Version May 2024
INTRODUCTION — The goals for acute pain management are to relieve suffering, facilitate function, and enhance recovery. The optimal strategy for acute pain control consists of multimodal therapy to increase efficacy, reduce side effects of therapy, and minimize the need for opioids. This topic will discuss multimodal analgesia based on the expected degree of pain for patients in the ambulatory setting.
Treatment of acute pain for patients chronically using opioids and for inpatients after surgery is discussed separately. (See "Management of acute pain in the patient chronically using opioids for non-cancer pain" and "Approach to the management of acute pain in adults".)
GOALS AND PRINCIPLES — The goal for acute pain control should not be zero pain, but rather a tolerable level of pain that allows physical and emotional function. Often this means balancing analgesia with achieving functional goals, while avoiding preventable complications.
General principles include the following:
●Create an individualized plan for pain management based on the expected degree of pain and patient factors that may affect the plan
●Offer multimodal analgesia, adding opioids only as necessary
●Provide patient education
●Adjust the pain management plan based on adequacy of pain relief and the occurrence of adverse events
Use multimodal analgesia — We suggest a multimodal approach to analgesia for acute pain, with nonpharmacologic techniques, regional anesthesia techniques as appropriate, nonopioid analgesics, and opioids only as necessary. Multimodal analgesia involves the use of two or more agents that employ different mechanisms for pain management, thereby reducing overreliance on and adverse effects from a single class of agents, most importantly opioids.
Use opioids safely — An overarching principle of acute pain management is to avoid excessive or prolonged use of opioids. Opioids are associated with short term side effects (eg, respiratory depression, sedation, nausea and vomiting, pruritus, urinary retention, constipation) and long term adverse effects (eg, tolerance, dependence, opioid induced hyperalgesia, withdrawal upon conclusion of therapy, opioid use disorder, and overdose). (See 'The decision to prescribe opioids' below.)
PATIENT EVALUATION — Patient evaluation should include assessment of medical and psychological conditions, substance use disorder, pain treatment history, and long term medications, all of which may affect the plan for analgesia. These considerations are discussed separately. (See "Approach to the management of acute pain in adults", section on 'Patient evaluation'.)
If opioids are considered, the Prescription Drug Monitoring Program (PDMP) database should be checked prior to prescribing. In the United States, all states have instituted PDMPs. Some states require, and others suggest, that clinicians check the PDMP database prior to prescribing opioids. Studies on the efficacy of PDMPs regarding opioid prescribing practice are limited and have found mixed results, however a general practice of checking PDMP prior to prescribing may be helpful in confirming other controlled substance prescriptions a patient is receiving [1]. (See "Prescription drug misuse: Epidemiology, prevention, identification, and management", section on 'Prescription monitoring programs'.)
PAIN TRAJECTORIES — For many patients, acute pain peaks at one to three days after injury or surgery and should be much less by seven days. However, the expected degree of pain and time course of resolution varies widely with both the type of injury or surgery and patient factors, including prior history of alcohol, drug, or opioid use; history of anxiety or depression; and patient age.
As has been demonstrated for perioperative pain, the anatomic location, type of tissue damaged, and type of surgery affect the degree of pain. In general, procedures and injuries that involve bones and joints are more painful than those that involve soft tissue [2-4]. In one prospective study involving approximately 5100 ambulatory surgical patients who received multimodal analgesia (ie, naproxen premedication, local anesthetic infiltration, or regional anesthesia as appropriate), the percent of patients with severe pain at 24 hours varied by the type of surgery [5]. Patients who underwent microdiscectomy were most likely to have severe pain, followed by laparoscopic cholecystectomy, shoulder surgery, elbow/hand surgery, ankle procedures, inguinal hernia repair, and knee surgery.
A number of studies have examined the degree of pain and/or the quantity of opioid required for pain relief after specific ambulatory surgical procedures [2,5-9]. Generalizability may be limited, as most are single institution studies, and some do not report the use of non-opioid medications or analgesic techniques (eg, local anesthetic infiltration, peripheral nerve blocks).
