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PAIN AND PAIN CONTROL

Updated January 29, 2024

What this section covers:

  • Types of pain

  • Pain evaluation: what to expect

  • Pain Treatment

    • Non-drug pain treatments

    • Pain medications

      • Drugs for nociceptive pain

      • ​​Drugs for neuropathic pain

  • Key points

Types of pain

Clinicians recognize two general categories of pain: nociceptive pain and neuropathic pain.

Types of pain

Nociceptive (no-see-SEP-tive) pain

 

Almost everyone has experienced this kind of pain. Nociception involves special receptors that detect heat, cold, pressure, pinching, and chemicals that could cause injury. Broken bones, burns, and crush injuries cause this type of pain. Pain receptors -- nociceptors -- are present in the skin, muscles, joints, and bones (somatic nociceptors) as well as internal organs (visceral nociceptors). In general, somatic receptors can pinpoint the location of injury, whereas visceral receptors in internal organs such as the heart, liver, and pancreas give a less localized signal.

 

Somatic pain is often constant and aching, may be sharp, and often gets worse with movement. In addition to injuries noted above, somatic pain can be caused by arthritis, cancer, and osteoporosis

Visceral pain may be constant or crampy, aching, and difficult to localize. Visceral pain can be “referred” to another part of the body so that it seems to be coming from another source. This is what can happen in a heart attack: pain (or numbness) can be felt in the neck, left shoulder, and down the left arm, as shown in the figure at right. These areas share nerve pathways with the heart. 

Neuropathic Pain

Referred pain
Neuropathic pain

Neuropathic pain involves damage to nerve cells from past injury or disease. It can also arise in conditions such as diabetes or Vitamin B12 deficiency. 

Neuropathic pain can take the form of steady burning, tingling (“pins and needles”), squeezing, numbness, itching, or aching. Examples are diabetic neuropathy and post-herpetic neuropathy, which is a complication of shingles. Alternatively, neuropathic pain can take the form of intermittent stabbing, shooting, or electric shock-like sensations that can be very severe. Trigeminal neuralgia (tic douloureux) is one example of this, with extremely severe face pain coming from the trigeminal nerve (with branches shown at right). Trigeminal neuralgia pain can occur spontaneously, or be elicited by shaving or brushing teeth, or even a puff of air to the face. 

Trigeminal neuralgia

Acute and chronic pain 

A clinical distinction is also made between acute and chronic pain. Acute pain usually involves a traumatic event such as surgery or accident with injury, and lasts 90 days or less. Acute pain is treated with strong pain relievers at high doses, which are then tapered and discontinued when the injury has sufficiently healed. 

Chronic pain is characterized by pain every day (or most days) for longer than 90 days. Chronic pain that limits life or work activities is designated “high impact chronic pain.” This type of pain must be treated to minimize long-term disability. 

The Pain Evaluation: what to expect

Although many primary care clinicians are well able to diagnose and treat pain, a visit to a pain specialist — one familiar with multimodal pain care who is likely to be more aggressive in treatment — may be in your best interest. 

The pain evaluation: what to bring 

  • Eyeglasses 

  • Hearing aids 

  • Record of pain treatments tried 

  • Medical history from primary clinician 

  • X-rays if relevant 

  • A family member, friend, or caregiver as additional informant, if necessary 

At the evaluation, you will be asked to describe the pain, and asked questions such as the following: 

  • How bad is the pain? 

  • What does the pain feel like? (aching, stabbing, etc.) 

  • Where is the pain? 

  • How long does it last? 

  • How often does it happen/how much of the day or night is it present? 

  • What makes the pain better? What makes it worse? 

 

A pain scale will likely be used to help you give a number to pain severity, something like this: 

Pain scale

Individuals with dementia who may be unable to express pain complaints are evaluated by observation, using a scale such as the Abbey Pain Scale, shown below. (Enlarge to read.) 

