Note that this first example is directed toward the management of acute pain, and the interventions take place in the hospital or surgical facility. Many people, however, suffer chronic pain and self-medicate to treat it. In either case, multimodal analgesic techniques may still be used.

Patient A is scheduled to receive a total knee replacement arthroplasty [123]. Preoperatively, the patient is counseled regarding what pain might be expected with this surgery and how it might be treated. After the patient has been worked up, she receives acetaminophen 1,000 mg and celecoxib 400 mg by mouth [123]. This is referred to as pre-emptive analgesia and is done to ensure that the processes needed to, in this case, block the inflammatory effects of prostaglandins released by surgery are beginning to function prior to initiation of surgery [124].

The patient is next taken to a block room and receives local anesthesia in the knee area. In other cases, surgeons may inject local anesthesia at the end of the case.

During surgery, the patient receives a spinal anesthetic with local anesthesia. The anesthetic is placed in the subarachnoid space with local anesthesia. Because the local anesthetic is deposited so close to the nerves, a very small dose can provide several hours of anesthesia.

After surgery, the patient begins to receive several pain management interventions almost immediately, the first of which is cryotherapy. Next, as the body is responding with an inflammatory process releasing prostaglandins and other neurotransmitters in response to an injury (albeit a therapeutic one), the patient receives 1,000 mg of acetaminophen every six hours around the clock [123]. This patient tolerated oral analgesics, but acetaminophen can be administered intravenously for those experiencing problems with postoperative nausea and vomiting. The patient is also started on celecoxib 200 mg twice per day for up to five days. At this point, Patient A begins to question the need for NSAIDs when she is "having no pain." The nurse describes the importance of reducing inflammation in simple terms. He also explains that the long-acting local anesthetics will wear off over time, and it is important to pre-emptively control pain. Despite these interventions, some patients will experience postoperative pain exceeding the ability of NSAIDs to mitigate. For these individuals, an opioid rescue (oxycodone tablet 5 mg and intravenous hydromorphone 0.2 mg) every four hours as needed will help bring most pain under control [123].

Patient B is an elderly man (85 years of age) with chronic and unremitting pain. Initial assessment of the patient's pain remains important. While Patient B is experiencing chronic pain, he may also have an unresolved injury or illness causing the pain. In such a case, treatment of the underlying pathology could result in mitigation of pain [125].

Therapeutic intervention for Patient B begins with the use of NSAIDs and COX-2 inhibitors, especially for a pathology such as osteoarthritis, which is quite common among the elderly. As part of the assessment in this example, remember that elderly patients tend to have less total body water, decreased muscle tone, increased fat stores, and normal age-related degeneration of the liver and kidneys [125]. Unless there are other factors (e.g., current opioid use disorder), the best approach is to start low and titrate slow—use the smallest dose possible and increase it incrementally in small doses. The elderly often experience depression as part of their chronic pain; this should not be surprising, as living with unresolved pain each day can be psychologically taxing. Antidepressant agents, such as an SNRI, may be added to the care plan, with the caveat that there is an increased risk of falling [126]. Gabapentinoids may replace the antidepressant if the pain is neuropathic in nature, and opioids can be added on an as needed basis, though it is crucial to start at the low end of the dosing scale [126]. This follows the WHO guidance of NSAIDs first and opioids last.

While it is fine to conduct mental exercises with imaginary patients, the guiding standard for the clinician is whether the analgesia works. This is an important question, so at this point a small number of studies will be presented for your review.

In this example, Patient C, a man 71 years of age, presents with a severe case of recurring right sciatic pain [127]. On history and examination, the patient describes persistent pain at a scale of 8 out of 10, starting in the lumbar area of his back and running down his right thigh. Further comorbidities include chronic obstructive pulmonary disease (COPD) and previous right-side neck surgery to remove a buccal tumor. An MRI is ordered, revealing spondylolisthesis, which causes pain in lower back or legs at L5–S1, and the patient was also identified as having degenerative disk disease at L5–S1, and disk herniations at L3–L4, L4–L5, and L5–S1 [127]. This patient is taking 20 mg oxycodone daily in an effort to mitigate his pain.

The pain control team begins to titrate back the patient's oxycodone with tramadol and offers surgical decompression. After the patient refuses surgical intervention, the team decides to administer an ultrasound-guided caudal epidural steroid injection of triamcinolone 40 mg and 2% lidocaine 20 mg (local anesthetic) mixed in 12 mL of normal saline [127]. The mixture of normal saline is necessary because epidural injections require a greater volume to ensure the nerve roots are all bathed in the solution.

After the injection, Patient C's walking distance increases from 20 meters to 200 meters, and his pain score reduces from 10 to 7. One month later, the patient remains improved, but the team decides to add 5 mg oxycodone (25% of the original dose) as needed back to the patient's regimen. By his third month post procedure, the patient's pain score has dropped to 2. The multimodal plan, when compared with the singular large dose opioid plan, proved to be life-changing for this patient [127].