The Michigan OPEN website provides evidence based opioid prescribing recommendations for over 70 common adult and pediatric surgical procedures, with citations for supporting literature, and based on data collected across the state of Michigan.
BASIC MEASURES FOR ALL PATIENTS — For all patients, regardless of the expected degree of pain, acute pain management should include:
●Nonpharmacologic techniques (eg, ice or heat, elevation, immobilization, rest, relaxation techniques or meditation) as appropriate
●Local or regional anesthesia/analgesia techniques when appropriate, and
●We suggest acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) unless there are contraindications, rather than either drug alone.
Local and regional anesthesia techniques are most commonly used for patients who undergo surgical procedures, often to provide analgesia after discharge from the hospital or day surgery unit. (See "Overview of peripheral nerve blocks", section on 'Use of nerve blocks'.)
STRATEGY BASED ON EXPECTED DEGREE AND DURATION OF PAIN — After evaluating for risk factors that may predispose a patient to greater than expected acute pain, it is reasonable to create a management strategy based on the expected or existing degree of pain and the likely trajectory, recognizing that the degree of pain may not fit into discrete categories of mild, moderate, or severe pain.
Clinicians should avoid basing decisions regarding analgesia on the basis of race. Studies have demonstrated racial disparities in both acute and chronic pain management. As an example, a systematic review of studies examining acute pain treatment in emergency departments found that Black patients were significantly less likely to receive analgesia than White patients [10]. Implicit bias and false beliefs about biological differences in pain tolerance may contribute to ongoing racial disparities [11].
The components of pain control strategies are discussed here. The use of specific analgesics is discussed below. (See 'Analgesics' below.)
Expected mild pain — Mild pain can be expected after sprains, nonspecific low back pain, dental extraction, superficial surgical procedures, and headaches. Opioids should not be required to adequately treat minor pain. Acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) or cyclooxygenase (COX)-2 inhibitors usually provide adequate pain relief in the treatment of mild to moderate pain [12-14].
Expected moderate pain — Most laparoscopic and minimally invasive surgery, most soft tissue surgeries, and non-compound and non-comminuted fractures result in moderate pain. For some patients, regional anesthesia techniques (eg, single injection or continuous peripheral nerve blocks) may be appropriate. In addition to regularly scheduled non-opioid analgesics, opioids may be necessary for some of these patients. In most cases, a three-day prescription of short-acting opioid should suffice. (See 'Opioids for moderate pain' below.)
Expected severe pain — Severe pain can be expected after major non-laparoscopic surgery, maxillofacial surgery, total joint replacement, compound fractures, and long bone fracture prior to definitive stabilization. In addition to non-opioid analgesics, regional anesthesia techniques should be used when possible. Opioids are typically necessary. A prescription for up to seven days of higher dose opioid may be required to adequately manage pain. If follow-up can be arranged prior to seven days, the prescription should be written for the time period up until the follow-up appointment. Initiation of extended release/long-acting opioids should generally be avoided even with expected severe acute pain. If these agents are considered (eg, new onset of severe cancer-related pain), we suggest involving a specialist in pain medicine. (See 'Opioids for severe pain' below.)
ANALGESICS
Nonopioid analgesics — We suggest using both acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) as part of multimodal analgesia for patients without contraindications, rather than either drug alone. We suggest taking acetaminophen and NSAIDs on a scheduled basis rather than "as needed," with the rationale that pain control may be more sustained than if taken as needed. However, there is very little literature comparing these dosing strategies [15].
NSAIDs may be more effective than acetaminophen for some types of pain (eg, dental pain [16,17]), and a combination of an NSAID with acetaminophen may be more effective than either type of drug alone for various types of acute pain [16,18,19].
Use of nonopioid analgesics for acute pain is discussed in detail separately. Doses are shown in a table (table 1). (See "Nonopioid pharmacotherapy for acute pain in adults".)
