Acute pain management

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

Acetaminophen 650 mg PO q4-6h PRN or 1000 mg PO q6h PRN PO (max 4 g/day) — Risk of liver dysfunction and necrosis Aspirin 650 mg PO q4-6h PRN or 1000 mg PO q6h PRN PO — Reye syndrome in children; tinnitus, metabolic acidosis Ibuprofen 400-800 mg PO q6-8h PRN PO (max 3200 mg/day) — GI upset, platelet dysfunction, renal dysfunction Gabapentin 300 mg PO qhs (starting dose) PO Naproxen 250 mg PO q6-8h or 500-1000 mg PR q6-8h PO/PR — GI upset, platelet dysfunction, renal dysfunction Indomethacin 25-50 mg PO q12h or 100 mg PR q24h PO/PR — GI upset, platelet dysfunction, renal dysfunction Ketorolac 15-30 mg IV q6h or 30-60 mg IM IV/IM — Greater GI bleeding risk than ibuprofen; limit to 3 days IV, 5 days PO Hydrocodone 5-10 mg PO q4-6h PRN (with acetaminophen 325 mg) PO Oxycodone 5-10 mg PO q4-6h PRN PO Codeine 30-60 mg PO q3-4h PO — Some patients cannot convert to active metabolite Tramadol 50-100 mg PO q4-6h PO (onset 10-15 min, duration 4-6 hours) — CNS side effects; display=Tramadol (Ultram) Morphine 0.1 mg/kg IV or 10 mg IM or 0.3 mg/kg PO; titrate 2-5 mg IV q5-10min IV/IM/PO (onset 1-2 min (IV), 10-15 min (IM), duration 1-2 hours (IV), 3-4 hours (IM)) — Histamine release may cause transient hypotension or nausea Hydromorphone (Dilaudid) 0.015 mg/kg IV or 1-2 mg IM; titrate 0.5-1.0 mg IV increments IV/IM (onset 3-5 min (IV), duration 2-4 hours (IV)) Fentanyl 1.0 mcg/kg IV; titrate 25-50 mcg IV q2-3min IV (onset <1 min (IV), duration 30-60 min (IV)) — High doses (>5 mcg/kg) can cause chest wall rigidity Meperidine (Demerol) 1.0-1.5 mg/kg IV/IM; titrate 12.5-50 mg IV increments IV/IM — Contraindicated with MAOIs; neurotoxic metabolite with repeated dosing Butorphanol (Stadol) 0.5-2.0 mg IV; average 2 mg q3-4h IV — Mixed agonist-antagonist; may cause withdrawal in opioid-dependent patients

See Also

• Opioid overdose
• Opioid withdrawal
• Analgesics and Sedatives (Pediatrics)
• Complex regional pain syndrome

References

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