Pain Management : Acute & Chronic

Pain management requires a structured approach. Acute pain is usually short-lived and treated with a stepwise ladder, while chronic pain demands a biopsychosocial and multidisciplinary strategy. Both rely on accurate assessment and safe prescribing.

📝 Assessment

• History 🕰️: Onset, duration, character. Use validated scales (NRS, VAS). For chronic pain, ask about daily impact, sleep, and mood.
• Examination 👩‍⚕️: Look for injury, red flags, and underlying causes. Assess function and quality of life.
• Pain Diaries 📖: Encourage in chronic pain to track triggers and responses.
• Screening Tools 🧾: Pain Catastrophizing Scale, Brief Pain Inventory (chronic pain).

💡 Teaching Pearl: Acute pain should be controlled promptly to enable recovery and prevent complications, while chronic pain should be reduced to a manageable level that restores function, independence, and quality of life - not eliminated entirely.

💊 General Analgesic Principles

⚠️ Always prescribe laxatives with opioids, and ensure naloxone is available to reverse respiratory depression.

• Set expectations - acute pain usually resolves; chronic pain is managed not cured.
• Complete pain relief is often unrealistic in chronic syndromes.
• Step down analgesia as pain improves to avoid long-term dependence.

🌱 Mild to Moderate Acute Pain

• Paracetamol 💊: 500 mg–1 g QDS (PO/IV). Adjust dose in frail/low-weight patients.
• Ibuprofen 🌿: 400–600 mg TDS. Avoid in renal disease, peptic ulcer, heart failure, asthma. Add PPI in elderly/high-risk.
• Weak opioids 💊: Codydramol or dihydrocodeine PRN.

🔶 Moderate Acute Pain

• Codeine: 15–60 mg QDS (but 10% of people are non-metabolisers).
• Tramadol ⚡: 50–100 mg 4–6 hourly. Watch for hallucinations, seizures, serotonin syndrome.

🔥 Severe Acute Pain

• Oral Morphine 💉: 10–20 mg QDS. Switch to modified-release once stable.
• IV Morphine 💉: 1–2 mg/min for acute severe pain.
• Antiemetics 🤢: Cyclizine, prochlorperazine, ondansetron.

🛑 Avoid

• Paracetamol alone for low back pain.
• Opioids for non-specific low back pain (unless specialist advice).
• SSRIs, SNRIs, TCAs or anticonvulsants for simple back pain.

✅ Do Offer

• Topical NSAIDs for OA (hand/knee) as per NICE guidance.
• Non-drug approaches: reassurance, TENS, physiotherapy, education.

🛑 Reversal of Opioid Overdose

• Dilute naloxone 400 mcg in 10 ml saline.
• Give 0.5 ml (20 mcg) IV every 2 mins until adequate breathing.

🔍 Specific Pain Syndromes

• Neuropathic Pain 🧠: Amitriptyline, gabapentin, carbamazepine. Specialist: ketamine.
• Bone Metastases 🦴: Orthopaedic stabilisation + bisphosphonates ± radiotherapy.
• Liver Capsule Pain: Corticosteroids in palliative care.
• Raised ICP 💥: Codeine, dexamethasone (esp. brain tumours).
• Muscle Spasm 💪: Baclofen or botulinum toxin for focal spasm.
• Intestinal Colic 🌊: Hyoscine or other antispasmodics.

🌈 Chronic Pain Management

Chronic pain persists beyond normal healing time (>3 months). It often has a psychological and social component, requiring a holistic approach.

1. Non-Opioid Analgesics: Paracetamol/NSAIDs may help but avoid long-term toxicity.
2. Neuropathic Agents: Amitriptyline (10–25 mg nocte), gabapentin, pregabalin.
3. Opioids: Only short courses if severe, with regular review - avoid long-term use unless under specialist care.
4. Topical: Capsaicin, topical NSAIDs for localised pain.

Non-Pharmacological Therapies

• CBT 💬: Helps patients reframe pain, reduce catastrophising.
• Exercise 🏃: Swimming, walking, yoga to improve mobility.
• Mindfulness 🧘: Meditation, MBSR, breathing techniques.
• Education 📚: Self-management strategies, pacing, goal-setting.
• Complementary: Acupuncture 🪡, massage, aromatherapy.

Specialist Referral

• Severe pain unresponsive to standard treatment.
• Complex psychosocial factors (depression, substance misuse).
• Consideration for nerve blocks, spinal cord stimulation, advanced palliative interventions.

🌍 General Advice for Pain Management

• 🧾 Holistic assessment: Address biological, psychological, and social contributors to pain.
• 📊 Measure and monitor: Use scales such as NRS or VAS in adults, and FLACC for children.
• 🎯 Realistic goals: In chronic pain, the aim is to reduce pain to a manageable level, not to abolish it completely.
• 💪 Function first: Focus on improving mobility, daily activities, and quality of life.
• ⚠️ Safe prescribing: Use the lowest effective dose, co-prescribe laxatives with opioids, and review regularly.
• 🌱 Non-drug strategies: Physiotherapy, CBT, education, pacing, and lifestyle measures are as important as medications.
• 🤝 Shared decisions: Involve patients (and families in children) in setting realistic expectations and treatment plans.

Conclusion

Acute pain is best managed with a stepwise pharmacological ladder and regular review. Chronic pain requires a multidisciplinary biopsychosocial approach, with realistic expectations and integration of non-drug therapies. Both demand safe prescribing, patient education, and regular reassessment.