Topical analgesics (eg, topical diclofenac and/or lidocaine) may be beneficial for some patients with localized pain (eg, sprain or muscle strain), particularly for patients who are at increased risk of side effects from systemic analgesics. Topical NSAIDs penetrate local tissues in the area of application but have limited systemic absorption and therefore fewer side effects and drug interactions. (See "Nonopioid pharmacotherapy for acute pain in adults", section on 'Choice of NSAID' and "Nonopioid pharmacotherapy for acute pain in adults", section on 'Topical lidocaine'.)
Opioids
The decision to prescribe opioids — The decision to prescribe opioids for acute pain should always involve a risk benefit analysis, balancing the need for analgesia against opioid side effects (eg, constipation, nausea, drowsiness, dizziness), and risks of respiratory depression, dependence, long term use, and use disorder. We reserve opioids for patients in whom other therapies are either contraindicated or likely to be incompletely effective on their own, and we evaluate the patient’s risk of opioid-related harm. When deemed necessary for acute pain, we prescribe opioids at the lowest effective dose and for the shortest duration possible.
Factors that increase the risk of opioid misuse or long term use are discussed in detail separately. (See "Risk of long term opioid use and misuse after prescription of opioids for pain".)
Avoid excessive prescription — Every effort should be made to avoid prescribing more opioid than necessary. Leftover pills are available for diversion and inappropriate use. Among those who engage in nonmedical prescription opioid use, over 70 percent obtain opioids without a prescription, and 40 to 50 percent receive the drug from family members or friends who have leftover pills [20-22]. Overprescription can also lead to overconsumption [23], which can lead to very high doses (usually without functional benefit), which is associated with an increased risk of overdose.
Multiple studies have shown that excessive opioid medications are routinely prescribed for all types of surgical procedures, as well as after emergency department visits for painful conditions [24,25], and most patients save leftover pills [2,4,6,7,9,26-36]. As a result, large amounts of opioid tablets are available for non-medical use.
A number of institutions have implemented protocols, educational programs, or feedback systems designed to reduce unnecessary opioid prescription for acute pain [7,37-41]. In general, such efforts result in reduced number of prescribed pills, without an increase in refills or reduced patient satisfaction [42]. As an example, a retrospective study of over 600 opioid naïve patients who underwent laparoscopic cholecystectomy, thyroidectomy, or inguinal hernia repair compared patient reported outcomes in patients who participated in an opioid sparing postoperative pathway versus patients who received standard care [37]. Patients in the opioid sparing pathway used fewer opioid pills, reported less pain, and had similar satisfaction. In the opioid sparing pathway, patients received a median of four oxycodone tablets (5 mg) postoperatively, compared with a median of 20 tablets for patients who received standard care. Forty percent of patients in the opioid sparing pathway received no postoperative opioid prescription. Conclusions from this study are limited by lack of data on intraoperative analgesic strategies, the retrospective nature of the study, and the limited range of surgical procedures studies.
Choice of opioid — In the United States, the most commonly prescribed opioids for acute pain include oxycodone, hydrocodone, and to a lesser extent, codeine and tramadol [43,44]. Morphine immediate release (IR) and hydromorphone are other options.
●Short versus long-acting opioids – Consistent with the guidelines from the Centers for Disease Control and Prevention (CDC) and other professional and governmental organizations, we suggest that IR opioids should be used for acute pain management in opioid naïve patients in the ambulatory setting, rather than long-acting or extended release opioids. IR opioids reach peak effect within 45 to 60 minutes, compared with three to four hours for extended release (ie, slow release or prolonged release) opioids. Thus, rapid titration to effect is safer and easier with IR drugs.
Unintentional overdose may be more likely if opioid therapy is initiated with long-acting opioids. In one cohort study involving initiation of opioid therapy in approximately 840,000 opioid naïve patients over 10 years, unintentional overdose in the first two weeks was five times more likely in patients who received long-acting opioids, compared with those who took short-acting opioids [45]. Generalizability may be limited by the patient population (chronic pain, veterans) and conclusions are limited by the retrospective nature of the study and limited information on patient substance use disorder, psychiatric illness, or comorbidities.
