Pain Mgmt Intro


Pain is what the patient says it is … but not all pain is mu-opioid responsive …


assume most acute pain is predominantly "bio"

assume most chronic pain has elements of "psycho-social-spiritual" + neuropathy


pain mgmt case #1

78 female severe lower extremity ulcerations – circumferential on right

diabetes, morbid obesity, s/p multiple debridements, skin graft several years ago

c/o pain – constant, prickly … “don’t kill me with that morphine”

ms elixir (20 mg/ml ‘roxanol’) 2-5 mg po q 2 hrs prn

first 36 hrs used 50 mg ms

start ms contin 15 mg po bid (basal)

continue prn roxanol (breakthrough)


General Guidelines for Opiate Administration

peak effect in 15-20’ iv, 30’ sq, 60-90’ po; 1st order kinetics

chronic pain – basal + breakthrough

acute pain – morphine dose: 2.5-10 mg SC/IM/IV q2-6h prn; Alt: 0.05-0.1 mg/kg IV load, then 0.8-10 mg/h IV; Info: consider lower dose, longer interval in elderly pts or pts <50 kg (epocrates)


start low, go slow

7-9/10 increase 50-100%; 4-6/10 increase 25-50%

frequent assess – re-assess

know opiate equivalents

risk of opiates is greatest when first begun


Opiate Equivalents

ms = hydrocodone = oxycodone

hydromorphone = 4 * ms

fentanyl patch = ½ daily po ms dose

oral/parenteral = 3/1

meperidine = 1/10 ms

methadone = ms/15 + 15


allow 25% cross tolerance

conservative basal … liberal bolus


pain mgmt case #2

31 yo male with acute severe abdominal pain

no significant pmh

right side radiating to groin/testicles

options … ?


Clinical Assessment

level of symptoms; use of breakthrough doses; pupils; resp rate; level of consciousness/arousability

clinical setting; consider n of 1 trial


Opiate Prescribing … some common concerns…




respiratory depression


Opiate Side Effects (ADE’s)

GI – dry mouth, nausea/vomiting, constipation

Derm – pruritus

GU – urinary retention

Neuropsych – sedation, mild cognitive dysfunction

neurotoxicity – delirium, perceptual disturbances


pain mgmt case #3

72 yo lung ca with bone mets

increasingly severe hip and arm pain – constant, aching, well localized

initially controlled with 4-6 percocet 5’s/day

over past 2 weeks has used 12/day with only partial relief

options … ?


Opioid Neurotoxicity

delirium; perceptual disturbances; myoclonus (jerky movements); hyperalgesia (heightened pain level)

allodynia (pain on light touch); seizures


r/o other causes … esp meds; decrease dose; lorazepam (not anti-psych); change opiate; use other analgesic

change route (decrease metabolites)


pain mgmt case #4

67 yo male with idiopathic peripheral neuropathy

lower extremity pain moderate at rest

hx alcoholism

significantly interferes with activity (walking, golf)

significant ade’s (cns) as pregabalin titrated to max dose (600/d)

options … ?


pain mgmt case #5

58 yo with metastatic breast cancer and associated pain is well controlled on 0.8mg/hr ms with rare boluses

She is being discharged home today, gut working fine … orders for po pain mgmt?


Chronic ‘Benign’ Pain

opiate pendulum swinging back

no data opiates help in this setting

opiates might harm including OD

treat anxiety-depression (50% incidence)

adjuvants – PT – cog/behavioral …

“We do not have safe and effective treatments for your pain syndrome.”

Grady – Opioids for Chronic Pain – Archives Int Med – June 13, 2011. doi:10.1001/archinternmed.2011.213