• Difficulty arousing patient during daytime
• Confusion or altered mental status
• Fever, increased swelling, or other signs of complications

Essential safety messages 2:

• Take potent analgesics only as prescribed
• Do not self-adjust doses without provider discussion
• Do not mix with alcohol or illicit substances
• Properly safeguard controlled substances in the home
• Expect constipation—start stool softeners/laxatives prophylactically

Critical Pitfalls to Avoid

Never rely solely on pain intensity scores—pain is multidimensional and requires assessment of functional impact and patient-centered goals 1

Never use PRN-only dosing for persistent pain—around-the-clock scheduled dosing is essential for continuous pain control 3

Never ignore underlying treatable causes—providing only analgesics without addressing pathology (e.g., spinal cord compression, infection) is inappropriate 1

Never undertreate high-risk patients—early intensive management reduces long-term disability 1

Never assume opioids will cause addiction in pain patients—when used appropriately for cancer or acute pain, addiction is rarely a problem 2

Never withhold opioids due to psychiatric symptoms—failure to control pain may worsen delirium and psychiatric symptoms 5