●Choice of drug – The typical opioid prescription for acute pain consists of oxycodone 5 mg pills, or the equivalent dose of hydrocodone (approximately 5 mg) and such doses appear in most opioid prescribing guidelines. There is little evidence to support the systematic choice of one of the commonly used opioids over another, either in terms of efficacy, tolerability, or risk of misuse. Factors that may influence the choice or dose of opioid include the patient’s age, hepatic or kidney impairment, genetic polymorphisms (eg, for codeine or tramadol), and interactions with other drugs the patient is taking (table 2). We avoid the use of codeine and tramadol as first line agents because of wide interpatient variability in metabolism, unreliable analgesia, and related incidences of adverse events. Tramadol has mixed pharmacologic effects and is a weak mu opioid receptor agonist. It is associated with similar adverse effects as other opioids, including risks of misuse and physiologic dependence as well as unreliable metabolism due to its dependence on unpredictable P450 hepatic conversion to an active metabolite. In an insurance database study that included over 350,000 patients who received a prescription of opioids after surgery, tramadol was associated with a higher risk of prolonged opioid use, compared with other short-acting opioids [46].
Considerations when choosing among oxycodone, hydrocodone, and morphine IR include the following:
•Potency – A number of state, federal, and professional guidelines for opioid prescription base the recommended or allowed doses on morphine milligram equivalents (MME). However, there are no standard methods for opioid conversion, and available online calculators and published conversion tables provide variable and inconsistent conversion ratios [47,48]. In addition, there is wide variability among clinicians when converting opioid doses, whether they use printed or online opioid conversion tables [49]. Therefore, whereas it may be necessary to calculate MME for regulatory reasons, morphine equivalents should only be used clinically as a general guide for starting doses, with modification based on patient factors, age, prior opioid history, concomitant drug therapy, and available preparations (table 3). (Related Pathway(s): Morphine milligram equivalent calculator for adults with chronic non-cancer pain.)
When considering dose equivalence, it is preferable to underestimate the opioid dose with a watchful approach that includes incremental dose escalation, rather than risking overestimation of dosage. Starting doses for opioids are discussed below and appear in a table (table 2).
Generally accepted conversion ratios may not reflect actual clinical effect. As examples:
-Despite the fact that hydrocodone is thought to be approximately two thirds as potent as oxycodone, oxycodone 5 mg or hydrocodone 5 mg, each in combination with acetaminophen or ibuprofen, may be similarly effective when administered for a variety of painful conditions [50-52]. One retrospective study of over 6840 surgical patients from 64 hospitals in Michigan compared outcomes in patients who were prescribed 5 mg tablets of hydrocodone or oxycodone [53]. Patients who were prescribed hydrocodone took slightly more pills (mean 7 versus 6 pills) than those who were prescribed oxycodone. Pain scores, patient satisfaction, and opioid refills were similar in the two groups.
-Some conversion tables show the potency of morphine IR to be approximately half that of oxycodone. However, in one randomized crossover study in volunteers who took 10 or 20 mg oxycodone versus 30 or 60 mg morphine IR, the potency ratio between morphine and oxycodone was 3:1 [54]. Opioid effect was determined by the degree of miosis. The lowest dose tablet available for morphine IR is 15 mg, which was as efficacious as oxycodone 5 mg by the results of this study.
•Misuse potential – Oxycodone may have greater likability (positive subjective effects) than hydrocodone and morphine, though the evidence supporting this is not conclusive. In a review of nine small randomized trials that compared the relative likeability of various opioids, oxycodone was associated with greater likeability and/or misuse potential than hydrocodone or morphine, which were similar [55]. However, the included studies used various routes of opioid administration, different methods for outcome assessment, and all study subjects were either current or former opioid users. In the randomized trial described above, there was no difference in likeability between oxycodone and morphine IR [54].
•Risk of overdose – Evidence comparing the risk of overdose with the commonly prescribed opioids is limited. In a retrospective database study of opioid related adverse events in the year after initial opioid prescription of oxycodone or hydrocodone, for patients who took either drug along with acetaminophen, oxycodone was associated with a lower risk of long term opioid use, but a higher risk of overdose [56]. The risk of overdose in patients who took oxycodone-acetaminophen was 0.27 percent, versus 0.24 percent in patients who took hydrocodone-acetaminophen. Risk of overdose was higher in patients who took oxycodone monotherapy, at 0.44 percent.
