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  • image Understanding the pathogenesis of pain guides treatment and patient education.

  • image It is important, whenever possible, to ask patients if they have healthcare pain, to identify the source of pain, and to assess the characteristics of the pain.

  • image The etiology of pain may not always be identifiable.

  • image Whenever possible, a multidisciplinary approach and nonpharmacologic strategies should be incorporated.

  • image Chronic pain treatment should focus on self-management strategies and focus on active, rather than passive approaches.

  • image Selection of nonopioids and opioids should be based on the characteristics and type of pain as well as individual patient factors.

  • image Oral or topical analgesics are preferred over other dosage forms whenever feasible, but it is important to adjust the route of administration to the needs of the patient.

  • image Patients taking analgesics should be monitored for response (analgesia, functionality, quality-of-life) and side effects.

  • image Doses must be individualized for each patient and administered for an adequate duration of time. Around-the-clock regimens should be considered for acute and chronic pain. As-needed regimens should be used for breakthrough pain or when acute pain displays wide variability and/or has subsided greatly.

  • image Consider a trial of opioids in those with severe pain that have failed nonpharmacologic and nonopioid treatment when the anticipated benefits are expected to outweigh the risks.

  • image Use risk mitigation strategies (informed consent/patient agreements, urine drug monitoring [UDM], opioid overdose education and naloxone distribution, prescription drug monitoring program [PDMP] checks) prior to and periodically during opioid therapy, with frequency determined on the basis of patient risk and presence of aberrant drug-taking behaviors.


Patient Care Process for Pain Management



  • Patient-specific characteristics (eg, age, gender, pregnancy, ethnicity)

  • Pain and symptom-specific history (eg, onset, location, duration, characteristics, aggravating factors, alleviating factors, timing, and severity)

  • Patient history including current and past medications, nonpharmacologic trials, allergies or medication intolerance, and pertinent social history (eg, tobacco, alcohol, or recreational drug use)

  • Family history focusing on symptoms (ie, Rheumatoid arthritis) and social behavior (ie, alcoholism, recreational drug use)

  • Objective data including vitals, pertinent labs, targeted physical exam, and drug screen results


  • Presence of co-occurring mental health conditions (ie, depression, anxiety, or bipolar) which may confound treatment decisions

  • Aberrant drug-taking behaviors as evidenced by prescription drug monitoring programs (PDMP), urine drug screen results, and validated risk screening tools

  • Relative or absolute contraindications to the use of opioids, acetaminophen, antidepressants, anticonvulsants, nonsteroidal anti-inflammatory drugs (NSAIDs), or skeletal muscle relaxants

  • Chronicity of pain symptom (eg, acute or chronic), likely etiology (eg, neuropathic, musculoskeletal, or visceral), and severity


  • Patient and symptom-specific lifestyle modification (eg, weight loss, smoking cessation, self-pacing, and pain-trigger avoidance; see Table 77-2)

  • Nonpharmacologic treatment modalities (see Table 77-3)

  • Drug therapy regimen including dose, route, frequency, and duration (see Table 77-4)

  • Monitoring drug therapy regimen including efficacy (analgesic and functional improvement), toxicity, misuse, and ongoing necessity using tools such as urine drug screening, PDMP, and risk assessment tools (see Table 77-14...

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