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CDHB

Severe Acute Pain

Opioids are the most potent analgesics and should be used where there is a diagnosis of severe pain. The summary guidelines for intermittent opioid dosing for acute pain are as follows. They are reproduced in card form for attaching to identity card lanyards.

Adult Guidelines for Intermittent Opioids - Oral, Intravenous, Subcutaneous

General considerations

• Before opioid administration, ensure simple analgesics are being administered, e.g., paracetamol, NSAIDs (if not contraindicated).
• Intermittent opioids should only be given by one route at any time.
• Oral administration is usually the route of choice. Consider subcutaneous when absorption compromised (e.g., ileus).
• Intravenous administration may be preferable in situations of severe acute pain.
• Morphine is considered the first-line opioid for PRN administration. If GFR <30 mL/min or history of morphine intolerance, consider fentanyl (IV or subcutaneous) or oxycodone (oral).

  Note: Check dose conversion.

• Avoid co-administration of other opioids or sedatives except pre­existing background opioids which should be continued.
• When prescribing opioids ensure antiemetic(s) are prescribed and laxatives if not contraindicated.
• Increasing sedation or respiratory rate less than 12/minute should prompt increase in frequency of observations and dose reduction.

Dose prediction

• Initial dosing: for the opioid naïve patient, begin at lower end of dose range.
• Age: best dose predictor. Lower doses are usually required with increasing age.
• Renal impairment: morphine may be inappropriate (see general considerations). Consider longer dosing interval.
• Weight: dose adjustment may be required at extremes of body weight.
• General physical condition, frailty: less opioid if frail or poor general condition.
• Pre-existing opioid use: opioid tolerance occurs with long term opioids, larger doses often required.

Discharge

• Opioids are not recommended for routine prescription on discharge.
• If prescribed, the patient and patient's GP should be informed.
• Discharge summary should include plan for weaning opioid.
• Recommend 1 week only in decreasing daily doses. Please prescribe a maximum amount to be dispensed.
• If pain requires opioid beyond this time, a GP review is required.
• Prescribed doses should not exceed last inpatient doses.

Dosing Guide for Acute Pain

Notes

• Morphine remains the gold standard and is generally well tolerated, although nausea can be a problem along with constipation.
• If taking regular morphine or oxycodone e.g. for cancer pain, the q2h prn oral (or subcut) breakthrough dose needs to be 1/6 to 1/10 of the total daily oral (or subcut) dose.
• Fentanyl, a synthetic opioid, can also be used, especially where severe pain is anticipated in certain procedures. Transdermal fentanyl (fentanyl transdermal patch) is not appropriate for the management of acute pain, but can be used for chronic management. Discuss with APMS.
• Tramadol can be used as a second line of management after morphine in acute pain. It causes less constipation and has a quick onset of action. The parenteral dose is the same as the oral dose. May cause confusion in the elderly, and may cause Serotonin Toxicity.
• Pethidine is not recommended. It does not have any specific benefit in smooth muscle spasm. It has a short half-life. Pethidine is almost never used in chronic/persistent pain, as there are more effective and less toxic alternatives such as transdermal fentanyl, oxycodone and methadone. Pethidine toxicity with convulsions can be an issue.
• Local anaesthetic agents can be useful for providing sensory block of specific dermatomes, e.g., femoral nerve block for fractured femur, and abdominal wound catheters.

A wide range of modalities is used to manage severe acute pain. These include:

• Patient controlled analgesia (PCA).
• Regional nerve and wound blocks/catheters.
• Intrathecal morphine.
• Epidural infusions.

Perioperative care has been improved with newer anaesthetic and analgesic techniques, development of minimally invasive surgery, and drugs to reduce surgical stress. Fast-track surgery or enhanced postoperative recovery programmes have been developed by combining these techniques with evidence-based adjustments to the use of nasogastric tubes, drains, and urinary catheters, preoperative bowel preparation, and early initiation of oral feeding and mobilization. This needs 'the right care, delivered to the right patient at the right time, by the right person, in the right way'.

The Acute Pain Management Service (APMS), available on pager 8114 (Christchurch Hospital) or 7015 (Christchurch Women's) or via the on-call Anaesthetist, can advise on the appropriate technique.

Acute episodes of pain also occur in patients receiving opioids for chronic/persistent pain. In these situations, higher doses of breakthrough analgesia may be needed to gain effect compared to opioid-naive patients. During working hours, advice is available from either the APMS or Palliative Care Service  81473 (or page via the operator) - whoever is deemed most appropriate to involve. In-depth prescribing guidelines for oxycodone and transdermal fentanyl are available in the Palliative Care Guidelines.

Doctor's Responsibilities

• Initial assessment of patient:
  • Magnitude and cause of pain.
  • Existence of factors that might affect the patient's handling of opioids e.g., weight, children, elderly, liver or renal disease, drug dependence.
  • Contraindications e.g., airway obstruction, respiratory failure, hypovolaemia, raised intracranial pressure.
• Decide on drug, method of administration, safe dose range and dose interval (see table) and chart according to hospital protocols/algorithms such as the IV Opioid policy for hospital wards.
• Reassess at regular intervals and adjust prescription accordingly.

Nurse's Responsibilities

• Assess opioid dosing levels at regular intervals.
• Administer opioid according to existing hospital protocols and patient's drug chart.
• Decide on appropriate dose within the dose range on the patient's prescription form using patient's response to previous doses as a guideline.
• Monitor and record pain levels, degree of sedation, blood pressure, respiratory rate, and sat.O₂ before and at appropriate intervals after the administration of the opioid. See Frequency of Observation during Acute Pain Medication and Pain and Sedation Scores.
• Request an urgent medical review if the pain protocol/prescription is not fully effective.

Management of Complications

Manage appropriately any untoward effects (see Management of Severe Complications and Management of Opioid Side Effects).

Frequency of Observation during Acute Pain Medication

Pain and Sedation Scores

Management of Severe Complications

Adjuncts to Opioids for Severe Acute Pain

NSAIDs remain the standard approach, but are relatively contraindicated where there is a bleeding disorder, renal dysfunction, or upper GI dysfunction.

Topic Code: 1569