•Available preparations – Other opioids may be preferred rather than hydrocodone for patients who take regularly scheduled acetaminophen and NSAIDS as part of multimodal pain control, because the others are available as sole drugs. In the United States, IR hydrocodone is only available in combination with acetaminophen or ibuprofen. Therefore, the maximum recommended doses of the non-opioid component may complicate and limit administration of hydrocodone when those medications are also taken separately.
The lowest dose available tablet of morphine IR is 15 mg, such that a starting dose of 7.5 mg requires splitting the tablet or using the oral solution.
Opioid dose and duration — When possible, medical centers should create procedure specific guidelines for opioid prescription based on patient utilization data [57]. Lacking such data, online tools (eg, Opioid Prescribing Recommendations for Surgery from Michigan OPEN) can be used to guide post procedure prescribing, based on current data. The following is a reasonable strategy for opioid prescription based on the expected level of pain.
Opioids for moderate pain — For patients who are expected to have moderate pain (eg, most laparoscopic and minimally invasive surgery, most soft tissue surgeries, and non-compound and non-comminuted fractures), the following are reasonable prescriptions for patients without risk factors that require modification of the choice or dose of drug. For older adult or frail patients, lower dose opioid may be sufficient and safer (eg, oxycodone 2.5 mg).
Note that the number of pills in parentheses refer to the number of pills to be dispensed for the entire prescription. Patients should be directed to take one tablet as needed, no more frequently than every three to four hours and usually three doses per day will suffice. This will translate into 3 to 4 pills per day of one of the following:
●Oxycodone 5 mg (ie, 12 tablets) or
●Hydrocodone 5 mg (ie, 12 tablets) (available only with acetaminophen or ibuprofen) (see 'Choice of opioid' above) or
●Hydromorphone 2 mg (ie, 12 tablets)
●Morphine IR 7.5 mg (ie, 6 tablets, to be split)
We avoid prescribing tramadol because of wide interpatient variability in metabolism, unreliable analgesia, and related incidences of adverse events. However, if tramadol is used because the options listed above are problematic, it is usually prescribed as three to four 50 mg pills per day (eg, 12 tablets).
For pain that is expected to last beyond three days, a five-day prescription (eg, 20 tablets of oxycodone 5 mg or hydromorphone 2 mg) may be reasonable [58].
Opioids for severe pain — For patients expected to have severe pain (eg, after major non-laparoscopic surgery, maxillofacial surgery, total joint replacement, compound fractures, and long bone fracture prior to definitive stabilization), a prescription for up to seven days of higher dose opioid may be required after discharge to adequately manage pain. For patients who are inpatients after surgery or injury, their opioid usage in the 24 hours prior to discharge may be used to guide outpatient prescription. As an example, for a patient who uses oxycodone 10 mg every 4 hours in the 24 hours prior to discharge, the prescription should be written for 10 to 12 tablets of oxycodone 5 mg for use on day 1 to 2 after discharge, with enough additional tablets for an expected taper over the five- to seven-day prescription. Patients should be provided with clear guidance about the expectations for tapering and should be instructed to return for follow up if severe pain persists prior to expected follow up.
If follow-up can be arranged prior to seven days, the prescription should be written for the time period up until the follow-up appointment. Since electronic prescribing for opioids is now available in most of the United States, there is less need to write excessive prescriptions "just in case," as the clinician can generate an additional prescription without the need for the patient to visit the clinic.
Patients should be instructed to take one to two tablets every three to four hours as needed for severe pain. This guidance should translate into an average of 4 to 6 pills per day of the entire prescription of one of the following opioids, for patients without risk factors that require modification of the choice or dose of drug.
