Please note: The scenarios presented in this module are intended to highlight and reinforce broad principles. Specific case details are left out (e.g. source of pain, reason for admission).
Ongoing Treatment, Functional Goals, Reassessment
Mrs. Miller says, “My goal for pain relief is less than 5/10. Why are you reducing my opioid dose? I need more, not less!”
There is a lack of a predictable relationship between an opioid dose and pain relief. Do not prescribe a predetermined opioid dose based on pain intensity or chase a pain rating goal with opioids.
You might respond to this patient by asking, “What does 5 out of 10 mean to you?” Then follow with, “The goals for acute (and chronic) pain are function1 and safety.”
Mrs. Miller replies, “I need to be able to get out of bed and walk to the nursing station several times a day.”
You could say, “That’s a good goal. Let’s focus on reaching it.”
Mrs. Miller says, “Well, how am I going to get there if you’re already starting to decrease my opioids?”
This patient is focused on opioids as the only means of pain management. You might reply with, “Well, we’re doing other things already to manage the pain. For your safety, we want to aim for the smallest dose for the shortest amount of time.”
Acute pain resolves quickly (usually within days). The 3-7 days of opioid guidance for acute pain in the CDC guidelines do not refer to postoperative pain. The CDC defers to the WA Agency Medical Directors Group 2015
opioid guidelines for guidance on postoperative pain management.
1 Function” refers to emotional state, physical activity, and sleep quality
Mrs. Miller says, “Okay, I get it, but this makes me really nervous. I can’t imagine how I’m going to manage it. Can I have some Lorazepam?”
Clinicians should avoid prescribing opioid and benzodiazepines concurrently whenever possible.
Your response could be, “I understand you are concerned and want to reassure you we will work together to control your pain. However, adding lorazepam is not safe.”
Test Your Knowledge
Patient 1
A patient who is opioid naïve has been on IV PCA for 48 hours and is now ready to convert to oral analgesia. The patient has consumed relatively stable doses of hydromorphone using 0.2mg patient initiated doses totaling 12mg hydromorphone per day. You decide to transition to oral oxycodone.
What factors do you consider in deciding what oral dose to transition to? More than one answer may apply.
Discussion
Acute pain tends to diminish rapidly and for many acute pain conditions, 3 days or less of opioid treatment will be sufficient; more than 7 days will rarely be needed. Use caution with equianalgesic calculations as they are rough approximations and one should always consider a number of current patient factors including the anticipated course of pain and risk factors for opioid adverse events.
Patient 2
Patient admitted yesterday with acute severe pain anticipated to last several days longer. Patient has been requiring frequent prn IV opioid doses from his nurse.
What would be the best next step in managing this patient’s opioid treatment?
Discussion
Consider the use of patient controlled analgesia (PCA) initially in cases where repeated doses of parenteral opioids are anticipated or required. Providers should be aware of the doses being self-administered by their patients via PCA to guide adjustments. Routine use of continuous opioid infusions (basal rates with PCA) is NOT recommended.
Patient 3
38-year-old patient recovering on oral hydromorphone and reported worse and poorly controlled pain. You performed focused history and physical exams and discovered no new complications or conditions.
Your next best action would be to:
Discussion
When titrating opioids for uncontrolled pain, increase in increments of 25-100% at subsequent dosing intervals. You should also provide optimal multimodal analgesia.
Summary
- Oral is the preferred route
- Consider IV PCA if repeated doses of parenteral opioids are necessary
- Avoid the routine use of continuous (basal) rates with IV PCA
- Avoid co-administration of benzodiazepines
- Do not add or increase extended release opioids for acute pain
- Avoid multiple opioid orders (therapeutic duplication). If PRN opioids from different routes are needed, provide a clear indication for use.
