Cuaderno de enfermería. Revista científica
Vol. 3(2), 1-15, 2025
https://doi.org/10.62574/frj12277
1
Pharmacological and non-pharmacological therapies in the management of
pain in critically ill patients. Systematic review
Terapias farmacológicas y no farmacológicas en el manejo del dolor en
pacientes críticos. Revisión sistemática
Lisbeth Nayeli Arciniega-Garrido
nachasnaye27@gmail.com
Universidad Iberoamericana del Ecuador, Quito. Pichincha, Ecuador
https://orcid.org/0009-0008-8439-0267
Mónica Gabriela Moreira-Meza
icabymez@gmail.com
Universidad Iberoamericana del Ecuador, Quito. Pichincha, Ecuador
https://orcid.org/0009-0002-2138-1204
Kleber Alexander Rodríguez-Merchán
alexander999@live.com
Universidad Iberoamericana del Ecuador, Quito. Pichincha, Ecuador
https://orcid.org/0009-0003-7435-897X
ABSTRACT
Objective: To analyse pharmacological and non-pharmacological therapies in pain management in
critically ill patients. Method: Documentary, qualitative and systematic review research, with a sample
of 40 articles. Results and conclusions: Due to their analgesic potency, opioids remain the first-line
analgesic. Morphine and fentanyl are the main opioids used in pain management. Adjuvants also
stand out as a fundamental component of the analgesic approach to minimize opioid doses. Non-
pharmacological treatment, on the other hand, seeks to reduce pain, improve cognitive function,
reduce stress, etc. The main non-pharmacological therapies include music therapy, massage, family
presence, and cryotherapy. Finally, the most commonly used scales in the ICU include the EVA,
ESCID, BPS, and CPOT, as they offer multiple classification categories.
Descriptors: intensive care; pain; pharmacological therapy; non-pharmacological therapy; pain
scales (DeCS).
RESUMEN
Objetivo: Analizar las terapias farmacológicas y no farmacológicas en el manejo del dolor en
pacientes críticos. Método: Investigación de tipo documental, cualitativa y de revisión sistemática,
con una muestra de 21 artículos. Resultados y conclusiones: Por su potencia analgésica, los
opioides siguen siendo el analgésico de primera línea. La morfina y el fentanilo son los principales
opioides utilizados en el manejo del dolor. Asimismo, los coadyuvantes, destacan como un
componente fundamental del abordaje de analgesia para minimizar la dosis de opioides. Por otra
parte, el tratamiento no farmacológico, busca la reducción del dolor, mejorando la función cognitiva,
reduciendo el estrés, etc. Entre las principales terapias no farmacológicas se encuentran:
musicoterapia, masajes, presencia de familiares y crioterapia. Por último, entre las escalas más
utilizadas en la UCI, se encuentran la EVA, ESCID, BPS y CPOT, pues cuentan con más categorías
de clasificación.
Descriptores: cuidados intensivos; dolor; terapia farmacológica; terapia no farmacológica; escalas
de dolor. (DeCS).
Received: 03/04/2025. Revised: 13/04/2025. Approved: 19/04/2025. Published: 08/05/2025.
Original short
Cuaderno de enfermería. Revista científica
Vol. 3(2), 1-15, 2025
Terapias farmacológicas y no farmacológicas en el manejo del dolor en
pacientes críticos. Revisión sistemática
Pharmacological and nonpharmacological therapy for pain management in critically ill
patients. Systematic review
Lisbeth Nayeli Arciniega-Garrido
Mónica Gabriela Moreira-Meza
Kleber Alexander Rodríguez-Merchán
2
INTRODUCTION
Pain is a sensory and emotional experience described by the individual as
unpleasant and associated with actual or potential damage to the organism (1). It
can be noted that in intensive care units (ICU), it is common for patients to
experience pain, whether acute or chronic, depending on their illness, as well as
altering physiological parameters, being irritable and apathetic towards healthcare
staff, which leads to a slower recovery process. Pain is a worrying symptom in the
ICU due to the fact that most users present invasive approaches, injuries,
complications of the underlying pathology and the stay in the unit itself (2).