Abbey Pain Scale for elders with dementia

At the evaluation, you will be asked questions about function in daily life and any limitations on function due to pain. As pain is often associated with anxiety and depression, screening questions about mood will also be asked. Part of the physical exam will be focused on the painful area, and range of motion of the spine and affected limbs and neck will be checked. Rising from the chair and walking will be assessed. 

Interview during the pain evaluation

For your own protection, questions will be asked about your past drinking and drug use as well as that of your blood relatives, because a history of substance abuse increases your risk of addiction to opioids (narcotics). This line of questioning is not meant to exclude you from prescribed opioid use, but to indicate whether you might best be referred or co-managed by an addiction specialist. 

The potential for substance abuse (in more severe cases, known as “addiction”) will always be in the back of your clinician’s mind when planning pain treatment. Abuse and addiction refer to persistent use of a substance despite harmful consequences. 

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Most seniors who are prescribed opioids do not have problems with addiction; they do not persist in increasing the dose of drug to achieve a “high,” they don’t get prescriptions from more than one doctor, and they don’t “lose” their pills. The big problem for those who do become addicted is that the drug hijacks the brain’s reward circuitry and changes the brain’s structure and function so that judgment, decision-making, and self-control are impaired. The clinician seriously wants to avoid addiction as far as humanly possible, so don’t be offended when you are asked question after question about alcohol and drug use. 

Opiates hijack the brain's reward circuits

Although routine laboratory testing for pain evaluation is minimal, seniors should have liver and kidney function testing if medication treatment is to be used. This is done by a simple blood draw. A Vitamin D level in the blood is also advised to check for deficiency, as this can be associated with bone pain and back pain that improves with Vitamin D supplementation. 

Pain treatment 

Non-drug pain treatments 

Seniors with pain issues are often surprised to learn about the wide range of helpful non-drug treatments available. For many patients, these treatments are so effective that drugs aren’t needed. A partial list of these treatments is shown in the box below, with comments following that list. Note that all these non-drug treatments could be available to you through a pain rehabilitation program prescribed by your clinician. 

List of non-drug pain treatments

Acupuncture 

In this procedure, specific points along meridians (energy pathways) of the body are stimulated by the insertion of fine needles. Although there is a wide variation in knowledge and skill level of practitioners around the world, well-trained and experienced acupuncturists report positive effects on pain from various musculoskeletal disorders. This is confirmed by a recent review cited in the References section at the end of this topic. Acupuncture may be particularly helpful for back and neck pain, osteoarthritic knee pain, and headache (both tension and migraine types).

Acupuncture

Therapeutic massage 

This type of massage — also known as deep tissue massage — improves circulation, reduces stiffness, increases range of motion and flexibility, and relieves pain. This is unlike other forms of massage, which are intended to provide relaxation. 

Ultrasound

Ultrasound 

In addition to its use in medical diagnosis, ultrasound can be used to treat chronic pain and accelerate healing of injured tissue. It works by sending heat into tissues, which improves circulation and loosens tight muscles. Ultrasound has been used successfully by pain rehabilitation specialists for many years. It is known to treat carpal tunnel syndrome, frozen shoulder, tendinitis such as “tennis elbow,” joint tightness, and injuries to ligaments. 

Ice and heat 

Ice packs cool surface tissues to reduce inflammation and swelling and to relieve pain by numbing the affected area. Acute injuries are often treated with ice for this reason. Chronic pain can also be reduced using alternating cold and heat applications. Cold treatment is limited by the need to remove ice after 15-20 minutes to avoid further tissue injury, and by muscle contraction, which is unpleasant for many people. 

Heat is well known to provide temporary reduction of pain. Hot baths, showers, and heating pads help to relax muscles and improve flexibility and range of motion. Deep heat, accomplished with ultrasound and infrared devices, reaches deeper tissues, and is also said to improve blood and lymph circulation and promote tissue repair. Infrared heat devices are now available for home use in the form of heating pads, wraps, and saunas

Ice vs. Heat

Transcutaneous Electrical Nerve Stimulation (TENS)

This therapy uses a low-voltage electrical current passed between two electrodes placed on the skin overlying selected nerve pathways to provide pain relief. Pulses of electrical energy can be adjusted for intensity, frequency, duration, and mode (burst or continuous).

