72 M , acute femoral fracture. History of
hip, knee OA. Uses Tylenol, ibuprofen.
 Used Norco in the past very infrequently.
Keeps an old bottle in the medicine
chest.
 Poor baseline pain control, function is
limited due to pain, slowly declining over
time prior to admission
 Fentanyl 50mcg IVP PRN. Pain well
controlled.

Patient is delighted-Never experienced
such relief! Only used it 3 times total over
2 days.
 Long term plan/discharge med(s)?

› A. Fentanyl patch 50mcg q72 hours
› B. PO PRN Norco q4 hours
› C. PO Scheduled Norco q4 hours
› D. PO Dilaudid 2mg q4 hours
› E. PCA pump at home with home health
Fentanyl is an opioid with high lipid
solubility, suitable for intravenous, spinal,
transmucosal and transdermal
administration.
 After placement of a fentanyl patch,
serum fentanyl concentrations gradually
increase during the first 14 h and stay
relatively constant from 14 to 24 h. The
increase in plasma fentanyl
concentration is slower in elderly people.

53 F with acute gallstone pancreatitis
admitted for pain, ERCP.
 Nausea, vomiting, poor PO intake,
miserable with pain
 At home, uses PO PRN Dilaudid 2mg
maybe 1x a week for OA pain.
 Treatment: NPO, IVF, antiemetics and
PCA for pain control.


PCA medication and settings?
› A. Fentanyl 50 mcg q10 mins PRN
› B. Fentanyl 50mcg basal and 50mcg q10
mins PRN
› C. Dilaudid 1mg q15 mins PRN
› D. Dilaudid 1mg basal and 1mg q15 mins
PRN
› E. Morphine 2mg basal and 3mg q20 mins
PRN
Somnolence in response to opiate
therapy occurs BEFORE respiratory
depression.
 DO THE MATH!!

› Example: our patient doesn’t even take ANY
opiates on most days.
 Basal of1mg Dilaudid/hr=24mg/day= 480mg
PO morphine.

Would you administer MScontin 200 PO
BID to this patient?
38 M with ESRD on HD, DM1, HTN, CHF,
anxiety, hyperlipidemia and hx CVA.
 Admitted for severe diabetic foot ulcer
that progressed to necrotizing fasciitis.
Pain out of control.
 Has chronic neuropathy for which he
uses PRN Norco.

To surgery, now has a fasciotomy, just
arrived back to the floor and RN would like
to know:
 How should we control his pain?

› A. PRN Norco q4 hours
› B. MScontin 15mg PO BID with PRN Norco
› C. PCA Morphine 2mg basal, 2mg q15 min PRN
› D. PCA Dilaudid 2mg basal, 2mg q15 min PRN
› E. PCA Dilaudid no basal, 0.5mg IV q10 min PRN

NOT recommended:
› Morphine
› Codeine
› Demerol

Use with CAUTION
› Oxycodone
› Hydromorphone

SAFEST
› Fentanyl
› Methadone
Build up of 3-glucuronide metabolite
implicated
 Myoclonus – the uncontrollable twitching
and jerking of muscles or muscle groups
– usually occurs in the extremities,
starting with only an occasional random
jerking movement.
 Progresses to delirium-> +/- hyperalgesia
-> seizure->coma->death.

69 F with severe DJD, recent fall,
vertebral fracture causing acute spinal
cord impingement on top of chronic
stenosis. Uses PRN PO Dilaudid daily at
home.
 Severe pain, OR planned tomorrow.
 How can we make him comfortable now
AND address his chronic poorly
controlled back pain from underlying
disease?

› A. Start Methadone 5 PO BID, PCA Dilaudid
›
›
›
›

(bolus only) + Ketamine +Neurontin +Effexor
B. Start Methadone with Dilaudid
breakthrough
C. Start Ketamine and Neurontin to add to
home Dilaudid
D. Start a PCA Dilaudid (bolus only)
E. Start Morphine and increase his Dilaudid
Hint: PO Dilaudid already tried… Only
“took the edge off” Still excruciating!

Types of Pain: Acute post traumatic and
chronic
› Inflammatory from the fall/trauma
› Neuropathic from the cord impingement

Why does his PO Dilaudid only “take the
edge off?”
› Neuropathic pain is opiate refractory by
definition!


A. Start Methadone 5 PO BID, PCA Dilaudid
(bolus only) + Ketamine +Neurontin +Effexor
WHY all the meds:



Dilaudid and Ketamine will exert analgesic effect
within seconds to minutes, one with primarily
NON Neuropathic use, and one for Neuropathic
Methadone: hours to days
Neurontin and Effexor: days to weeks

The 5 drugs we chose represent most of
the major categories of medications
used for neuropathic pain:
› Methadone: Opiate agonist, NMDA receptor
antagonism
› Ketamine: NMDA receptor antagonist
› Effexor: SNRI antidepressant
› Neurontin: antiepileptic (although not used
as such in practice)
Opiate naïve patients need to be
handled with care=Low doses of short
acting medication.
 Basal infusion on PCA is the exception,
rather than the rule. Again, NOT for naïve
patients.
 Morphine is a poor choice in renal
failure.
 Neuropathic pain is difficult to control
and frequently needs a multi-drug
regimen
