8 Safe Pain Management in Practice

Assess pain and the person

Pain management is individualized. The aim is not only to lower pain intensity, but also to improve function, sleep, and quality of life while minimizing treatment harms. No single treatment works for everyone, and a risk factor should prompt thoughtful planning rather than dismissal of a person’s pain.

A Pain assessment should guide treatment choices and establish what improvement would matter to the person. Use the person’s report as central evidence, and reassess both pain and function after a treatment change; a pain score alone cannot show whether a plan is helping.

Clarify the following before choosing treatment:

• Location and pattern: Ask where the pain is, when it began, how long it has lasted, whether it is acute, subacute, or chronic, and what makes it better or worse.

• Quality and severity: Ask whether it is aching, sharp, burning, or electric. A rating from $0$ to $10$ can help track change, but does not capture the whole experience.

• Cause and associated symptoms: Look for a treatable underlying condition and symptoms that need urgent evaluation.

• Effect on function: Ask what the person can and cannot do, such as walking, sleeping, working, or completing daily activities, and what they hope to regain.

• Previous treatments: Review prescription and over-the-counter medicines, physical or behavioral therapies, responses, and adverse effects.

• Safety factors: Review medical conditions, allergies, pregnancy where relevant, kidney and liver function, falls or breathing risks, alcohol and other substance use, and the full medication list, including supplements.

Match treatment to pain and needs

A Multimodal plan uses complementary approaches where appropriate. Options may include movement or physical therapy, heat or ice, sleep support, behavioral strategies, and one or more carefully selected medicines. Nonopioid and nonpharmacologic treatments are preferred for many common acute pain conditions and for subacute or chronic pain. An opioid may be appropriate in selected situations when expected benefits outweigh risks, but it is not automatically the first or only option.

Common medication groups

Acetaminophen may help some mild-to-moderate pain. Check the active ingredients on all product labels because combination cold medicines and prescription pain medicines may also contain it. Do not exceed product directions or combine acetaminophen-containing products without professional advice; excess can cause severe liver injury. Ask a clinician or pharmacist about use with liver disease or regular alcohol use.

NSAIDs, such as ibuprofen and naproxen, may help pain with inflammation. Topical NSAIDs can be an option for some localized pain. Use them only as directed, and do not take multiple NSAIDs together unless specifically instructed. They can cause stomach bleeding and kidney problems and may increase cardiovascular risks; individual risk varies. Seek advice before use if there is a history of ulcer or bleeding, kidney or heart disease, use of blood thinners, or pregnancy.

Opioids, including morphine, oxycodone, hydrocodone, and fentanyl, may be considered for selected severe acute pain or other carefully assessed circumstances. They can cause sleepiness, constipation, impaired coordination, physical dependence, opioid use disorder, and life-threatening respiratory depression. When initiating an opioid, clinicians generally use an immediate-release product at the lowest effective dose and for no longer than needed, then reassess benefits, risks, and function. Do not abruptly stop long-term opioid therapy without a clinician’s plan unless emergency care is needed.

Adjuvant medicines can help selected nerve-related or localized pain. Certain antidepressants, including some SNRIs or tricyclics, and antiseizure medicines such as gabapentin or pregabalin may help selected nerve-related pain. Topical lidocaine or capsaicin may be useful for some localized pain. These medicines have their own risks and may take time to help. Antidepressants can cause effects such as nausea, sleep changes, or dizziness; gabapentinoids can cause sleepiness and dizziness. Combining gabapentin or pregabalin with opioids or other sedatives may increase breathing risk, especially in older adults or people with respiratory disease. Do not stop a prescribed medicine suddenly without advice.

Medication selection and dosing depend on diagnosis, age, other medicines, health conditions, and product instructions.

Prevent medication errors and harm

Patients can help reduce medication errors and adverse effects by following a few safety practices:

1. Keep one current medication list and share it with each clinician and pharmacist. Include nonprescription medicines, supplements, and alcohol or other substances when discussing safety.

2. Check active ingredients, not just brand names. Combination products may duplicate acetaminophen, an NSAID, or a sedating ingredient.

3. Follow the label or prescription exactly. Do not take extra doses, use another person’s medicine, or change the dose or schedule without checking with a clinician or pharmacist.