Likewise, patients admitted to the ICU are under life support measures such as
mechanical ventilation and certain medications that make effective verbal
communication with staff impossible. Pain is considered the fifth vital sign; however,
its assessment, already complicated by its subjectivity, is more difficult in these units
(3). Studies indicate that a significant proportion of ICU patients experience
moderate to severe pain. The incidence varies, but it is estimated that between 40%
and 70% of critically ill patients report pain. Untreated pain is associated with
increased hospital stay, increased risk of complications and impaired post-ICU
quality of life (4).
In the ICU, the prevalence of pain is around 40-77% according to a study carried out
in 45 units in the United Kingdom. The American College of Critical Care Medicine
(ACCM) indicates that the incidence of pain in critically ill patients, whether medically
or surgically intervened, is 50%, generating physical and psychological alterations,
and consequently, patient dissatisfaction with care (15%) (5). The World Health
Organisation (WHO) has shown that pain is a major problem, affecting 12-23% of
the population in Spain. The prevalence and intensity of pain is higher in females
than in males (4).
Cuaderno de enfermería. Revista científica
Vol. 3(2), 1-15, 2025
Terapias farmacológicas y no farmacológicas en el manejo del dolor en
pacientes críticos. Revisión sistemática
Pharmacological and nonpharmacological therapy for pain management in critically ill
patients. Systematic review
Lisbeth Nayeli Arciniega-Garrido
Mónica Gabriela Moreira-Meza
Kleber Alexander Rodríguez-Merchán
3
Similarly, around 190 million people suffer from chronic pain in Latin America,
representing 30% of the population; 63% of critically ill patients experience moderate
to severe pain during their hospital stay in the ICU. Nursing care categorised as
painful stands out as the main cause (2). In Ecuador, the results of the "Burden of
Disease Study of Chronic Pain in Ecuador" were presented and revealed that more
than 3.6 million patients, equivalent to 21 % of Ecuador's population, had chronic
pain. Almost 11% of chronic pain patients are people aged between 55 and 59 years
(6) however, there are no concrete statistical data on the prevalence of pain within
ICUs in the country.
Pain management in the ICU is complex to assess given its unique characteristics.
Therefore, this research arises from the question, what are the pharmacological and
non-pharmacological therapies in pain management in critically ill patients? In
systematic studies worldwide, opioids are the mainstay of pain management in
critically ill patients (7). Therefore, a comprehensive pain assessment is
recommended, based on validated pain assessment scales, such as the BPS
(Behavorial Pain Scale) and the CPOT (Critical Care Pain Observation Tool), which
should be simple, understandable and individualised in order to adjust treatment to
the patient's needs (4).
Although drugs are essential, non-pharmacological therapies play a crucial role.
These include mainly music therapy, massage therapy and companionship. These
techniques promote relaxation, help to decrease anxiety and reduce pain perception,
reduce stress, improve mood and physiological parameters (8). Therefore, pain
reduction is considered a quality standard in the care of critically ill patients (3).
Consequently, the aim of this research is to analyse pharmacological and non-
pharmacological therapies in the management of pain in critically ill patients from a
systematic review.
Cuaderno de enfermería. Revista científica
Vol. 3(2), 1-15, 2025
Terapias farmacológicas y no farmacológicas en el manejo del dolor en
pacientes críticos. Revisión sistemática
Pharmacological and nonpharmacological therapy for pain management in critically ill
patients. Systematic review
Lisbeth Nayeli Arciniega-Garrido
Mónica Gabriela Moreira-Meza
Kleber Alexander Rodríguez-Merchán
4
METHOD
This is a qualitative, qualitative, systematic review research study. Twenty-three
scientific articles were analysed following the guidelines established by the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol.