TENS has been used to treat arthritis, tendinitis, bursitis, fibromyalgia, lower back pain, diabetic neuropathy, and peripheral vascular disease. TENS should not be used near implanted electronic devices such as pacemakers, over cancerous or infected tissue, on broken skin, over the chest in those with heart disease or arrhythmias, near the head and neck in those with epilepsy, over blood clots, or in those with bleeding disorders. Although TENS units are relatively inexpensive and readily available without a prescription, patients are advised to see a rehabilitation specialist to become familiar with this therapy before unsupervised use. 

TENS
Cold laser and Light Therapies

Cold laser and light therapies 

Cold (low-level) laser treatments shine light on the body surface, sending packets of energy called photons to deeper tissues such as joints. Cold laser therapy is used to reduce pain and inflammation, promote tissue growth, improve blood circulation, and speed wound healing. This type of laser does not cut or heat the skin or underlying tissue, so the procedure is painless. Cold lasers are used to treat the same conditions treated by TENS and ultrasound. Similar to the cold laser, LED light in the red and near-infrared range can be used to reduce pain and inflammation at a lower cost and with a better safety profile than the laser, such that home use and wearable devices are possible with LED equipment. 

Stretching 

This is recommended for all chronic pain sufferers, particularly those with lower back and neck problems due to osteoarthritis and those with tension headaches. Stretching improves flexibility, reduces pain, stimulates blood circulation, improves posture, and lowers the risk of falling. This is one of the reasons that yoga has become so popular.

Stretching

The rules of stretching: 

  1. Do it every day, preferably more than once a day. 

  2. Before exercise, do small stretches and warm up slowly. Do your major stretches after exercise during your cool down phase. 

  3. If the stretch is painful, stop and resume more gently or in another muscle group. 

  4. Move slowly to stretch and don’t bounce. Bouncing can tear muscles. 

  5. Hold each stretch for at least 30 seconds. 

  6. Repeat each stretch at least twice on each side of the body. 

  7. While you stretch, take deep, slow breaths and relax. 

  8. Stretch all your muscle groups even if your pain is only in one area. 

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Movement and exercise 

Physical activity is well known to reduce pain and disability of musculoskeletal origin. Whether your preference is to swim or walk or perform Tai Chi, the bottom line is that if you KEEP MOVING, you will reduce problems with stiffness, pain, and weakness. 

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Meditation/relaxation 

Meditation and systematic relaxation can help to reduce pain by relaxing muscles, stimulating the release of natural pain-relieving chemicals such as endorphins, lowering the levels of stress hormones and inflammation, and helping to build emotional resilience. 

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Cognitive-behavioral therapy (CBT) 

CBT and related therapies focus on changing negative thoughts and behaviors that make pain worse. Catastrophic thinking and maladaptive behaviors such as staying in bed can be reduced, and these changes help the individual develop better pain coping strategies, even if the objective pain remains the same. In addition, these therapies can reduce stress and stress-related chemicals known to exacerbate pain. 

Pain medications (analgesics) 

As a last resort, when non-drug treatments fail to keep pain at a manageable level, medications are added, used in combination with treatments described above. Constant pain — as opposed to occasional pain such as headache — should be treated with drugs used on a fixed schedule rather than “as needed” (prn). This is because it is easier to prevent pain or keep pain from getting worse than it is to treat severe pain. Any person who suffers from even moderate persistent pain will tell you that missing a scheduled dose of analgesic can bring the pain roaring back.

