Pharmacologic and Non-Interventional Management
Principles
Multimodal analgesia combines agents with different mechanisms so that individual doses and toxicity stay low. Nonpharmacologic care-physical therapy, exercise, sleep, cognitive behavioral therapy-is part of the plan, not an optional add-on. Match drug to mechanism: neuropathic pain suggests a gabapentinoid, a tertiary amine TCA (nortriptyline, desipramine), or an SNRI (duloxetine); inflammatory nociceptive pain suggests an NSAID or acetaminophen; opioid therapy is reserved for situations in which benefit clearly outweighs risk.
Opioid safety
Before prescribing, assess risk, check the prescription drug monitoring program, obtain urine drug testing, document a treatment agreement, and co-prescribe naloxone for high-risk patients. Reassess function, not just the pain score. Traps: meperidine causes normeperidine accumulation and seizures; tramadol carries serotonergic and seizure risk; methadone prolongs the QT interval; codeine and tramadol depend on CYP2D6; buprenorphine is a high-affinity partial agonist that can precipitate withdrawal if started after a full agonist but is also useful for pain.
Opioid-induced hyperalgesia-diffuse worsening pain with escalating doses-is distinct from tolerance. Sedation and respiratory depression are the dangerous adverse effects; constipation does not develop tachyphylaxis and requires prophylaxis.
Non-interventional options
Topical lidocaine and capsaicin, TENS, acupuncture (limited evidence, low risk), and psychological therapies all have a role. In renal impairment, gabapentinoids require dose reduction.
Rule of thumb: "start low, go slow," titrate to functional effect, and reassess the substrate-nerve, nociceptor, or muscle-before escalating.