Give me pain management pathway and flowchart associated with that and

Give me pain management pathway and flowchart associated with that and images from the Harrison book, 22nd edition.

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pain pathways nociceptive neuropathic pain management analgesic ladder diagram

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"Pain Management"[MeSH Terms] AND "Systematic Review"[Publication Type]

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CDC 2022 Clinical Practice Guideline Prescribing Opioids for Pain updated 2024 page

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https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm

Adult pain-management pathway

This is a general clinical framework based on Harrison's Principles of Internal Medicine, 22nd ed., Chapter 14. It must be adapted for the pain cause, age, organ function, pregnancy status, comorbidities, and local protocols.

1. First assess and treat emergencies

Immediate urgent evaluation if pain is accompanied by:

Hemodynamic instability, altered mental status, respiratory distress
Acute chest, abdominal, or severe headache symptoms suggesting a time-sensitive disorder
New focal neurologic deficit, spinal cord compression features, cauda equina symptoms
Sepsis, acute limb ischemia, compartment syndrome, major trauma
Rapidly escalating pain out of proportion to findings

Principle: establish and treat the underlying cause while starting analgesia. Harrison's describes this as the ideal treatment for acute pain. (Harrison's Principles of Internal Medicine, 22nd ed., p. 140)

Flowchart

PATIENT WITH PAIN
        │
        ▼
1. Rapid assessment
   • Pain score and functional impact
   • Site, onset, duration, character, radiation
   • Triggers/relievers, prior therapies, medication history
   • Examine for red flags / emergency cause
        │
        ├── Red flags or unstable patient
        │       ▼
        │   Resuscitate + urgent diagnosis-specific treatment
        │   Give appropriate titrated analgesia concurrently
        │
        └── Stable patient
                │
                ▼
2. Identify mechanism and time course
   ├─ Acute pain: <1 month
   ├─ Subacute pain: 1-3 months
   └─ Chronic pain: ≥3 months
                │
                ▼
3. Phenotype the pain
   ├─ Nociceptive
   │    • Somatic: localized, aching, throbbing
   │    • Visceral: deep, colicky, poorly localized
   ├─ Neuropathic
   │    • Burning, electric/shooting, tingling
   │    • Allodynia, sensory loss, hyperalgesia
   ├─ Nociplastic
   │    • Altered pain processing, often diffuse pain
   └─ Mixed pain
                │
                ▼
4. Start multimodal treatment
   • Education, reassurance, activity restoration, sleep support
   • Treat underlying pathology
   • Non-drug measures: heat/ice when appropriate, exercise/physiotherapy,
     psychological strategies, rehabilitation
   • Mechanism-directed nonopioid medication where appropriate
                │
                ▼
5. Reassess pain AND function
   ├─ Adequate relief / improving function
   │      → Continue briefly as needed, de-escalate when possible
   │
   └─ Inadequate relief
          │
          ├─ Recheck diagnosis, mechanism, adherence, adverse effects
          ├─ Add or change a mechanism-specific therapy
          ├─ Consider short opioid trial only when expected benefit outweighs risk
          └─ Refer for pain, palliative-care, neurology, or procedural input
             when pain is refractory, complex, or functionally disabling

Mechanism-directed treatment map

Pain pattern	Typical clues	Usual treatment direction
Inflammatory or somatic nociceptive pain	Localized aching or throbbing, tissue injury/inflammation	Treat cause; acetaminophen or an NSAID if appropriate; local measures, rehabilitation
Visceral nociceptive pain	Deep, cramping/colicky, poorly localized	Diagnose and correct visceral cause; use condition-specific treatment plus analgesia
Neuropathic pain	Burning, electric-shock quality, tingling, numbness, allodynia	Consider topical lidocaine for focal allodynia; gabapentin/pregabalin or selected antidepressants such as duloxetine, venlafaxine, nortriptyline, or desipramine, individualized to patient factors
Nociplastic or chronic widespread pain	Diffuse tenderness, altered processing, sleep/mood symptoms may coexist	Exercise and rehabilitation, sleep and psychological interventions, selected centrally acting drugs when indicated; avoid escalating analgesics without functional benefit
Cancer or end-of-life pain	Often mixed nociceptive and neuropathic mechanisms	Multimodal analgesia, opioids when indicated, adjuvants, radiotherapy or nerve/neuraxial procedures when appropriate, specialist palliative-care involvement

Harrison's notes that neuropathic pain following peripheral or central nervous-system injury can be severe and often responds poorly to standard analgesics. It describes anticonvulsants such as gabapentin/pregabalin and certain antidepressants as first-line medication options, selected individually. (Harrison's Principles of Internal Medicine, 22nd ed., pp. 139-144)

Opioid decision branch

Is an opioid necessary after diagnosis, non-drug care,
and suitable nonopioid treatment have been considered?
        │
        ├─ No
        │   → Continue multimodal, mechanism-targeted plan.
        │
        └─ Yes, benefit for pain AND function is expected to exceed risk
                │
                ▼
      • Define functional goal and exit/taper plan
      • Screen for overdose, sedative co-use, substance-use and mental-health risk
      • Prefer immediate-release formulation for new acute use
      • Use the lowest effective dose for the shortest necessary duration
      • Avoid automatic continuation
      • Reassess benefit, function, sedation, constipation, misuse and overdose risk
                │
                ├─ Meaningful benefit outweighs harm → continue with periodic review
                └─ No meaningful benefit or harms predominate → taper/stop safely,
                   optimize nonopioid treatment, consider specialist support

For subacute and chronic noncancer pain, the current CDC opioid guideline prefers nonopioid therapies and recommends considering opioids only when anticipated benefits for pain and function outweigh risks. Harrison's also emphasizes assessment of function, adverse effects, adherence, and ongoing benefit-harm review during chronic opioid therapy. (Harrison's Principles of Internal Medicine, 22nd ed., pp. 143-144)

Harrison's 22nd edition image: pain transmission and descending modulation

This is Figure 14-4 from the Harrison's 22E content: peripheral nociceptor activation, spinal transmission through the spinothalamic tract, thalamic relay, cortical processing, and descending modulation from cortex/hypothalamus through midbrain and medulla.

Harrison's 22nd edition pain-transmission and modulatory pathways

Harrison's Principles of Internal Medicine, 22nd ed., p. 138, Figure 14-4.

Harrison's associated terminal pain-management flowchart

This figure presents a stepwise mild-to-severe analgesic approach and distinguishes nociceptive from neuropathic pain. Use it in the palliative or terminal-care context for which it was presented, rather than as a universal dosing protocol.

Harrison's terminal pain management flowchart

Key practical point: pain intensity alone should not determine treatment. Reassess the diagnosis, pain mechanism, functional effect, response to prior treatment, and medication risks at every escalation step.

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