Pain medication (Analgesics)

Analgesic medications are most easily given by mouth. For those who cannot take drugs orally, sublingual (under the tongue) or subcutaneous (just under the skin) routes are preferred to intravenous administration. The intramuscular route (injection into muscle) should generally not be used for pain treatment because it worsens discomfort, and absorption of the drug can be unreliable. 

Medications to treat constant pain should be given 

by mouth and by the clock. 

The choice of drug to treat pain depends in large part on the type of pain, whether nociceptive or neuropathic. 

Drugs for nociceptive pain 

A stepped approach to the treatment of nociceptive pain is widely used, based on the analgesic ladder first proposed for cancer-related pain by the World Health Organization in 1986, shown below. 

The Analgesic Ladder

The use of this ladder for the treatment of chronic non-cancer pain has been controversial, and several modifications have been introduced for this reason, including the introduction of minimal invasive interventions such as nerve blocks and integrative medicine approaches to limit the need for strong opioids. 

Ladder for Chronic Non-cancer Pain

  • For pain occurring after trauma or surgery, treatment would begin near the top of the ladder (Step 3) to get pain under control, and then the dose of drug would be tapered off as the wound healed. 

 

  • For chronic pain (or persistent pain, even if present <90 days), treatment would begin at the lowest step and proceed up the ladder until pain is controlled. Using this approach, it may be possible to avoid strong opioids altogether. 

 

  • MILD PAIN (Step 1) treatment begins with the non-opioid acetaminophen (Tylenol) given by the clock. For seniors, the daily dose of acetaminophen should not exceed 3,000 mg and no single dose should exceed 1,000 mg. That maximum dose may be even lower for seniors who have pre-existing liver disease, regularly drink alcohol, are malnourished, or are currently fasting. Unintentional acetaminophen overdose is the leading cause of liver failure requiring transplant in the US, and the second leading cause worldwide

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If acetaminophen is not effective in alleviating pain, it is replaced by a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen. Although NSAIDs are not addictive, they have several potentially serious side effects, including kidney function impairment and bleeding problems (especially from the stomach and upper GI tract). Taking acetaminophen with NSAIDs may increase the risk of these side effects. In addition, if NSAIDs are taken longer than about 10 days, follow-up is recommended to check for GI bleeding (with a blood draw and stool testing) and kidney effects (blood draw to check electrolytes, creatinine, and creatinine clearance). Not all NSAIDs are equal in their effects on the kidney; ibuprofen appears to be the best tolerated NSAID for long-term use. An alternative to ibuprofen is the prescription drug choline magnesium salicylate, which is related to aspirin, but is less likely than aspirin and other NSAIDs to cause bleeding problems. 

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  • MILD TO MODERATE PAIN (Step 2) is treated with a weak opioid such as codeine, hydrocodone, or tramadol with or without acetaminophen or an NSAID, and with or without an adjuvant. 

 

  • MODERATE TO SEVERE PAIN (Step 3) is treated with a strong opioid such as morphine, oxycodone, methadone, hydromorphone, tapentadol, or fentanyl with or without acetaminophen or an NSAID, and with or without an adjuvant. 

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Adjuvants are drugs given along with analgesics that, through various mechanisms, help to lessen the need for higher doses of analgesics. Adjuvants are listed in the table below. 

Adjuvants for Pain Control

Drugs for neuropathic pain 

A different approach is used for drug treatment of neuropathic pain. First-choice drugs include the anticonvulsants gabapentin or pregabalin; low-dose tricyclic antidepressants (TCAs) such as amitriptyline, nortriptyline, imipramine, desipramine, or doxepin; and serotonin-norepinephrine reuptake inhibitor antidepressants (SNRIs) such as duloxetine or venlafaxine. Second-choice drugs — either added to the first drug used or substituted — include tramadol and topical analgesics. Third-choice drugs include strong opioids (e.g., morphine, oxycodone) and Botox injections. As with nociceptive pain, opioids are effective, but are a last resort because of side effects and addiction potential. In recent years, both gabapentin and pregabalin also have been noted to have addiction and diversion potential. Neither acetaminophen nor NSAIDs are considered effective for neuropathic pain. 