4. Use one pharmacy when practical and ask the pharmacist to check for duplicate ingredients or interactions.

5. Avoid dangerous combinations. Do not combine opioids with alcohol, benzodiazepines, sleep medicines, or other sedating drugs unless the prescriber has specifically reviewed the combination and made a safety plan. Opioids combined with sedatives, including gabapentinoids, can cause profound sedation and slowed or stopped breathing.

6. Store medicines securely, away from children, visitors, and anyone for whom they were not prescribed. Dispose of unused medicines using a recommended take-back or disposal option.

7. Report concerning effects promptly. Severe allergic symptoms, black stools or vomiting blood while using an NSAID, possible acetaminophen overdose, or unusual confusion and extreme sleepiness warrant urgent professional advice.

For opioid treatment, clinicians may also review the state prescription drug monitoring program, discuss overdose risk, consider toxicology testing when appropriate, and arrange early follow-up. These are safety tools to support care, not substitutes for respectful clinical judgment.

Recognize and respond to overdose

An Opioid overdose can slow or stop breathing. Warning signs include being difficult or impossible to wake, slow or shallow breathing, gurgling or choking sounds, limpness, and pale, blue, or cold skin.

Treat suspected overdose as an emergency:

1. Call 911.

2. Give Naloxone if available, following its instructions.

3. Stay with the person until emergency help arrives.

Naloxone can wear off before the opioid does. Emergency evaluation is still necessary even if the person wakes up, and the person should not be left alone because overdose symptoms may return.

Discuss access to naloxone with a clinician or pharmacist when opioids are prescribed, especially when there is a history of overdose or substance use disorder, sleep-disordered breathing, concurrent sedative use, or another increased overdose risk. Household members should know where naloxone is kept and how to use it.

Set goals and follow up

A useful shared plan includes concrete treatment goals for function as well as pain relief, such as improving sleep or walking farther. It should state what medication and nonmedication steps to try, the expected benefit, relevant adverse effects, when to contact the care team, and how medicines will be used, combined, stored, and disposed of safely.

Plan when to reassess whether pain, function, and side effects have improved. For opioid therapy for subacute or chronic pain, CDC recommends evaluating benefits and risks within 1 to 4 weeks of starting or increasing treatment, and periodically thereafter.

If long-term opioids no longer provide enough benefit to justify their risks, the clinician and patient should discuss options together. Unless there is an immediate life-threatening concern, sudden discontinuation or rapid dose reduction can cause harm. A gradual, individualized plan with continued pain care is generally safer.

Apply the safety principles

These situations illustrate how assessment, medication safety, and follow-up guide decisions.

Duplicate acetaminophen

A person takes a prescription pain medicine containing acetaminophen and plans to take an over-the-counter cold remedy. First, check the active ingredients on both labels and ask a pharmacist or clinician before combining them. Both products may contain acetaminophen, and taking more than directed can cause severe liver damage.

NSAID risk

A patient with a history of stomach ulcer who takes a blood thinner asks about over-the-counter ibuprofen. Do not assume an over-the-counter medicine is risk-free. NSAIDs can increase stomach bleeding risk, especially with ulcer history or blood thinner use; the patient should consult a clinician or pharmacist about safer options before taking it.

Sedation and breathing risk

A person taking an opioid is also prescribed a benzodiazepine and has begun gabapentin, and now feels unusually sleepy. This combination can increase sedation and respiratory-depression risk. The person should promptly contact the prescriber or pharmacist for an urgent medication-safety review and should not add alcohol or other sedatives. If they are difficult to wake or have slow, shallow, or difficult breathing, someone should call 911 and give naloxone if available.

Suspected overdose

If a family member cannot wake a person who uses prescribed opioids and their breathing is very slow, call 911 immediately, give naloxone if available and follow its instructions, and stay with the person while monitoring them until emergency help arrives. Do not leave the person alone because overdose symptoms may return.

Nerve-related pain and function

For burning, electric pain after a nerve injury that has not responded much to an over-the-counter analgesic, reassess the cause, symptoms, effect on function, and previous treatments. Some antidepressants or antiseizure medicines can help selected neuropathic pain. The clinician can weigh potential benefit, side effects, interactions, and nonmedication options. Include a functional goal and follow-up rather than focusing only on a medication name.

Long-term opioid treatment

If a patient’s benefit from a long-term opioid has declined, encourage a prompt, nonjudgmental discussion with the prescriber to reassess pain, function, benefits, harms, and other treatment options. Do not recommend abrupt self-discontinuation. If a change is appropriate, the clinician should help plan it gradually and continue supporting pain care.