The Balancing Act of Pain Management

Dr. Spaeth

Hospitalists continue to grapple with the best multimodal way to control patient pain while maximizing the use of medications and other available choices.

“Pain is uniquely personal and requires engagement of both the physician’s heart and mind to provide an individualized, holistic plan of care,” said Lauren Spaeth, DO, an internal medicine chief resident and hospitalist with Ohio Health Riverside Methodist Hospital in Columbus, Ohio. “If at first your plan doesn’t succeed, persist, and try again.”

The Hospitalist spoke with several hospitalists to discover recent advances in pain medicine and what challenges remain.

Recent Advances

A focus on reducing opioid misuse has changed the pain management focus for hospitalists and other physicians.

Dr. Jaffee

“The standard of care in- and outpatient has been a more aggressive multimodal pain approach, which is great,” said Will S. Jaffee, DO, a hospitalist with MaineHealth Maine Medical Center Portland in Portland, Maine, and assistant professor of clinical medicine at Tufts University School of Medicine in Boston.

This includes a greater emphasis on physical therapy, cognitive behavioral therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), inpatient nerve blocks, and opioids when needed.

Dr. Herzig

Suzetrigine (JOURNAVX), approved by the U.S. Food and Drug Administration in 2025, was the first new class of pain medicine approved in more than 20 years, says Shoshana J. Herzig, MD, MPH, associate chief of hospital medicine for academic affairs at Beth Israel Deaconess Medical Center, associate professor of medicine at Harvard Medical School, and co-director of the Prescribing Wisely Lab, all in Boston.

It targets a pain-signaling pathway involving sodium channels in the peripheral nervous system, helping to avoid addictive potential and central side effects associated with opioids.

“Initial trials have been in small, highly select patient populations undergoing relatively minor procedures, so its role in more severe postoperative pain and its long-term safety remain to be defined,” Dr. Herzig said.

That, combined with the high cost of suzetrigine at this point, has led to a limited number of hospitals using the drug for pain control.

Dr.Rambachan

“Movement toward suzetrigine is very exciting, and it would be great if we had access to some more of those types of medications,” says Aksharananda (Akshar) Rambachan, MD, MPH, a physician-investigator and hospitalist with the UCSF division of hospital medicine at the University of California San Francisco in San Francisco.

Until then, hospitalists find other workarounds.

Ketamine for Pain

At Dr. Jaffee’s hospital, a ketamine order set for patients without psychotic disorders makes subanesthetic dosing easy to follow. The subanesthetic or analgesic dosing the hospital uses is 0.05 to 0.2 mg/kg/hour compared with an anesthetic dosing of more than 1 mg/kg/hour.

Physicians at Dr. Jaffee’s hospital offer ketamine “somewhat frequently,” he said, with a soft majority of patients having a positive response to ketamine infusions.

With the positive results, Dr. Jaffee wonders about an unintended positive side effect of temporarily treating depression in some patients.

“Outpatient ketamine protocols for depression often involve a 0.5 mg/kg infusion over 40 minutes, repeated over multiple visits. We are certainly hitting that dose in patients receiving infusions,” he said.

The use of repeat depression screenings by primary care physicians or mental health colleagues may help to track any effects from ketamine, he says.

Dr. Jaffee has seen some side effects such as transient hypertension, dissociation, and nausea. He has not seen any respiratory side effects.

“This side effect profile is far safer than the opioids we are all quite familiar with,” he said.

Nondrug Approaches for Pain

Another pain management area that continues to grow is the use of nondrug therapies, which span the range of standard ice and heat regimens, massage, physical therapy, nerve blocks, music or art therapy, acupuncture, aromatherapy, and better sleep protocols.

Dr. Rambachan sees many advantages from inpatient massage therapy, especially for musculoskeletal and even abdominal pain.

“It makes patients feel like human beings instead of people who are stuck in this sterile hospital environment,” he said. “I wish we could provide it to every single patient because I haven’t yet seen a patient who’s been unhappy with it.”

Because of the limited number of massage therapists on staff, massage therapy is usually reserved for patients with cancer or cancer-related pain.