 

Neuropathic pain can be hard to treat. It’s important to recognize from the outset that each drug trial will require a careful increase in dosage as well as sufficient time at the target dose to be effective, usually weeks or months. In addition, many patients find that, even when the drugs are optimized, pain or discomfort is not completely gone. Before initiating treatment, it will be necessary to agree on treatment goals. For example, one patient wanted to be able to play golf again, so his goal was to treat to the point that he could walk for nine holes without too much discomfort. This goal helped to manage his expectations, and provided a measurable marker of treatment success. 

Drugs for Neuropathic Pain

Tramadol and tapentadol are like narcotics in binding to the mu opioid receptor, and have been found to have definite abuse and diversion potential, with tapentadol being worse than tramadol. These two drugs also are norepinephrine reuptake inhibitors. In addition, tramadol is a much stronger serotonin reuptake inhibitor than tapentadol. Tapentadol is a stronger analgesic than tramadol, but both have ceiling effects for pain control, meaning you can’t just keep increasing the dose to control discomfort. Some pain specialists would also list tapentadol as a second-choice drug for neuropathic pain. 

Topical lidocaine 

Topical lidocaine blocks the transmission of pain impulses and numbs the area to which it is applied. The drug is available by prescription, with weaker formulations available over the counter. 

Lidocaine is used for postherpetic neuralgia (shingles pain) and other neuropathic syndromes. Before using lidocaine, it is important to be informed about precautions and side effects. The prescription patches tend to be very expensive. 

Topical Lidocaine
Topical Capsaicin

Topical capsaicin 

Capsaicin is a natural chemical found in hot chili peppers that blocks nerve impulses just as lidocaine does. Capsaicin is available in various over-the-counter preparations as well as a very concentrated patch (Qutenza) that is applied at the clinician’s office and left in place for one hour. Up to four prescription patches can be applied at one time. This treatment may provide relief for up to three months, but is very expensive. Before using prescription or over-the-counter capsaicin, it is important to be informed about precautions and side effects. 

Botox injections 

The injection of botulinum toxin relaxes tight muscles, and may reduce transmission of pain impulses. This is a third-line treatment for peripheral neuropathy that may provide relief for up to four months. This treatment is sometimes used short-term for knee joint injection in osteoarthritis. 

Cannabinoids (THC and CBD) 

These two compounds present in marijuana — THC and CBD — are widely believed to be effective in reducing pain, particularly neuropathic pain. This opinion is based on a large anecdotal experience, but is not supported by federal agencies such as the FDA or the CDC, which generally have taken a harm-avoidance stance. High-quality research has been limited, so that claims regarding analgesia should be viewed with some degree of skepticism. 

Cannabinoids (THC and CBD)

What is known is that in states in which medical marijuana has been legalized, a corresponding reduction in opioid and benzodiazepine prescriptions is seen. In addition, when cannabinoids are added to an established pain regimen for an individual patient, the need for opioid drugs is reduced. THC is psychoactive, meaning that it is associated with a “high,” whereas CBD is not. In fact, when CBD is combined with THC, that “high” is attenuated. Many medical users report that this combination (or THC alone) effectively reduces treatment-refractory neuropathic pain. CBD also has anti-inflammatory and anxiety-reducing effects. Even topical CBD has been shown to be effective in treating neuropathic foot pain. A review of cannabinoids and pain can be found in the References section at the end of this lecture. 

Opioids (narcotics) 

For patients whose pain has not responded to treatments discussed above and who continue to have functional impairment from pain, a trial of opioid drugs is indicated, whether the pain is nociceptive or neuropathic. These drugs have numerous side effects in seniors, are dangerous in overdose, and have high abuse/addiction and diversion potential. For elderly patients with clearly defined pain syndromes and no history of alcohol or drug abuse, however, the addiction potential appears to be low. Side effects can be managed if anticipated. In addition, opioid drugs available in generic form are more affordable than many of the non-opioid alternatives.

