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Last Updated: 12/10/2013  


  • Screen older patients and those with cancer or other chronic conditions for pain at every visit.

  • Use the patient's self-report of pain as the primary source of assessment and use a standard pain scale (such as a visual analog scale, numerical scale, or verbal rating scale) to quantify pain intensity.

  • Obtain a detailed history and perform a physical exam in patients with pain. Assess functional capacity.

  • Identify comorbid medical conditions that may affect the pain or its management through appropriate testing, including testing for kidney and liver disease, baseline ECG, and toxicology screen in appropriate patients.

  • Choose initial drug therapy based on pain intensity and patient-specific pathophysiology, risks, and drug interactions. Begin therapy with acetaminophen or NSAIDs in most patients with mild pain and with opioids in most patients with severe pain.

  • Use opioids alone or in combination with non-opioids (as in multimodal therapy) for patients with severe pain or pain despite maximal non-opioid therapy, and for patients who cannot tolerate non-opioids or for whom the harms outweigh the benefits.

  • Consider adjuvant analgesics for specific types of pain including tricyclic antidepressants or gabapentin for neuropathic or chronic pain.

  • Consider cutaneous techniques such as the application of ice and heat, especially for pain associated with muscle spasm or tension.

  • Use a multimodal approach including drug therapy and other therapeutic interventions such as acupuncture, ablative techniques, and blocks in patients with chronic pain.

  • Predict, recognize, and treat side effects of opioids, including nausea, constipation, somnolence, ataxia, and pruritus.

  • Realize that psychological dependence (addiction) may occur in patients who receive opioids for pain control.

  • Understand “drug seeking” behavior, drug abuse, misuse, or diversion, and doctor shopping; concepts of tolerance and psychological dependence (addiction); and monitor for each regularly.

DOI: 10.7326/d325
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Author(s) and Disclosures:
Linda King, MD has nothing to disclose. Rowena Schwartz, PharmD has nothing to disclose. Bob Arnold, MD has nothing to disclose. Robert L. Barkin, MBA, PharmD, FCP received honoraria and consultancies. Robert L. Barkin, MBA, PharmD, FCP received honoraria and consultancies.

One or more of the present or past ACP Smart Medicine physician editors worked on this module and had nothing to disclose: Davoren Chick, MD, FACP; Deborah Korenstein, MD, FACP; Marjorie Lazoff, MD, FACP; Richard Lynn, MD, FACP.

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