Factors to Consider When Treating Acute Pain

Benjamin W. Friedman, MD, MS: If I could move the discussion from diagnosis and assessment toward treatment, what factors do you consider when deciding on a treatment for a specific patient? Jeff, is it OK if I turn to you for that?

Jeff Gudin, MD: Sure. Obviously, there are lots of them, and we’ve already touched on a number of them in our discussion. I look at a couple of things. I look at previous analgesics that have been tried. I ask almost every patient, “What kind of pain medicine have you had in the past? How did you respond to it?” I take into account their age, their comorbidities, and their regimen of medications. We’re aware that drug-drug interactions are a cause of morbidity and often mortality, so we want to be careful using certain combinations of medications. I try to look at the patient as a whole.

For me, it’s important to ask, “What types of therapies have you been on the in past?” and back to the nonpharmacological and pharmacological. For somebody who has recurrent acute pain syndrome, someone who hasn’t done NSAIDs [nonsteroidal anti-inflammatory drugs] for gout or topical analgesics, we don’t jump to an opioid prescription. We try to think from a multimodal standpoint what we could do. But I take a lot of the patient factors into account.

Benjamin W. Friedman, MD, MS: There’s general consensus among us. Would everybody agree that considering the patient’s experience with different medications is quite important when deciding where to go as you move forward in the patient’s care?

Paul Arnstein, PhD, RN, FAAN: I’d add that while taking a patient’s past experience with a particular pain treatment, sometimes you need to drill down a little. A person might say, “I’m allergic to this or that,” and it’s important to find out whether that’s a true allergy or an adverse effect of the medication. The other thing is that sometimes when we’re using some of the opioid-sparing adjuvant medicines, such as some of the gabapentinoids, a patient might say, “That doesn’t work, and it knocked me out. I was too sleepy.” Then you ask, “What dose were you on and how long were you on it?” and you find out that the person wasn’t on a therapeutic dose or didn’t have the duration of therapy required for you to be able to evaluate the effectiveness of a particular treatment.

As a person ages—looking at the over-70 crowd—they might say, “When I was in my 30s, I tried that and it didn’t work.” But as people age, they become more sensitive to the desired and undesired effects of the medication. Something that worked or didn’t work in the past might work for older adults when they’re being monitored, and something that they tolerated in the past might not be tolerated as they age. You take some of that personal history of exposure to medications as an important guiding factor of where we might go with treatment, but it isn’t the only thing that we’d do. It wouldn’t preclude using particular agents in particular situations where they might be deemed best.

Francesca Beaudoin, MD, PhD, MS: We also need to consider the underlying condition that’s being treated as much as we can. For example, migraine has very specific and evidence-based treatments that we wouldn’t necessarily apply to low back pain. It’s important to understand the evidence that’s out there and the quality of that evidence, in addition to all the things Jeff and Paul mentioned. That’s the nature of evidence-based medicine: taking the universe of data and applying it to the individual patient based on factors about that person and trying to figure out what fits best in that situation for that individual patient.

Transcript Edited for Clarity