 

Opioids are controlled substances, and are assigned a Schedule number from I to V based on accepted medical use and potential for abuse/dependence. Schedule I drugs such as LSD and heroin have high potential for abuse and no medical use. Schedule II drugs have high potential for abuse, but include most of the opioids discussed in this section. Schedule V drugs have a lower potential for abuse, and include preparations with small quantities of opioids, such as cough syrup with codeine. 

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Programs in place to detect problem opioid users include the following: 

  • Screening for addiction potential at first clinic visit. 

  • Urine drug screening (possibly at first visit and at random). 

  • State and nationwide prescription monitoring programs to flag double-doctoring. 

  • Severe penalties for drug diversion. 

 

Before opioids are prescribed for chronic pain, it will be necessary to discontinue benzodiazepines (e.g., Valium, Ativan) and to agree to keep alcohol consumption to a minimum. These drugs add to the respiratory depressant effects of opioids. 

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Before opioids are prescribed for any pain, kidney and liver function testing must be performed to determine which drugs should be used. 

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A checklist from the CDC for prescribing opioids for chronic pain is reproduced below. The checklist is intended as a tool for clinicians, but includes information that could be helpful to any patient considering whether to include opioids in their own treatment regimen. A more readable version of the checklist can be found online by searching for CDC Checklist Opioids.

CDC Checklist for Prescribing Opioids

When opioids are initiated for seniors, a short-acting drug is started first, at a dose of 25-50% of what would be used in a younger adult. Also, the between-dose interval may be longer than in a younger patient. The dose is increased slowly, with careful attention to the four “A” elements of pain assessment: 

  • Analgesia — has the pain improved? 

  • Activity —is the patient able to increase activity? 

  • Adverse effects — side effects (discussed below) 

  • Aberrant behaviors —losing pills, trying to get pills from another doctor, etc. 

A patient not yet exposed to opioids (“opioid-naïve”) should not be given a long-acting drug first in case problems such as respiratory depression develop. 

If pain and activity have improved, side effects are manageable, and no aberrant behaviors are noted, the opioid could be continued indefinitely, with regularly scheduled follow-up. 

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It’s important to know from the start that nociceptive pain responds more readily to opioids than does neuropathic pain. High doses of opioids may be needed to control neuropathic pain. If expectations are not realistic, the patient with neuropathic pain might be thought to be drug-seeking because of “pseudo-addiction,” as noted in the box below. 

Watch out for “pseudo-addiction” 

If a patient with severe ongoing pain is treated with an opioid dose that is too low or a between-dose interval that is too long, that patient may require and demand more drug. In some cases, that demand is interpreted as drug-seeking behavior, when in fact all that is needed is a higher dose or a shorter interval. The demand stops when pain control is adequate. 

Short-acting opioids are used for acute pain. 

  • hydromorphone 

  • morphine 

  • oxycodone 

  • oxymorphone. 

 

Long-acting opioids are used for persistent pain and chronic pain. 

  • oxycodone controlled release (CR) 

  • oxymorphone extended release (ER) 

  • hydromorphone ER 

  • morphine CR and ER 

  • methadone 

  • tapentadol ER 

  • transdermal fentanyl 

  • transdermal buprenorphine 

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Fast-acting opioids are used for severe pain that breaks through the current pain regimen.

For this indication, various forms of transmucosal immediate-release fentanyl are available,  including sublingual tablets and spray, lozenges, and nasal spray.

Opioids not recommended for seniors include the following:

  • Codeine — many individuals cannot metabolize this drug to the active form, so the drug doesn’t provide pain relief.

  • Meperidine (Demerol) — an active metabolite can build up in the system and cause seizures. This drug also interacts with many other drugs, particularly those affecting the serotonin system, such as SNRI or SSRI antidepressants and some over-the-counter drugs such as dextromethorphan (in cough syrup) and St. John’s wort.

