Acute pain management

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Opioid Epidemic

  • Consider that with a 10-day supply of an initial opioid prescription, the odds of still being on opioids a year later is ~20%
  • Consider opioid free regimens

Continued Opioid Use After First Prescription

WHO 3-step Ladder for Pain Control

Agent Oral Parenteral
Step1. Mild Pain, Nonopioid, +/- Adjuvant
Acetaminophen 650mg q4-q6h prn or 1000mg q6h prn -
Aspirin 650mg q4-6h prn or 1000mg q6h prn -
Ibuprofen 400-800mg q6-8h prn -
Gabapentin (neuropathic Pain) Start 300mg qhs -
Step2. Mod Pain, Opioid for mild/mod pain, +/-nonopioid, +/-Adjuvant
Hydrocodone (5mg/Acetaminophen 325mg) 1-2 tabs PO q4-6h prn -
Oxycodone (5mg/Acetaminophen 325mg) 1-2 tabs PO q4h prn -
Oxycodone (Oxycontin) 5mg q4-6h -
Tramadol 50-100mg q4-6h (max 400mg/day) -
Step3. Severe Pain, Opioid for mod/sev pain, +/- nonopioid, +/-Adjuvant
Morphine 10-30mg q3-4h 0.1-0.2mg/kg(up to 15mg q4h)
Morphine (controlled release) Start 30mg q8-12h , increase prn to 90-120mg q12h -
Fentanyl - mcg/kg q1-3h
Hydromorphone (Dilaudid) 2-4mg q4-6h 1-4mg q4-6h
Levorphanol 2mg q6-8h

2mg q6-8h

^In elders, use a bulk laxative and give instructions regarding activity, hydration and close follow-up

General Opioid Analgesics Chart

DRUG

TYPICAL ADULT DOSE

PHARMACOKINETICS

COMMENTS

Morphine

0.1 mg/kg IV

10mg IM

0.3 mg/kg PO

Onset: 1-2 min (IV), 10-15 min (IM/SC)

Peak effect: 3-5 min (IV), 15-30 min (IM)

Duration: 1-2 h (IV), 3-4 h (IM/SC)

  • Histamine release may produce transient hypotension or nausea and emesis,
    • neither require routine adjunctive treatment

Hydromorphone

(Dilaudid)

0.015 mg/kg IV

1-2 mg IM

Onset: 3-5 min (IV)

Peak effect: 7-10 min (IV)

Duration: 2-4 h (IV)

Fentanyl

1.0 mcg/kg IV

Onset: <1 min (IV)

Peak effect: 2-5 min (IV)

Duration: 30-60 min (IV)

  • High doses can cause chest wall rigidity (>5 mcg/kg IV)

Meperidine

(Demerol)

1.0-1.5 mg/kg IV/IM

Onset: 5 min (IV)

Peak effect: 5-10 min (IV)

Duraction 2-3 h (IV)

  • Contraindicated when patient taking a MAOI
  • Neurotoxicity occur when multiple doses given in the presence of renal failure

Oxycodone

5-10 mg PO

30 mg PR

Onset: 10-15 min (PO)

Duration 3-6 h (PO)

  • Possible inadvertent acetaminophen overdose with combination agents

Hydrocodone

5-10 mg PO

Onset: 30-60 min (PO)

Duraction 4-6 h (PO)

  • Lower incidence of nausea
  • Possible inadvertent acetaminophen overdose with combination agents

Codeine

30-60 mg PO

30-100 mg IM

Onset: 30-60 min (PO)

Duraction: 4-6 h (PO)

  • High incidence of GI side effects
  • Some patients cannot convert to codeine-6-glucuronide and morphine
  • Possible inadvertent acetaminophen overdose with combination agents

Tramadol

(Ultram)

50-100 mg PO

Onset: 10-15 min (PO)

Duration: 4-6 h (PO)

  • Central nervous system side effects

Non-Opioid Analgesics Chart

DRUG
TYPICAL ADULT DOSE
COMMENTS
Acetaminophen

650-1000mg PO q4h

1-2 g PO q4h

  • Liver dysfunction and necrosis
Aspirin 650-1000mg PO q4h
  • Reye syndrome in children, tinnitus, central nervous system toxicity, metabolic acidosis
Ibuprofen 400-800mg PO q4-6h
  • GI upset, platelet dysfunction, renal dysfunction, bronchospasm
Naproxen

250mg PO q6-8h

500-1000mg PR q6-8h

  • GI upset, platelet dysfunction, renal dysfunction, bronchospasm plus interacts with protein-bound drugs
Indomethacin

25-50mg PO q12h

100mg PR q24h

  • GI upset, platelet dysfunction, renal dysfunction, bronchospasm
Ketorolac

15-30mg IV q6h

30-60mg IM

  • GI upset, platelet dysfunction, renal dysfunction, bronchospasm
  • Much greater risk of GI bleeding than ibuprofen; use limited to 3d IV and 5d PO

Parenteral Opioid Dosing Chart

DRUG ROUTE DOSAGE COMMENTS
Morphine IV or IM

Titrate 2-5 mg increments q5-10 min

Peak analgesia in 10-20 min

Average: 10 mg q3-4h

Preferred first-line agent in most situations
Fentanyl IV or IM

Titrate 25-50 mcg increments q2-3 min

Peak analgesia in 3-5 min

Duration 30-60 min

Ideal for short procedures

No histamine release

Typically not suitable for the ED

Meperidine

(Demerol)

IV

Titrate 12.5-50 mg increments

Peak analgesia in 5-10 min

Average: 100 mg q2-3h

Risk of unique CNS toxicity with repeated dosing

IM injection is very irritating to tissue

Hydromorphone

(Dilaudid)

IV

Titrate 0.5-1.0 mg increments

Peak analgesia in 5-15 min

Average: 1.5 mg q3-4h

Butorphanol

(Stadol)

IV

Titrate 0.5-2.0 mg increments

Peak analgesia in 4-5 min

Average: 2 mg q3-4h

Mixed agonist-antagonist

May be preferred in biliary colic

Oral Opioid Dosing Chart

DRUG ANALGESIC EQUIVALENCE USUAL STARTING DOSE USUAL INTERVAL
Morphine (MSIR, Roxanol, others) 30 mg 15-30 mg 3-4 h
Morphine: sustained release (MS Contin, Oramorph-SR) 30 mg 30 mg 8-12 h
Meperidine (Demerol) 300 mg 50-100 mg 2-3 h
Codeine (in Tylenol #3, others) 200 mg 30-60 mg 3-4 h
Oxycodone (Roxicodone, also in Percocet, Percodan, Tylox, others) 20-30 mg 5-10 mg 3-6 h
Hydrocodone (in Lorcet, Lortab, Vicodin, others) 30 mg 5-10 mg 3-6 h
Hydromorphone (Dilaudid) 7.5 mg 4-8 mg 2-3 h
Tramadol (Ultram) N/A 25-50 mg 4-6 h

See Also

References

Adapted from Tintinalli and Harwood & Nuss, World Health Organization 3-Step Analgesia Ladder for Cancer & Washington Manual Intership Survival Guide, 2008

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