The search was conducted in recognised scientific databases, such as PubMed,
SciELO, Dialnet, Science Direct. Filters were applied to limit the results to studies
published in English, Spanish and Portuguese between January 2020 and April
2025, with open access and thematic correlation; repositories were excluded. The
following health descriptors were used to establish search strategies: "intensive
care", "pain", "pharmacological therapy", "non-pharmacological therapy", "pain
scales".
RESULTS
According to Zakeri, et al., (9) pain is classified as a frequent and complex symptom
in hospitalisation in both critical and non-critical areas, covering a variety of
conditions, therefore, all manifestations of pain should be considered real and
existing due to the complications of its clinical picture. Within the intensive care
setting a large percentage of patients experience pain, however, not all can express
it verbally as they are sedated or with neurological injuries, otherwise, they present
alterations in their physiological constants and delay in their recovery (10). As a
consequence, several authors describe pain as the fifth vital constant and point out
that it should always be recorded and evaluated.
Adequate pain assessment should be accompanied by a timely, multimodal and
evidence-based treatment strategy (2). The selection of pain management strategy
in ICU patients should encompass pharmacological and non-pharmacological
approaches. In addition, standardised techniques, including the use of accepted
Cuaderno de enfermería. Revista científica
Vol. 3(2), 1-15, 2025
Terapias farmacológicas y no farmacológicas en el manejo del dolor en
pacientes críticos. Revisión sistemática
Pharmacological and nonpharmacological therapy for pain management in critically ill
patients. Systematic review
Lisbeth Nayeli Arciniega-Garrido
Mónica Gabriela Moreira-Meza
Kleber Alexander Rodríguez-Merchán
5
methods, are needed to perform a comprehensive assessment given the complex
nature of pain in these patients (9).
Pharmacological treatment
Analgesia is based on reducing or eliminating the painful experience. Therefore, the
World Health Organisation (WHO) proposes pain management starting from weaker
drugs such as paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) to
more potent drugs such as opioids, and is represented in its well-known "WHO
analgesic ladder" (Figure 1). (Figure 1). Non-opioid analgesics are used to treat mild
pain, and are beneficial in reducing the use of opioids. Paracetamol, NSAIDs and
dipyrone are mainly mentioned (4). On the other hand, opioids are the analgesic
drug of choice in critically ill patients with non-neuropathic pain and are very useful
because of their speed of action and potency, although their major drawback is their
numerous adverse effects (11).
Opioids are a cornerstone of pain management and sedoanalgesia in the
mechanically ventilated patient (MVAP). The best evaluated and most recommended
in clinical practice guidelines for critically ill patients are fentanyl and morphine. In
critically ill patients, opioid withdrawal syndrome is a common and clinically
significant condition, i.e. they are less susceptible to its effects requiring higher doses
to achieve the expected analgesia, making future weaning difficult as mentioned by
Delgado, et al (2). Thus, to guarantee an adequate effect, the association of opioids
with adjuvant drugs is useful.
Cuaderno de enfermería. Revista científica
Vol. 3(2), 1-15, 2025
Terapias farmacológicas y no farmacológicas en el manejo del dolor en
pacientes críticos. Revisión sistemática
Pharmacological and nonpharmacological therapy for pain management in critically ill
patients. Systematic review
Lisbeth Nayeli Arciniega-Garrido
Mónica Gabriela Moreira-Meza
Kleber Alexander Rodríguez-Merchán
6
Figure 1. WHO analgesic ladder.
Source: (4).
Therefore, non-opioid analgesics can improve the overall efficacy of analgesia
and/or reduce opioid requirements, i.e. the combination of opioids with adjuvants
can reduce pain in critically ill patients. Pota, et al. (11), mention that the main
adjuvant treatments are: dexmethedomidine, NSAIDs (including diclofenac,
indomethacin and ketoprofen), ketamine, nefopam, gabapentin, carbamazepine,
clonidine, magnesium sulphate, pregabalin.
