Pain management

Last updated: November 15, 2023

Summarytoggle arrow icon

Pain is an unpleasant sensation (sensory and emotional) with biological, psychological, and social components. There are a number of ways to differentiate between types of pain, the most common of which is the distinction between acute and chronic pain. Acute pain lasts for < 1 month. It can indicate actual or potential tissue damage and is associated with trauma, surgery, and illness. Subacute pain lasts for 1–3 months and chronic pain is generally defined as pain lasting > 3 months (normal tissue healing time). Standardized pain intensity scales are used to evaluate pain in a clinical setting. Pain management uses a multimodal approach, which may include the use of pharmacological therapy, physical therapy, behavioral therapy, and/or interventional or surgical methods. Acute pain requires prompt treatment. Analgesics should be tailored to the inciting cause; the WHO analgesic ladder can be used to help structure pain relief strategies. The management of chronic pain can be challenging; initial management involves nonpharmacological therapy (e.g., physical therapy, cognitive behavioral therapy), nonopioid analgesia, and consideration of interventional pain management. For chronic pain refractory to nonopioid management, opioid therapy may be considered only if benefits outweigh risks. Patients who are prescribed opioid therapy for chronic pain should undergo close monitoring, and the risks versus benefits of treatment should be regularly reassessed; opioids should be tapered or discontinued if the benefits no longer outweigh the risks. For information on psychogenic pain, see “Somatic symptom and related disorders.”

Classification of paintoggle arrow icon

By duration

  • Acute pain
    • A warning signal indicating actual or potential tissue damage that triggers a protective reaction
    • Typically associated with trauma, surgery, and acute illness
    • Lasts < 1 month [1]
  • Subacute pain: lasts 1–3 months [1]
  • Chronic pain
    • Pain that lasts beyond the normal tissue healing time (> 3 months) [1][2]
    • Unlike acute pain, chronic pain has no protective role in preventing further tissue damage and can be considered a disease entity in its own right.

By type

Pathophysiologytoggle arrow icon

Pain sensitization [4][5]

  • Abnormal pain perception due to increased neuronal sensitivity to noxious stimuli (hyperalgesia) and/or reduced neuronal threshold to otherwise normal stimuli (allodynia) in response to local injury, inflammation, and/or repetitive stimulation
  • Plays a major role in the generation and maintenance of chronic pain and neuropathic pain (e.g., postherpetic neuralgia)
  • Although not completely understood, the pathophysiology is thought to involve the following two mechanisms:
    • Peripheral sensitization
      • Injury, inflammation, or repetitive stimulation of the peripheral nociceptive neurons local release of chemical mediators (e.g., cytokines, nerve growth factors, histamine)→ repeated or prolonged exposure to chemical mediators upregulates the ion channels in the nociceptors increases sensitivity and/or reduces threshold to chemical mediators even further → increased action potentials → abnormal pain perception
      • Usually ceases once the tissue injury or inflammation heals
    • Central sensitization
      • Injury and/or inflammation of the CNS (e.g., dorsal horn of the spinal cord, brain) → increased excitability and reduced inhibition in the CNS and recruitment of non-nociceptive fibers (e.g., Aβ fibers) into the nociceptive pathway → abnormal pain perception
      • Chronic peripheral pain disorders can be a significant driver to the sensitization of central nociceptive neurons
      • Usually continues even after the initial injury has healed

Subtypes and variantstoggle arrow icon

Referred pain

Overview of referred pain
Organ Dermatome Projection
Diaphragm C4 Shoulders
Heart T3–4 Left chest
Esophagus T4–5 Retrosternal
Stomach T6–9 Epigastrium
Liver, gallbladder T10–L1 Right upper quadrant
Small bowel T10–L1 Periumbilical
Colon T11–L1 Lower abdomen
Bladder T11–L1 Suprapubic
Kidneys, testicles T10–L1 Groin


Phantom limb syndrome


Evaluation of paintoggle arrow icon

To optimize pain management, a thorough history and assessment of pain is required prior to initiating treatment.

  • Pain characteristics (location, quality, temporal aspects, triggers)
  • Associated symptoms (changes in mobility and strength)
  • Previous pain assessments and/or treatment
  • Pain intensity scale: subjective grading of pain severity by the patient
  • Impact of pain
    • E.g., on daily life, sleep, activities
    • This may also be evaluated through the use of validated scales, e.g., the PEG pain scale for chronic pain
  • Pain diary: regular documentation of the pain intensity to identify peaks and triggers; enables treatment optimization

Pain can be difficult to assess in nonverbal patients; obtain supporting information from caretakers and use a specialized pain score, e.g., the nonverbal pain scale.