  • Methadone — takes a long time to be eliminated from the body, so repeated dosing can cause it to build up in the system, producing toxicity problems. Methadone has effects on the heart (seen on EKG) and interacts with many other drugs. Even so, methadone is sometimes used in seniors who develop hyperalgesia, as discussed below.

Avoid opioid combination drugs

Fixed-dose combination drugs such as Percocet (acetaminophen and oxycodone) were intended to make life easier for those in pain. Unfortunately, dosing of these drugs is problematic because there is a ceiling to the amount of non-opioid that can be given in a 24-hour period. For acetaminophen, that amount is 3,000 mg (3 g) daily. Use of combination drugs is not recommended for seniors.

Specific Cases

  • For patients with kidney problems, preferred opioids include oxycodone, hydromorphone, and fentanyl. Morphine should be avoided in those with severe kidney impairment because of the build-up of a potentially toxic metabolite.

  • For patients with liver dysfunction, fentanyl is a preferred opioid. Severe liver dysfunction can also result in build-up of many drugs and their metabolites, exacerbating side effects such as constipation, over-sedation, and confusion.

  • Tramadol should be avoided in patients with declining kidney and/or liver function, and those taking other serotonergic medications such as SNRI or SSRI antidepressants and some over-the-counter drugs such as dextromethorphan (in cough syrup) or St. John’s wort.

Adverse effects of chronic opioid use are numerous, and include an increased risk of falls with hip fracture, sedation and respiratory depression (which can lead to pneumonia), delirium, cardiovascular events such as heart attack and heart failure, an increased sensitivity to pain known as hyperalgesia (see box below), lowered bone mineral density, and constipation. For the latter problem, an aggressive laxative regimen should be considered when opioid therapy begins.

Hyperalgesia

Some patients who take opioids chronically develop a condition known as hyperalgesia, in which pain increases due to activation of a receptor known as the NMDA receptor. In these cases, if the dose of opioid is increased, the pain gets worse. NMDA receptor blockers can treat this condition. For this purpose, the patient can be switched to methadone, which has NMDA blocking effects. Alternatively, ketamine, memantine, amantadine, or dextromethorphan could be added to the opioid regimen.

Key points

  • Effective pain control for elderly patients is best achieved using a multi-disciplinary model in which a variety of treatments are used, based primarily on non-drug interventions.

  • Non-drug treatments are effective for all types of pain, and may work so well that drug treatment is not needed.

  • Nociceptive and neuropathic pain have different drug treatment protocols, although there is some overlap between them.

  • For drug treatment of constant pain — as opposed to occasional pain such as headache — drugs should be given on a fixed schedule rather than “as needed.”

  • Opioid (narcotic) drugs are used as a last resort, only if other interventions have not been effective.

References

 

Hulland O, Oswald J. Cannabinoids and Pain: The Highs and Lows. Rheum Dis Clin North Am.2021 May;47(2):265-275. doi: 10.1016/j.rdc.2020.12.005. Epub 2021 Feb 27. PMID: 33781494.

 

Rajan J, Behrends M. Acute Pain in Older Adults: Recommendations for Assessment and Treatment. Anesthesiol Clin. 2019 Sep;37(3):507-520. doi: 10.1016/j.anclin.2019.04.009. Epub 2019 Jul 1. PMID: 31337481.

 

Schwan J, Sclafani J, Tawfik VL. Chronic Pain Management in the Elderly. Anesthesiol Clin. 2019 Sep;37(3):547-560. doi: 10.1016/j.anclin.2019.04.012. Epub 2019 Jun 18. PMID: 31337484; PMCID: PMC6658091.

 

Skelly AC, Chou R, Dettori JR, Turner JA, Friedly JL, Rundell SD, Fu R, Brodt ED, Wasson N,Winter C, Ferguson AJR. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review [Internet]. Rockville (MD): Agency for Healthcare Research and Quality.

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