Dr. Calcaterra

A lack of insurance coverage often limits approaches like massage and reiki (a Japanese energy healing technique), says Susan L. Calcaterra, MD, MPH, MS, director of the addiction medicine consultation service and associate professor of medicine in the divisions of general internal medicine and hospital medicine at the University of Colorado Hospital in Aurora, Colo, and a program physician with Denver Health Opioid Treatment in Denver.

Although it may sound basic, better sleep also plays a role in pain control.

“Poor sleep lowers pain threshold and gets under-addressed in the hospital,” Dr. Herzig said.

At Dr. Spaeth’s hospital, earplugs, sleep masks, and avoiding new sleep aids may be advised. Timing considerations, like retiming morning labs for after 6 a.m. and scheduling diuretics for early morning and afternoon dosing, can help avoid nighttime sleep disruption.

When it’s available, those massages can also eventually help with general relaxation and sleep as well, Dr. Rambachan says.

Aggressive treatment of constipation also becomes important as untreated side effects often drive perceived poor pain control, Dr. Herzig says.

Also, don’t neglect the value of simply listening to patients and staying aware of emotional factors at play.

Dr. Icaza

“We know there are many factors that can influence one’s perception of pain,” said Eduardo Icaza, MD, clinical assistant professor at Florida International University Herbert Wertheim College of Medicine and interventional pain management physician at Baptist Health Miami Neuroscience Institute, both in Miami. “Emotional stressors, including anxiety and deep depression, can be large drivers [of pain].”

Gentle encouragement can also help. “It can reassure [patients] that something nefarious isn’t happening every time their pain changes slightly,” Dr. Jaffee said.

Underlying mental health disorders (which can be screened for), hospital-induced insomnia, and underdosing of chronic pain medications are also important to consider, Dr. Spaeth says.

So is the role that religious beliefs might play in a person’s pain experience and the need for a doctor’s cultural competence in managing expectations.

Managing Opioid Medication Use

Many hospitals will begin with acetaminophen or NSAIDs as first-line pain management and escalate from there, using multimodal approaches to address pain.

At Dr. Rambachan’s hospital, the electronic health record will prompt a choice for acetaminophen unless it’s contraindicated. That alone triggers some behavioral decision making to lean toward a less advanced drug choice for pain, he believes.

He sees this as a positive, except for patients who need higher-intensity pain medications immediately. “They have pain so severe that Tylenol by itself is not going to cut it,” Dr. Rambachan said.

For some patients, when pain is not well controlled with the basics, opioid medications may be used.

Dr. Calcaterra describes how multimodal therapy works at her hospital. It may include acetaminophen or NSAIDS (oral or IV, including Toradol), antineuropathic agents for neuropathic pain, antidepressants if there is co-occurring depression, muscle relaxants for muscular pain (while avoiding benzodiazepines or carisoprodol), and topical agents.

If available, Dr. Calcaterra will partner with the acute pain service to offer regional anesthesia, ketamine, or lidocaine infusions.

All of these are in addition to non-drug strategies, including ice, position changes, relaxation strategies, reading, music, and even just distraction with family and friends.

“We use opioids when these therapies are insufficient to control pain. IV opioids like morphine and hydromorphone are helpful to capture acute pain with as-needed oral opioids like oxycodone or hydromorphone, which have a longer duration of action than IV opioids,” Dr. Calcaterra said. “We use patient-controlled analgesia in select scenarios when patients need continuous IV pain medication and additional IV doses, such as with a sickle cell pain crisis.”

For a patient on chronic opioid therapy for chronic pain who does not have opioid use disorder, Dr. Calcaterra recommends continuing at least half of the home opioid regimen with as-needed short-acting opioids depending on the clinical picture and the acuity or severity of their pain.

This also includes the use of continuous pulse oximetry for safety and monitoring, as well as naloxone on the Medication Administration Record for overdose reversal if needed.

Dr. Icaza is also a proponent of prescribing intranasal naloxone and finds that patients and their family members are receptive to it if physicians explain that it has a purpose beyond opioid misuse.

Opioids and Higher-Risk Patients

When patients are opioid-tolerant or have opioid abuse disorder, hospitalists take a careful look at pain treatment options.

This often means working with addiction medicine, but it doesn’t necessarily mean avoiding the use of opioids.