●Oxycodone 5 mg or
●Hydrocodone 5 mg (available only with acetaminophen or ibuprofen) (see 'Choice of opioid' above) or
●Hydromorphone 2 mg
For morphine IR 15 mg, the prescription should include 2 to 3 pills per day of the prescription. Patients should be instructed to take ½ to 1 tablet every three to four hours as needed for severe pain.
Discuss naloxone — Clinicians should discuss the availability of naloxone with patients and caregivers. In 2020 the US Food and Drug Administration (FDA) required that labels for all opioids include the recommendation that care providers discuss availability of naloxone with all patients who are prescribed opioids, and specifically consider co-prescribing naloxone for patients who take benzodiazepines or other central nervous system depressants, who have a history of prior opioid overdose, or who have household members at risk for accidental ingestion [59]. Some states (eg, California) require prescribers to offer a prescription of naloxone if the daily opioid dose is >90 MME, the opioid is prescribed with a benzodiazepine, or there is an increased risk for opioid overdose. Additionally, some states require opioid prescribers to provide education on overdose prevention, including use of naloxone.
As of 2023, naloxone is available in the United States over the counter, without a prescription.
PATIENT EDUCATION — The clinician should discuss the goals for pain relief, reasonable options for pain management, and specific instructions on taking, tapering and stopping, storing, and disposing of medication. This is particularly important for patients who receive opioids. Some states mandate that the patient sign a consent prior to starting a long-acting opioid, while others (eg, Vermont) require a signed consent prior to starting any opioid.
Expectation for pain relief — Clinicians should discuss the goals for pain relief with patients, and if appropriate, their care providers, including reasonable expectations for pain relief. The goal should not be zero pain, but mild, tolerable pain that allows the patient to function.
Risks and side effects of opioid therapy — For patients who are prescribed opioids, clinicians should discuss the risks of physiologic dependence, addiction, and overdose, side effects of opioids, and the importance of additional or alternative treatment to reduce the required dose. An example of patient instructions on prescription opioids is available on the Centers for Disease Control and Prevention (CDC) website [60]. The American College of Surgeons provides patient oriented guidance for safe pain control on their website.
Opioids are associated with nausea and vomiting, dizziness, drowsiness, and a dose-dependent incidence of constipation [61]. For patients who are prone to constipation, older patients, and those who are prescribed more than a few days of opioids, we co-prescribe a laxative and stool softener (table 4).
How to take medication — The patient should receive specific instructions on the way to take opioid and non-opioid medication, including how to decrease or stop the medication. Patients should be informed that opioids should only be used when non-opioid pain medications/treatments fail to provide adequate pain relief, and opioids should be tapered quickly while continuing to take nonopioid analgesics. Patients should also be told that unless their health care provider advises otherwise, they should avoid taking benzodiazepines along with opioids.
Opioid taper and discontinuation – Acute pain often peaks at one to three days after injury or surgery, and should be much less by seven days (see 'Pain trajectories' above). Thus, patients for severe pain may require frequent and higher opioid doses (1 or 2 tablets every three to four hours) for the first postoperative day, and progressively less frequent and lower doses over the following days.
It is important to give patients specific instructions for tapering opioids. Patients should be instructed to take opioids as needed, while continuing nonopioid analgesics. As acute pain improves patients should be advised to reduce the individual doses and space out the dosing interval. As an example, a patient taking one pill every six hours for the first three days may be able to decrease to every eight hours on day 4, every twelve hours on day 5, just once in day 6 and then be done.
Safe storage and disposal — Opioids should be stored by patients in secure locations and excess pills should be disposed of properly, to minimize the risk of diversion and inappropriate use. Patients should receive specific instruction on both issues. Most studies have reported that patients do not routinely receive instruction on storage and disposal of opioids [27,62], and most keep surplus medication at home for later use [8,26,28]. Two randomized trials found that patients who were provided with disposal kits after receiving a postoperative opioid prescription were more likely to dispose of leftover opioids than those who did not receive these materials [63,64]. In 2023 the United States Food and Drug Administration (FDA) announced a new requirement that manufacturers of opioids must make available postage paid mail back envelopes at pharmacies that dispense opioids in outpatient settings [65].
