Pain Management
Pocket Tool
1. Ask the patient about the presence of pain. 2. Accept the patient’s report of pain. 3. Perform a comprehensive pain assessment, including: • Onset, duration, and location • Quality • Intensity (use appropriate scale) • Patient’s goal • Effect on function and • Response to prior • What makes the pain better or worse • History/physical exam
4. Avoid intramuscular route, the oral route is preferred
5. Treat persistent pain with scheduled medications 6. Ordinarily two drugs of the same class (e.g., NSAIDs) should not be given concurrently; however, one long-acting and one short-acting opioid may be prescribed concomitantly 7. Assess, anticipate, and manage opioid side effects aggres- sively thereafter. Use restricted to 5 days max. 8. Most opioid agonists have no ceiling dose for analgesia; titrate to relief and assess for side effects 9. With older adults, start low, go slow, but go! 10. Discuss goals and plans with patient and family No platelet effects. Risk of cardiovascu- 12. Avoid meperidine and propoxyphene
13. Addiction occurs rarely unless there is a history of substance 400 mg (300 mg in
Atypical opioid with additional non-opioid the elderly)
a) compulsive use, b) loss of control, c) use despite harm * Monitor for common adverse effects: GI ulceration and bleeding, decreased platelet aggregation, and renal toxicity When using long-acting opioids around-the-clock for persistent pain, obtain order for a short-acting opioid (rescue) for break-through pain. Begin bowel regimen when opioid therapy is initiated. Include a mild stimulant laxative (e.g., Senna, Cas-
• The rescue dose is 10-15% of the 24h total daily dose cara) + stool softener (e.g., Colace) at hs, or in divided doses as routine prophylaxis • Oral rescue doses should be available every 1-2h; par- Tolerance typically develops. Hold sedatives/anxiolytics, dose reduction; consider CNS stimulants (e.g., in- crease caffeine intake, methylphenidate or dextroamphetamine) • If patient is consistently using 3 or more rescue doses daily, consider increasing the around-the-clock dose Dose reduction, opioid rotation; consider metoclopramide, prochlorperazine, scopolamine patch • Whenever the around-the-clock dose is increased, the res- Dose reduction, opioid rotation; consider an anthihistamine such as diphenhydramine • Consider using the same drug for both scheduled and break- Dose reduction, opioid rotation; consider neuroleptics (haloperidol or risperidone) through doses when possible (e.g., long-acting morphine + Dose reduction, opioid rotation; neuroleptic therapy (haloperidol or risperidone) Examples:
Dose reduction, opioid rotation; consider clazepam, baclofen Oral rescue dosing: Pt. is on MS Contin 200 mg q 12h
Sedation precedes respiratory depression. Hold opioid. Give low dose naloxone—dilute 0.4 mg (1ml of a 0.4
1. Total daily dose (200 mg x 2 = 400 mg morphine/24h) mg/ml amp of naloxone) in 9 ml normal saline for final concentration of 0.04 mg/ml 2. Calculate 10 to 15% of 24h dose for rescue dose (10% = 40 mg, 15% = 60 mg short-acting morphine) 1) American Geriatric Society Clinical Practice Guidelines (2002), The management of persistent pain in older persons. AGS. 3. Rescue dose = 40-60 mg of morphine q 1-2h 2) American Pain Society (2002), Guideline for the management of pain in osteoarthritis, rheumatoid arthritis, and juvenile chronic arthritis, 2nd ed., Glenview, Parenteral dosing: (based on continuous infusion)
Calculate rescue dose based on 25-50% of hourly dose 3) American Pain Society (2003), Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 5th edition. 4) American Pain Society (2005), Guideline for the Management of Cancer Pain in Adults and Children. Switching from One Opioid to Another: (Examples) Adjuvant Analgesic Drugs Most commonly used drugs. Consideration should be given to comorbidities, hepatic and renal insufficiency, and age. 1. Calculate the total 24h dose of pt’s opioid regimen 2. Locate new opioid on equianalgesic chart Antidepressants (o
ften use lower do
ses to treat pain than to t reat depression)
Tricyclic Antidepressants
For all: side effects include dry mouth, (10 mg or less for
drowsiness, dizziness, constipation, urinary 4. Divide the total daily dose of the new opioid by the nunber of elderly)
retention, confusion. Titrate dose every few days to minimize side effects. Avoid in the
(45 mg divided by 6 doses = 7.5 mg q 4h) elderly. Caution in patients with cardio-
5. Reduce calcuated dose of new opioid by 25 to 50% for incom- vascular disease.
plete cross tolerance; titrate up as needed. Lower side effect profile than amitriptyline. Transdermal Fentanyl (Duragesic patch)
Use caution in opioid-naïve patient.
Lower side effect profile than amitriptyline. Duragesic patch 25 :g q 72h = 50 mg oral morphine q 24h. Divided into 6 doses = 8.3 mg oral morphine or 2.8 mg IV
morphine q 4h. These are approximate doses.
Selective Serotonin an d Norepinephrine
Reuptake Inhibito
r (SSNRI) Antidepressant
Should not use with MAOIs. Consider lower starting dose for patients for whom tolerabil- Anticonvulsants
Adjust dose for renal dysfunction. Usually Monitor serum levels; multiple drug-drug Corticosteroids
High dose therapy should not exceed 72h. 3.5 mg po for long term use (can accumulate due to For cancer pain, continue treatment until Local Anesthetic
Patch may be cut to fit painful area(s). Place *Combination Opioid Drugs (have ceiling dose)
Other Adjuvant
80-120 mg po in 24h Caution in renal insufficiency. Disclaimer: The intent of this guide is to provide a brief summary of commonly used analgesics. It is not a complete pharmacol-
ogical review. All medications should be administered only with physician or licensed allied health provider orders. No liability

will be assumed for the use of this tool.
(4 g/24h ceiling dose with acetaminophen) Reprinted with permission from the Massachusetts Pain Initiative, in partnership with The American Cancer Society. This material from North Dakota Health Care Review, Inc. was adapted by CFMC, the Medicare Quality Improvement *Equianalgesic doses are approximate. Individual patient response Organization for Colorado, under contract with the Centers for Medicare and Medicaid Services (CMS), an agency of must be observed. Doses and intervals are titrated according to the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.



4622_200610PPAD_Gomes.qxd 11/7/06 11:03 AM Page AIsabel Gomes, DMD* • Pedro Moura, DMD†George Gomes, DMD‡ • Jorge Perdigão, DMD, MS, PhD§Dental staining can either be extrinsic or intrinsic. designated by nightguard vital bleaching (NGVB), sug-Tobacco, certain foods, and a selection of bev-gested using 10% carbamide peroxide gel in a tray.6erages are some of the materials respons

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