“We have both an inpatient addiction-medicine team to help manage opioid-tolerant patient pain and a ‘pain service’ under anesthesia,” Dr. Jaffee said. “However, many of us feel comfortable up titrating the PRNs for patients on methadone or buprenorphine … Our primary goal is to keep them comfortable enough that they stay in the hospital rather than leaving under-treated for an infection and coming back worse.”

This also involves frequent vital sign checks and establishing a rapport with patients.

One principle that Dr. Herzig and colleagues follow is recognizing that tolerance requires higher opioid doses for equivalent analgesia and that this is distinct from drug-seeking behavior. “Framing matters for both prescribing and staff attitudes,” Dr. Herzig said.

However, it also is a good idea to aim for the lowest effective dose for the shortest duration and check the Prescription Drug Monitoring Program before ordering opioids, not as a barrier but to calibrate monitoring intensity, she adds.

“Buprenorphine-methadone continuation for patients on medications for opioid-use disorder is now standard. Stopping it on admission is increasingly recognized as harmful and a missed opportunity,” she said. Bridging these patients to outpatient opioid-use disorder treatment at discharge is part of the plan, she adds.

“Unfortunately, evidence shows that patients with opioid use disorder or opioid tolerance receive inequitable care in hospitalized environments as their pain is often less believed … I think this is an educational opportunity for our clinicians,” Dr. Rambachan said.

When a patient is on buprenorphine, Dr. Calcaterra will typically recommend the use of two to three times the usual dose of short-acting opioids (such as hydromorphone or oxycodone) in addition to continuation of buprenorphine to account for a higher opioid tolerance.

“Similarly, if a patient is on methadone, use short-acting opioids at two to three times the usual dose for acute pain control,” she said.

Overall, a multimodal approach to pain and working with a team of multidisciplinary providers can help target pain in any patient, but especially with the more challenging patients with opioid tolerance or opioid abuse disorder, Dr. Icaza says.

“We aim to have honest conversations and set realistic expectations with these patients, for example, decreasing IV opioid dosing frequency on postop day two and scheduling outpatient follow-up,” Dr. Icaza said.

Palliative care can be an option for patients with uncontrolled pain despite increasing dosing and frequency, Dr. Spaeth says. “Our palliative care teams consist of trained chaplains, social workers, palliative advanced practice providers, and physicians to offer total pain care,” she said.

Future Pain Control

Going forward, hospitalists are eager to see more data on pain control, including real-world, longer-term data for suzetrigine and any similar next-generation drugs that may get approved in the future.

That includes data on whether these next-generation drugs can meaningfully displace opioids for more severe pain and not just mild to moderate pain, Dr. Herzig says.

Another pain point (pun intended) to address going forward is better integration of addiction medicine into general medicine workflows instead of siloed consults, Dr. Herzig says.

Hospitalists also say that they would like more non-pharmacological infrastructure, including regional anesthesia access and more massage and physical therapy staffing.

Dr. Rambachan believes in moving away from the simple 0 to 10 pain scale, which may give hospital systems an easy number to track but ignores the subjectivity and multidimensionality of pain. There may be a larger look at pain in terms of how it affects function, quality of life, and sleep. This also reflects many patients’ priorities, he adds. He cites the updated version of the Defense and Veterans Pain Rating Scale as an example of a pain scale that addresses function more closely.

“Of course, a patient wants to be in less pain numerically on an intensity scale, but what they really care about is being able to play with their grandkids or being able to go to the gym or ride their bike. And in the hospital setting, does pain limit them from eating, getting up to use the bathroom, or working through physical therapy?” he said.

Another area for continued examination is personalized pain management plans that tackle pain more equitably for all, Dr. Rambachan adds.

“We are hopefully moving away from a one-size-fits-all approach to pain management and trying to personalize things,” he said, pointing to the use of interpreter services to ask pain questions and the use of biometrics for real-time pain monitoring.

Dr. Spaeth agrees about the need to address equity and pain. “Discharge barriers due to uncontrolled pain and limited inpatient resources to actually address personal social determinants of health barriers remain challenging. Connection with outpatient pain clinics for appropriate follow-up is also needed,” she said. 

Vanessa Caceres is a medical writer in Bradenton, Fla.