Pain

Use at a glance

• Identify nociceptive, neuropathic + visceral mechanisms

Practical pearls

• Acetaminophen/NSAID for many acute nociceptive states

Choosing treatment

• Use nonpharmacologic + nonopioid therapy when effective
• Neuropathic pain needs mechanism-specific agents
• Opioids reserved for selected severe pain with clear goals

Monitoring / follow-up

• Reassess function, not pain score alone

Key points

• Acute mild-moderate: acetaminophen or NSAIDs 1st-line; NSAIDs > acetaminophen, may match opioids
• Acute moderate-severe: NSAID + acetaminophen ≈ opioid/acetaminophen; severe may need short-acting opioid, lowest dose/duration
• Chronic noncancer: nonpharmacologic 1st; NSAIDs > acetaminophen but long-term GI, renal, CV toxicity
• Localized pain (hand/knee OA): topical NSAID before oral; opioids only for refractory severe pain
• Chronic cancer pain, severe: full opioid agonists drugs of choice
• Neuropathic: TCA or SNRI, or gabapentin/pregabalin initially; combination may be synergistic
• Localized neuropathic: topical lidocaine/capsaicin; opioids if refractory; multimodal analgesia ↓ opioid need
• Noncancer pain: nonpharmacologic therapy and nonopioids preferred over opioids (CDC 2022)
• Acute: PRN not scheduled; subacute (1–3 mo)/chronic (>3 mo) → combine with nonopioid/nonpharm therapy

Nonpharmacologic therapies

• Physical therapy
• Psychological therapy
• Noninvasive chronic pain treatments
• Intrathecal infusion device
• Heat or ice
• Rest
• Elevation
• Immobilization

Pearls

• Salsalate, diflunisal: little GI bleeding; tolerated in asthma
• Abuse-deterrent opioids not proven to reduce abuse
• Gabapentinoid misuse rising; pregabalin Schedule V
• Cannabinoids: second-line at best for neuropathic or cancer pain

Self-check

• What pain approaches are used when effective?
  Nonpharmacologic + nonopioid therapy when effective.
• What should pain reassessment prioritize over pain score alone?
  Function.

Drugs used for this (51)

All clinical uses · Open Pain in the interactive console ↗