Non-pharmacological treatment
Non-pharmacological methods do not replace pharmacological treatments, but are
complementary to treatment. These strategies are especially worthwhile for the
management of mild to moderate pain (12,13). Delgado et al. (2) mention that non-
pharmacological therapy has a clear effect on vital signs such as heart rate,
respiratory rate, oxygen saturation, and reduces motor activity and arousal state
Cuaderno de enfermería. Revista científica
Vol. 3(2), 1-15, 2025
Terapias farmacológicas y no farmacológicas en el manejo del dolor en
pacientes críticos. Revisión sistemática
Pharmacological and nonpharmacological therapy for pain management in critically ill
patients. Systematic review
Lisbeth Nayeli Arciniega-Garrido
Mónica Gabriela Moreira-Meza
Kleber Alexander Rodríguez-Merchán
7
especially after the application of invasive methods. Potential advantages of non-
pharmacological therapy include more effective analgesia, lower doses of opioids
and a decreased risk of side effects related to their use, divided into invasive and
non-invasive techniques as shown in table 1.
Table 1. Adapted from "Pain management in critically ill patients".
Invasive techniques
Non-invasive techniques
Acupuncture
Behaviour modification
Ablative procedures
Aromatherapy
Nerve blocks
Cryotherapy
CNS stimulation
Psychotherapy
Music Therapy
Massage therapy
Source: (4)
Non-pharmacological interventions and treatments generally have effects on both
physiological and psychological dimensions. However, each type of intervention
usually has a primary goal (14). The most common non-pharmacological methods
for pain management include: massage therapy, cold therapy, music therapy and
relaxation techniques. These methods aim to address the physical-sensory
component of pain (massage therapy and pain therapy) and the emotional and
cognitive component (music therapy and relaxation techniques). Some methods
have demonstrated a reduction in pain scores on both visual/verbal numerical scales
and behavioural scales. In addition, family involvement should be considered (15,
16).
On the other hand, Nordness et al. (17) note that relaxation techniques and massage
reduce the impact of pain by providing comfort, relaxation and improving the quality
Cuaderno de enfermería. Revista científica
Vol. 3(2), 1-15, 2025
Terapias farmacológicas y no farmacológicas en el manejo del dolor en
pacientes críticos. Revisión sistemática
Pharmacological and nonpharmacological therapy for pain management in critically ill
patients. Systematic review
Lisbeth Nayeli Arciniega-Garrido
Mónica Gabriela Moreira-Meza
Kleber Alexander Rodríguez-Merchán
8
of sleep and rest. According to a high-quality systematic review, music therapy was
found to be the most effective technique for mechanically ventilated patients,
reducing their need for sedation and analgesics (18). Similarly, Wang et al (19) state
that the efficacy of massage therapy has been well documented through multiple
systematic reviews and meta-analyses; however, although this therapy has been
beneficial for pain intensity, it does not appear to improve physical function in people
with chronic pain.
Pain measurement scales
Identifying pain in patients in the Intensive Care Unit is the crucial start of their
therapy. However, clinical conditions may prevent verbal communication (sedation,
delirium, tracheal intubation, neuromuscular obstruction and weakness). The
application of scales has shown clinically relevant advances in outcomes, including
survival, use of mechanical ventilation, coma and delirium, ICU reintegration, among
others. Guerrero et al. (20) consider that self-assessment of pain is a standard and,
whenever feasible, attempts should be made to measure patient self-reported pain
using validated scales, at least every nursing shift (preferably every 4 h), when the
patient experiences pain before, during and after each procedure that may be
painful.
Thus, verified scales are applied based on the quantification of pain expressed by
the patient whenever feasible, notably the Visual Analogue Scale (VAS) and the
Verbal Numerical Scale (VNS) and other methods of identifying behavioural pain in
situations where communication is not possible (Campbell Scale or Pain Indicator
Behaviour Scale (PBS). The Behaviours Associated with Pain Scale (BPS) and the
Critical Care Observation Tool (CPOT) may also be useful for measuring pain in
non-communicating patients, linking temporary increases of 5-20% in their value to
the existence of pain (21).