Be aware of implicit bias in the assessment of pain: Hispanic and Black patients are less likely to receive any and/or appropriate analgesia compared to White patients, even when reported pain scores are identical. [11][12]

Pain is subjective! Pain scales are used to assess a patient's pain and response to pain management over time. They cannot be used to compare pain intensity between patients.


Analgesicstoggle arrow icon

WHO analgesic ladder

The WHO analgesic ladder is a 3-step algorithm for the management of acute and chronic pain.

  • Regular analgesic (modified-release drugs, administered at fixed times and doses)
    • By the mouth: preferably, analgesics should be given orally.
    • By the clock: regular administration at fixed times, rather than on demand
    • By the ladder (symptom-oriented): if the patient is still in pain, it is necessary to go up a step
  • Appropriate PRN medication
    • Short-acting analgesics for peaks in pain
    • If PRN medication is required ≥ 3×/day → inadequate analgesia likely; review the regular medication
  • Additionally, concurrent treatment with adjuvant drugs
Management of pain using WHO analgesic ladder [14]
Pain severity Nonopioid analgesics Mild opioids Strong opioids Adjuvant drugs
Step I Mild Include Avoid Avoid If required
Step II Moderate Include Consider Avoid If required
Step III Severe Include Consider Consider If required

Nonopioid analgesics are first-line agents for pain; prescribe them alone for mild to moderate pain and in combination with opioids for severe pain. [15]

For both opioid and nonopioid analgesics, use the minimal effective dose for the shortest duration of time to minimize adverse effects. Pain intensity scales should be used in regular intervals to assess the success of pain management.

Oral analgesics

Oral analgesics
Drug class Drug Important considerations
Nonopioids Acetaminophen [16]
NSAIDs [16]

Selective COX-2 inhibitor

  • Preferred second-line analgesic for mild to moderate pain [16]
  • Preferred over NSAIDs in patients with PUD
  • Use with caution in patients with renal or cardiovascular disease. [17]
  • See nonopioid analgesics for further information.

Combination analgesics

All patients being discharged with opioid medications should receive counseling on the use of prescription opioids.

Parenteral analgesics

Parenteral analgesics
Drug class Drug Important considerations

Analgesic suppositories

Topical analgesics

Topical analgesics
Drug Dose Indications

Adjuvant analgesics


Anticonvulsants are useful adjuncts in the management of neuropathic pain. They typically will not be helpful for acute pain, rather are more commonly used for chronic neuropathic pain.

Muscle relaxants

Consider muscle relaxants in patients with pain associated with muscle spasticity.


Tricyclic antidepressants and SNRIs can be helpful for chronic pain syndromes and neuropathic pain. Antidepressants for chronic or neuropathic pain are recommended by the American Society of Anesthesiologists in their 2010 guideline, but only duloxetine is FDA-approved for this indication. All others are off-label use. [25][26]

Intravenous patient-controlled analgesia

  • Infusion pump designed to release additional IV medication in response to patient's request
  • Indication: severe acute pain that is difficult to manage and is expected to be limited in duration

Management of side effects of analgesics

Condition-specific analgesia

Nonpharmacological analgesiatoggle arrow icon

Multiple nonpharmacological therapies are often used in combination (e.g., exercise therapy and cognitive behavioral therapy).

Physical modalities [1][28]

Consider referral to physical therapy and/or occupational therapy.

Patients may require analgesia to participate in physical therapy; maximize nonopioid pharmacological therapy first. [32][33]

Psychological modalities [1][28]

Refer to a psychologist as needed.

Other modalities [1][28]

Acute pain managementtoggle arrow icon

Approach [37]

Choice of analgesic for acute pain [1]

Choice of analgesic for acute pain [1]
Opioids likely required Nonopioid analgesics likely as effective as opioids
Other medical conditions

Administer acute pain management promptly; withholding it does not improve the accuracy of a physical examination. [37]

Opioids for acute paintoggle arrow icon

Only prescribe opioids if the benefits outweigh the risks. [1]

Acute-on-chronic pain managementtoggle arrow icon

Management of acute-on-chronic pain requires significant empathy and skill.

