Table 3. Scientific Evidence for Interventions to Manage Pain in Adults - Pharmacologic Interventions

Intervention [1] Type of Evidence [2] Comments
NSAIDs Oral (alone)Ib, IVEffective for mild to moderate pain. Begin preoperatively. Relatively contraindicated in patients with renal disease and risk of or actual coagulopathy. May mask fever.
Oral (adjunct to opioid)Ia, IV Potentiating effect resulting in opioid sparing. Begin pre-op. Cautions as above.
Parenteral (ketorolac)Ib, IVEffective for moderate to severe pain. Expensive. Useful where opioids contraindicated, especially to avoid respiratory depression and sedation. Advance to opioid.
Opioids OralIVAs effective as parenteral in appropriate doses. Use as soon as oral medication tolerated. Route of choice.
IntramuscularIb, IV Has been the standard parenteral route, but injections painful and absorption unreliable. Hence, avoid this route when possible.
SubcutaneousIb, IVPreferable to intramuscular when a low-volume continuous infusion is needed and intravenous access is difficult to maintain. Injections painful and absorption unreliable. Avoid this route for long-term repetitive dosing.
IntravenousIb, IV Parenteral route of choice after major surgery. Suitable for titrated bolus or continuous administration (including PCA), but requires monitoring. Significant risk of respiratory depression with inappropriate dosing.
Opioids PCA (systemic) Ia, IV Intravenous or subcutaneous routes recommended. Good steady level of analgesia. Popular with patients but requires special infusion pumps and staff education. See cautions about opioids above.
Epidural & intrathecal Ia, IV When suitable, intrathecal provides good analgesia. Significant risk of respiratory depression, sometimes delayed in onset. Requires careful monitoring. Use of infusion pumps requires additional equipment and staff education. Expensive if infusion pumps are employed.
Local anesthetics Epidural & intrathecalIa, IV Limited indications. Effective regional analgesia. Opioid sparing. Addition of opioid to local anesthetic may improve analgesia. Risks of hypotension, weakness, numbness. Requires careful monitoring. Use of infusion pump requires additional equipment and staff education.
Peripheral nerve blockIa, IV Limited indications and duration of action. Effective regional analgesia. Opioid sparing.

[1] Insufficient scientific evidence is available to provide specific recommendations regarding the use of hypnosis, acupuncture, and other physical modalities for relief of postoperative pain

[2] See type of evidence key

From: 1a, Adult Pain Management: Operative Procedures

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