Cuaderno de enfermería. Revista científica
Vol. 3(2), 1-15, 2025
Terapias farmacológicas y no farmacológicas en el manejo del dolor en
pacientes críticos. Revisión sistemática
Pharmacological and nonpharmacological therapy for pain management in critically ill
patients. Systematic review
Lisbeth Nayeli Arciniega-Garrido
Mónica Gabriela Moreira-Meza
Kleber Alexander Rodríguez-Merchán
9
So, the Visual Analogue Scale (Figure 2) is a tool in which the patient is asked to
point his or her finger at the intensity of pain he or she feels, going from the extreme
of "no pain" to the extreme of "the worst pain imaginable".
Figure 2. Visual Analogue Scale.
Source: (4).
In order to use this scale, the patient needs to have good motor and visual
coordination, so it has limitations in elderly and sedated patients (4). On the other
hand, the Pain Indicator Behaviours Scale (PICS) comprises 5 behavioural
indicators; López et al. (22) mention that it was mainly tested in critically ill medical
and postoperative patients, who could not self-report and were under mechanical
ventilation (table 3).
Cuaderno de enfermería. Revista científica
Vol. 3(2), 1-15, 2025
Terapias farmacológicas y no farmacológicas en el manejo del dolor en
pacientes críticos. Revisión sistemática
Pharmacological and nonpharmacological therapy for pain management in critically ill
patients. Systematic review
Lisbeth Nayeli Arciniega-Garrido
Mónica Gabriela Moreira-Meza
Kleber Alexander Rodríguez-Merchán
10
Table 3. Adapted from "Validation of the Pain Indicator Behaviours Scale to assess
pain in critically ill, non-communicative and mechanically ventilated patients: results
of the ESCID project".
0
1
2
Partial Score
Facial
musculature
Relaxed
Tension, frown/painful
gesture
Habitual frowning/
clenched teeth
"Peace of
mind"
Calm,
relaxed,
normal
movements
Occasional fidgeting
and/or posturing
Frequent
movements,
including head or
limbs
Muscle tone
Normal
Increased. Flexion of
fingers and/or toes
Rigid
Adaptation to
mechanical
ventilation (MV)
Tolerating
mechanical
ventilation
Coughing, but tolerates
MV
Struggling with the
respirator
Comfort
Comfortable,
quiet
Soothes to touch
and/or voice. Easy to
distract
Difficult to comfort
by touch or by
talking to him/her
Total score 10
0: no pain
1-3: mild-
moderate pain
4-6: moderate-severe
pain
> 6: very severe
pain
Consider
other possible
causes
Source: (22).
Likewise, the BPS, developed for incommunicable patients in critical settings, is
distinguished by its reliability and validity, which is supported by three essential
factors: facial expression, upper limb movement and adaptation to mechanical
ventilation. The scale measures the items presented in Table 4 and 5. Finally, one
study demonstrates that with the adoption of CPOT there was an increase in pain
relief interventions for mechanically ventilated patients, which contributed to effective
pain management and also to reduced levels of sedation. The applicability of the
Cuaderno de enfermería. Revista científica
Vol. 3(2), 1-15, 2025
Terapias farmacológicas y no farmacológicas en el manejo del dolor en
pacientes críticos. Revisión sistemática
Pharmacological and nonpharmacological therapy for pain management in critically ill
patients. Systematic review
Lisbeth Nayeli Arciniega-Garrido
Mónica Gabriela Moreira-Meza
Kleber Alexander Rodríguez-Merchán
11
CPOT scale in pain monitoring in primary sclerosing cholangitis with brain lesions
and their compromised verbal communication is highlighted (4,23).
Table 4. Adapted from "Pain management in the critically ill patient".
Description
Score
Relaxed
1
Partially tense
2
Totally tense
3
Grimacing
4
Relaxed
1
Partially flexed
2
Fully flexed
3
Fully contracted
4
Tolerating movements
1
Coughing, but tolerating for most of the
time.