The US FDA has issued guidelines for disposal of opioid medication. When possible, the US FDA recommends taking excess opioids to US Drug Enforcement Agency authorized take back locations, which are often pharmacies or police stations. Alternatively, opioids can either be combined with an unpalatable substance (eg, dirt or kitty litter) and placed in a sealed container in household trash, or flushed down toilet [66].
ADJUSTING THE PLAN AS NECESSARY — It is critical to frequently reassess patients, especially those reporting inadequate pain control after guidelines are followed. For patients taking opioids, avoid reflexively increasing the dose, and instead consider other options of multimodal medications, nonpharmacologic treatment such as physical therapy, and providing patient reassurance.
It is also important to evaluate for symptoms of opioid withdrawal, as tolerance can develop quickly after starting opioids and a patient’s perception of pain or side effects may actually be due to withdrawal from the prescribed opioids.
Some patients who complain of pain despite what is thought to be adequate analgesics should be reassessed for possible complications of the injury, condition, or surgery that was performed.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Acute pain management".)
SUMMARY AND RECOMMENDATIONS
●Goal for pain relief – The goal for pain control should be a tolerable level of pain that allows physical and emotional function. (See 'Goals and principles' above.)
●Patient evaluation – Patients should be evaluated for medical and psychological conditions, substance use disorder, pain treatment history, and medications that may make pain control more difficult or influence the choice of analgesics. (See 'Patient evaluation' above.)
If opioids are considered, the Prescription Drug Monitoring Program (PDMP) database should be checked.
●Basic measures for all patients – Acute pain management should include the following, regardless of the degree of pain (see 'Basic measures for all patients' above):
•Nonpharmacologic strategies (eg, ice or heat, elevation, immobilization, rest, relaxation techniques or meditation) as appropriate
•Local or regional anesthesia/analgesia techniques when appropriate
•We suggest acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) unless there are contraindications, and together rather than either drug alone (Grade 2C).
●Strategies based on the degree of pain
•Mild pain – Mild pain should be expected after sprains, dental extraction, superficial surgical procedures, and headaches. Basic strategies described above should suffice and opioids should not be necessary. (See 'Expected mild pain' above.)
•Moderate pain – Opioids may be necessary in addition to basic strategies. Regional anesthesia/analgesia techniques may be appropriate. (See 'Expected moderate pain' above.)
•Severe pain – Regional anesthesia/analgesia techniques should be used when possible. Opioids are usually necessary. (See 'Expected severe pain' above.)
●Nonopioid analgesics – We suggest taking acetaminophen and NSAIDs on a regular basis, rather than as needed (Grade 2C), for more even and sustained analgesia (table 1). (See 'Nonopioid analgesics' above.)
●Opioids – We prescribe opioids only when necessary, after evaluating the patient’s risk of opioid related harm, and at the lowest effective dose for the shortest duration possible. (See 'Opioids' above.)
•We suggest prescribing short acting (immediate release) opioids rather than long acting opioids for acute pain in opioid naïve patients (Grade 2C). This is consistent with guidelines from the Centers for Disease Control and Prevention (CDC) and other professional and governmental organizations. Rapid titration to effect is easier with immediate release opioids, and the risk of unintentional overdose may be greater with long-acting opioids (table 2). (See 'Choice of opioid' above.)
•Naloxone should be discussed with any patient who is prescribed opioids. (See 'Discuss naloxone' above.)
•Patients should be instructed to take opioids as needed, every three to four hours.
•Acute pain peaks at one to three days after surgery or injury, and decreases thereafter. Patients should receive specific instructions on tapering opioids by decreasing the dose and increasing the dosing interval over days as pain subsides, while continuing to take nonopioid analgesics. (See 'How to take medication' above.)
•Prescription details are discussed above. (See 'Opioid dose and duration' above.)
●Patient education – Expectations for pain relief and how to take medication should be discussed with all patients. For patients who take opioids, the discussion should include the risks and benefits, instructions on tapering and discontinuation of opioids, and safe storage and disposal of opioids. (See 'Patient education' above.)
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