Pain Management

Opioids remain a mainstay for pain management in many critically ill patients, as noted in the 2018 Pain, Agitation/sedation, Delirium, Immobility (rehabilitation/mobilization), and Sleep (PADIS) guidelines of the Society of Critical Care Medicine (Devlin et al, 2018) [Pain Control in Critically Ill Adult Patients]. Opioids are widely used for treatment of pain in patients with cancer because of their safety, multiple routes of administration, ease of titration, reliability, and effectiveness for all types of pain (ie, somatic, visceral, neuropathic) [Cancer Pain Management with Opioids]. Although neuropathic pain may be more difficult to treat, a favorable response to opioid-based analgesia is often possible. Opioids are the most widely used treatment of postoperative pain but should be used with caution. Morphine is the prototype opioid and the drug with which other analgesics are compared. An optimal strategy for multimodal analgesia entails maximizing the use of nonopioid analgesics to reduce the patient’s exposure to opioids (Management of Acute Perioperative Pain). The role of opioid therapy in the more severe forms of acute pain and in cancer pain is well established, but opioid administration in chronic non-cancer pain remains controversial (Von Korff et al, 2011; Ballantyne and Mao, 2003; Portenoy, 1996). For patients with chronic non-cancer pain, opioids should only be used when other potentially effective and safer therapies have not provided sufficient pain relief and pain is adversely affecting a patient's function and/or quality of life and when the potential benefits of opioid therapy outweigh potential harms. Opioids should be combined with nonopioid pharmacotherapy and nonpharmacologic therapies as appropriate [Use of Opioids in Management of Chroic Non-cancer Pain]. Opioids should be considered a second-line option for neuropathic pain. They may be considered earlier in the treatment of select patients with neuropathic pain, such as those with severe intractable pain, episodic exacerbations of severe pain, or neuropathic cancer pain (Dworkin et al, 2007).