2
Fighting the fan
3
Unable to control the fan
4
Final Score
Source: (4).
Cuaderno de enfermería. Revista científica
Vol. 3(2), 1-15, 2025
Terapias farmacológicas y no farmacológicas en el manejo del dolor en
pacientes críticos. Revisión sistemática
Pharmacological and nonpharmacological therapy for pain management in critically ill
patients. Systematic review
Lisbeth Nayeli Arciniega-Garrido
Mónica Gabriela Moreira-Meza
Kleber Alexander Rodríguez-Merchán
12
Table 5. Adapted from "Pain management in the critically ill patient".
Indicator
Description
Score
Facial
expression
Relaxed. No muscle tension
0
Tense. Presence of frown, low eyebrows, contracted
eye orbits.
1
All of the above facial movements plus tightly closed
and grimacing eyelids
2
Body
movement
No movement
0
Slow, cautious movements, no touching or rubbing of
the painful area, protection, sharp attention through
the movements
1
Pulls on the tube, moves or bangs limbs, tries to sit
up, does not follow commands, restlessness
2
Muscle
tension
(passive
flexion and
extension of
limbs)
Relaxed, no resistance to passive movements
0
Tight, rigid, with resistance to passive movements
1
strong resistance to passive movements, inability to
perform them completely, very tense
2
Ventilator
adaptation
(intubated
patients)
Well adapted to the fan, no alarms are triggered, easy
ventilation
0
Spontaneous arrest alarms, coughs, but tolerates
breathing
1
Asynchrony, fan stops, alarms are triggered
frequently, struggles with the fan
2
Vocalisation
(extubated
patients)
Speak in normal pitch or do not articulate sound
0
Sigh, moan
1
Shouting, sobbing
2
Final score
Source: (4).
Cuaderno de enfermería. Revista científica
Vol. 3(2), 1-15, 2025
Terapias farmacológicas y no farmacológicas en el manejo del dolor en
pacientes críticos. Revisión sistemática
Pharmacological and nonpharmacological therapy for pain management in critically ill
patients. Systematic review
Lisbeth Nayeli Arciniega-Garrido
Mónica Gabriela Moreira-Meza
Kleber Alexander Rodríguez-Merchán
13
CONCLUSION
Among pharmacological and non-pharmacological therapy, the use of drugs (most
commonly used are fentanyl and morphine) is still pointed out as the most effective
treatment for pain relief in critically ill patients, although non-pharmacological
techniques (music therapy, accompanying massage therapy) can complement it as
they encompass an emotional approach especially in conscious patients. Therefore,
preventive analgesia and non-pharmacological analgesic interventions are
recommended before invasive and potentially painful procedures in critically ill
patients. On the other hand, being subjective in nature, pain becomes a measurable
element, so that, among the pain measurement scales applied in the ICU, the BPS
and CPOT are indicated as the most effective in patients with deep sedation and
under mechanical ventilation, and the VAS is the most widely applied and effective
in awake and cooperative patients.
FUNDING
Non-monetary
CONFLICT OF INTEREST
There is no conflict of interest with persons or institutions involved in research.
ACKNOWLEDGEMENTS
To the UNIBE Research Directorate.
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Terapias farmacológicas y no farmacológicas en el manejo del dolor en
pacientes críticos. Revisión sistemática
Pharmacological and nonpharmacological therapy for pain management in critically ill
patients. Systematic review
Lisbeth Nayeli Arciniega-Garrido
Mónica Gabriela Moreira-Meza
Kleber Alexander Rodríguez-Merchán
14
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Cuaderno de enfermería. Revista científica
Vol. 3(2), 1-15, 2025
Terapias farmacológicas y no farmacológicas en el manejo del dolor en
pacientes críticos. Revisión sistemática
Pharmacological and nonpharmacological therapy for pain management in critically ill
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