General principles [37]

Follow local departmental policies if available.

  • Establish treatment goals.
    • The goal of treating the acute episode is to allow the patient to return to baseline function.
    • Complete alleviation of pain is typically not possible.
  • Obtain detailed pain assessment and review existing care plans.
  • Consult the clinical provider in charge of long-term pain management whenever possible.
  • Identify and treat reversible causes of pain, e.g., a new:
  • Consider systemic barriers to accessing treatment.
  • Consider admission for individual management of patients with progression of terminal illnesses if no reversible cause is identified.

Acute-on-chronic pain management in hospital-based settings [1][37]

Involve the patient's regular health provider in treatment decisions whenever possible and be aware of the potential for drug diversion of prescriptions made by other health providers.

Pain management in the emergency departmenttoggle arrow icon

Chronic noncancer pain managementtoggle arrow icon

Approach [1][28][39]

This content applies to the management of chronic and subacute pain unrelated to cancer, sickle cell disease, or other high-morbidity illnesses. For pain related to those conditions, see “Pain management in palliative care.” Acute pain management and acute-on-chronic pain management are detailed separately.

A biopsychosocial model of medical care is integral to chronic noncancer pain management. [28]

Use palliative pain management for pain related to cancer, sickle cell disease, or other high-morbidity illnesses. [1]

Avoid perpetuating existing racial and ethnic disparities in chronic pain management. [1]

Initial assessmenttoggle arrow icon

Indications for referraltoggle arrow icon

Refer patients with these indications to a pain management specialist: [1]

Individuals without indications for referral to pain management can typically be managed by a primary care clinician.

Patient educationtoggle arrow icon

  • Ensure patients understand the diagnosis and how to manage their condition; see “Managing chronic conditions.”
  • Provide pain neuroscience education. [41][49]
  • Manage the patient's expectations, e.g., explain that: [1]
    • It can take weeks to months for pain to improve in response to treatment.
    • Goals should be realistic, e.g., pain reduction (not elimination) and improvement in function.
    • Chronic pain is managed in a stepwise manner.
  • Educate patients on when to take medication for pain management.
  • Support patients in developing a self-management approach. [41][50]

Nonopioid managementtoggle arrow icon

A combination of multimodal nonpharmacological analgesia and various types of nonopioid pharmacotherapy for chronic noncancer pain may be used. To select the appropriate pharmacotherapy: [1]

There is insufficient evidence to support the use of cannabis or cannabinoids for chronic pain management; if being considered, check local laws before prescribing. [1][51]

Opioid managementtoggle arrow icon

Decision to initiate [1][32][43]

Ensure patients are aware that chronic use of opioids can interfere with employment opportunities, especially in safety-critical jobs. [1]

Before initiating opioid therapy, take a full patient history, screen for comorbid mental health conditions, and perform medication reconciliation to determine patient suitability for opioid therapy and to reduce modifiable risk factors.

Risk mitigation [1][43]

Consider risk mitigation for opioid prescribing prior to starting opioids and at each follow-up appointment.

Ensure patients with risk factors for opioid overdose have been provided with naloxone and educated on how to use it. [1]

The prescription of more than a 90-day supply of opioids is associated with a dose-dependent increase in the risk of adverse effects of opioid use, including opioid use disorder. [1]

Aberrant drug-related behaviors

Aberrant drug-related behaviors may suggest abuse, misuse, or diversion of opioids.

  • Concerning behaviors include: [54][55].
    • Obtaining medication from nonmedical sources
    • Requesting prescriptions early
    • Frequently reporting loss of prescriptions
    • Missing or canceling appointments at which no opioid refill is anticipated
    • Obtaining prescriptions from multiple providers
    • Presenting to the emergency department for medications
  • Managing patients with aberrant drug-related behaviors
    • Do not discharge patients from care unless they are violent or threatening. [1][56]
    • Evaluate for opioid use disorder and/or other substance use disorders; if present, provide treatment with a multidisciplinary team.

