Pain management should begin with a differential diagnosis for pain etiology, and the pain should be categorized by its archetype (somatic vs. inflammatory vs. visceral).
Goal of treatment should be to maximize the patient’s function, pain control and ability to enjoy life.
For pain with multiple etiologies a multimodal approach using opioid and non-opioid medications will be most effective.
Individualize each patient’s regimen based on patient-specific factors including but not limited to age, organ function, other co-morbidities and a thorough risk assessment using a validated tool.
The oral route is the preferred route of analgesic administration. It is the most convenient and cost-effective method.
Medications for persistent, chronic pain should be administered on a scheduled basis.
Intramuscular administration of medications should be avoided. This route is painful, inconvenient, and is prone to erratic absorption rates.
Placebos should not be used in the treatment of pain.
Follow a logical, stepwise process for the treatment of pain. Resources available include the World Health Organization Ladder for the treatment of Cancer Pain, Principles of Analgesic Use by the American Pain Society and the Centers for Disease Control Guidelines for Prescribing Opioids for Chronic Pain.
Generally:
For Mild to Moderate Pain, use non-opioid analgesics and adjuvants when possible to control pain. o Unless contraindicated NSAIDs and acetaminophen should be used. Adjuvant agents are those agents that enhance analgesic efficacy, treat concurrent symptoms that exacerbate pain, and/or provide independent analgesic activity for specific types of pain.
If non-opioid therapy is insufficient to provide adequate pain control, consider the benefits and risks to adding a short-acting opioid as needed to control pain. Single-agent, short-acting opioids are preferred over combination products for maximum flexibility in opioid dose.
For Severe Pain or Pain requiring around the clock pain control with short-acting opiates consider adding extended-release (ER) / long-acting opioids such as sustained release oxyCODONE, morphine, oxyMORphone, transdermal fentanyl, continuous opioid infusion or the long-acting methadone. Continue non-opioid therapy and short-acting as needed opioid therapy.
Non-opioid therapies including pharmacologic and non-pharmacologic therapies can benefit many patients, especially those with pain unrelated to cancer.
Non-opioid therapies should be used whenever possible in consideration of patient-specific factors including but not limited to age, organ function, other co-morbidities and goals of care.
For treatment of neuropathic pain, medications such as pregabalin, gabapentin, tricyclic antidepressants and topical lidocaine may be useful.
For inflammatory pain, medications like NSAIDs and steroids can be used.
Topical agents like lidocaine, capsaicin and NSAIDs can be used to provide analgesia to discrete painful areas with limited systemic exposure.
Non-pharmacologic interventions like exercise, cognitive behavioral therapy, and interdisciplinary rehabilitation can be helpful.
Treating underlying syndromes like depression and anxiety which can exacerbate pain can be effective methods of restoring patient function and quality of life.
Consider interventional therapies, like nerve blocks or corticosteroid injections, in patients who fail standard noninvasive therapies.
Opioids do not have a maximum pharmacologic dose, however dosing may be limited by side effects, including hyperalgesia, and individual patient response.
The appropriate dose is the one needed to control the patient’s pain with the fewest side effects.
Dosing of combination products containing acetaminophen, aspirin, or ibuprofen is limited by the maximum dose of the non-opioid ingredients. Ordering individual components allows for more convenient opioid titration
Constipation is a preventable yet common problem associated with opioid administration. It should be anticipated, treated prophylactically, and monitored carefully.
Consider opioid rotation (changing from one opioid to another), when side effects become intolerable, when a drug is not available by a new route, when pain is not controlled despite optimal opioid dose escalation, or when cost is an issue.
Meperidine should generally be avoided in the treatment of pain. It has an active metabolite with significantly a longer half-life that can accumulate and cause CNS toxicity.
Codeine dosing is limited by constipation and nausea, and ≥10% of patients lack the enzyme necessary to convert codeine into active metabolites.
When prescribing opiates initially start with a low dose of short-acting opioid for the shortest amount of time anticipated for the pain to continue- often 7 days or less in non-cancer pain. Higher doses, longer courses and long-acting medications should be initiated in a stepwise, logical manner.
Patients using ER / long-acting opioids may require a short-acting opioid for breakthrough pain. Each dose of the breakthrough opioid should equal 10-20% of the total daily requirement of ER opioid (e.g. ER morphine 60 mg po q12h with immediate release morphine 15 mg po q3h PRN pain).
If more than 3-4 doses of breakthrough medication are used daily for persistent pain, increase the dose of the ER opioid by an amount equal to 50-100% of the total amount of breakthrough medication used in 24 hours (e.g., a patient takes ER morphine 60 mg po q12h plus 6 doses of immediate release morphine 15 mg in 24 hours. Increase the daily ER morphine dose by 45 to 90 mg according to the patient's status and pain intensity- New regimen MS Contin 100mg Q12H and morphine 30mg q3h PRN pain).
Incident pain (breakthrough pain that is related to specific activity, such as eating, defecation, socializing or walking) may not require an increase of baseline opioid.
When calculating the initial dose of a different opioid in opioid rotation, the dose of the new opioid should be reduced by 25-50%. This is to account for incomplete cross-tolerance, due to differences in the structure of individual opioids and their action at the various mu opioid receptors. See page #8 for instruction.
Naloxone reverses sedation, respiratory depression, and ANALGESIA. In patients on chronic opioid therapy, reserve for use in life-threatening respiratory depression unresponsive to dose reduction and appropriate respiratory support. Administer cautiously to avoid withdrawal symptoms and severe pain.
For the management of pain, all opioids are equally effective, however, for the management of dyspnea the use of methadone may not be as effective as other opioids
Caution: benzodiazepines and antihistamines cause additive sedating effects but NOT analgesia.
Patients with chronic or persistent pain should be given a written pain management plan.
Patients may be encouraged to keep a pain diary including daily pain scores, use of prn medications, side effects and efficacy.
Communication about pain management should occur when a patient is transferred from one setting to another.
Continuous opioid infusion may be needed if no other routes of administration are available, and around-theclock opioid therapy is required to manage pain and/or dyspnea. Please also refer to policies available on the BWH Intranet for more information on continuous opioid infusions and intensive comfort measures.
“Titrate to comfort” is neither a clear nor acceptable order.
For patients already on opioids when initiating a continuous opioid infusion, calculate the approximate total daily dose and provide a continuous rate of infusion to approximate previously established opioid requirement.
PRN boluses of opioids should be made available on an every 1 hour or every 2 hour basis for acute symptom exacerbations and should be dosed at 10-20% of total daily infusion amount or 50-150% of hourly infusion rate.
Dose ranges for boluses should be specific and provide clear parameters for the interval of available boluses and a narrow parameter for the dose per bolus.
Morphine Sulfate IV 2-4mg every 2 hours OK
Morphine Sulfate IV 2-30mg every 2-3 hours NOT OK
Infusion rate should only be titrated based on symptom severity and frequency of boluses needed to maintain comfort from pain and/ or dyspnea. Infusion rate for continuous infusions should not be titrated more frequently than every 8 hours.
Titrating the continuous infusion rate without the use of PRN boluses may provide inadequate or delayed symptom relief, and increase risk of undesirable side effects such as myoclonus.
Patients should be judiciously monitored for side effects such as myoclonus or delirium
Judicious use of opioids for pain or dyspnea in actively-dying patients has not been shown to hasten death.
If the patient is not on opioids and is not in pain and does not have dyspnea, initiation of an opioid infusion at the end-of-life is unnecessary. Opioids should only be used to treat symptoms of pain and dyspnea.