Urine drug monitoring for opioid therapy [57][58]

  • Consider urine toxicology prior to starting opioid therapy and at least annually thereafter. [1][57]
  • Communicate clearly with patients to reduce misunderstandings.
    • Explain urine drug monitoring procedures; and their purpose in maintaining patient safety.
    • Ask nonjudgmentally about the nature and timing of all recent substance use before ordering a test.
  • Interpret results with care.
    • Screening immunoassays have limitations; ask patients nonjudgmentally about any unexpected results. [1][57][58]
    • If results are unexplained and/or will affect management, obtain confirmatory testing. [1][57]
    • Do not use results punitively (e.g., discontinuation of opioids, discharge from practice).

Initiation [1][39][43]

Ongoing therapy [1][43]

There is a paucity of evidence supporting > 12 months of opioid therapy for chronic pain management. [1][32]

Prescriptions ≥ 50 MME/day are unlikely to improve pain and also increase the risk of adverse effects of opioids. [1]


The decision to taper chronic opioid therapy (and, possibly, to discontinue therapy) should be made on an individual basis using shared decision-making, weighing up the benefits and risks of opioid therapy. [1][43]

The goal of tapering may be complete discontinuation or dose reduction to improve the risk versus benefit profile. [1]

Indications [1][32]

Consider tapering in the following scenarios:

Consult a pain specialist if considering tapering opioids in pregnant individuals. [1]

Process [1][43]

  • Use a multidisciplinary approach.
  • Avoid rapid tapering and sudden discontinuation.
  • Advise patients that pain may worsen initially.
  • First, reduce the dose per administration.
    • Maximize nonopioid therapy for chronic noncancer pain.
    • Determine tapering speed based on duration of opioid use: [1]
      • < 1 year: Taper at ≤ 10% of the original dose per week.
      • ≥ 1 year: Taper at ≤ 10% of the original dose per month.
    • Slow the taper if signs of withdrawal develop.
  • Once the lowest dose per administration has been achieved:
    • Gradually increase the dosing interval.
    • Discontinue opioids when the interval is less than once daily.
  • Follow-up monthly during tapering
    • Consider the patient's wishes to slow or pause the taper.
    • Evaluate for and manage complications of opioid tapering

Do not rapidly taper or discontinue opioids unless the patient is at imminent risk for life-threatening complications such as overdose. [1]

Inform patients that they are at increased risk for overdose during and shortly after tapering because of decreased tolerance. [1]

Most patients on long-term opioid therapy who agree to taper or discontinue opioids experience overall satisfaction, with improved quality of life and no increase in pain, but may experience short-term effects of hyperalgesia, insomnia, and agitation. [1]

Management of complications [1]

Special patient groupstoggle arrow icon

Pain in critically ill patients

Assessment of pain in the ICU

  • Patients in ICU are typically unable to communicate and require a specialized pain scale [60]
  • Behavioral pain scale
  • Critical care pain observation tool (CCPOT)
    • Used to identify pain in critically ill patients.
    • Four items are evaluated and awarded points: facial expressions, body movements, ventilator compliance in intubated patients or vocalization in nonintubated patients, and muscle tension
    • ≥ 3 points indicates significant pain
  • For subjective grading of pain severity by the patient, see “Pain intensity scale
Pain intensity scales for critically ill patients
Behavioral pain scale score CCPOT score
Facial expression
  • 1 point for relaxed
  • 2 points for partially tightened
  • 3 points for fully tightened
  • 0 points for relaxed
  • 1 point for tense
  • 2 points for grimacing
  • Upper limbs
    • 1 point for no movement
    • 2 points for partially bent
    • 3 points for fully bent with finger flexion
    • 4 points for permanently retracted
  • Body
    • 0 points for no movement or normal
    • 1 point for protection
    • 2 points for restless or agitated
Muscle tension
  • N/A
  • 0 points for relaxed
  • 1 point for rigid or tense
  • 2 points for very rigid or tense
Mechanical ventilation compliance
  • 1 point for tolerating movement
  • 2 points for coughing, but tolerating most of the time
  • 3 points for fighting ventilator
  • 4 points for unable to control ventilation
  • Intubated patients
    • 0 points for tolerating normally
    • 1 point tolerating but coughing
    • 2 points for fighting the ventilator
Vocalization for extubated patients
  • N/A
  • 0 points normal tone or no sound
  • 1 point for moaning or sighing
  • 2 points for crying or sobbing

Pain management [61]

Be aware of the adverse effects of opioids (e.g., delirium, CNS depression, tolerance) or NSAID therapy!

Pain in neonates and infants

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Referencestoggle arrow icon

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