Acute Pain Management
Solomon Liao, M.D.
Associate Clinical Professor
Director of Palliative Care Services
Hospitalist Program
Objectives
By the end of this session, participants will be able to:
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Use opioids with comfort in an
inpatient setting
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Address side-effects
Master opioid conversions
Choose the appropriate opioid
PRACTICAL
WHO pyramid
Severe Pain
Pure opioids: Morphine
Moderate Pain
Mild opioids: Codeine, Vicodin
Mild Pain
Non-opioids: Tylenol, NSAIDS
Back Pain
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56 yo chronic back pain
Pain well controlled with Oxycontin 20 mg
bid
Developed dysphagia
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Unable to swallow pills
Now admitted in severe pain
How do you write admit pain med?
Conversion
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Oxycodone 1 mg = 1.5 mg Morphine
40 mg Oxycodone/day = 60 mg PO
Morphine/day
1 mg IV Morphine = 3 mg PO Morphine
60 mg PO Morphine = 20 mg IV Morphine
20 mg IV Morphine/24 hrs = 1 mg/hr
Epigastric Pain
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46 yo Admit from ER for severe
acute epigastric pain
Radiates to back
Curled up in a fetal position
Amylase and lipase elevated
What pain medication would you
use?
How would you give it to her?
DEMEROL
Demerol Side-effects
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Partial mu agonist, most kappa
effects
Most addictive
short acting
 high peaking
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Lowers seizure threshold
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active metabolite - normeperidine
Anticholingeric - not for elderly
PCA Titration
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Better pain control
Less medication, less side effects
Titration Principle
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Smaller dose, more frequent
Matches pain curve
Anticipatory pain effect
PRN match continuous rate
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2 mg/hr & 0.5 mg q 15 min PRN
Trauma
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76 yo Adm to trauma Svc, s/p MVA
Pulmonary contusion, rib Fx
Delirious - confused
Pulling off O2, hard collar on, 4
point restraints, pulling at foley
Given MS PCA by surgery team
What is wrong with the picture?
Titration
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Short acting agent (fast route)
For opioid naïve – start 2 mg IVP q
1-2 hr
Can safely increase by 50-100% q
day
No ceiling (Max. dose) for pure
opioids
Add PRN to standing dose
Morphine Pharmacokinetics
Onset
Peak
Duration
IVP
8-10 min
1 hr
2-3hrs
Elixir/IR
30-60 min
2 hrs
4-6 hrs
Ext
Release
3-4 hrs
6-8 hrs
12-16 hrs
Fentanyl Case
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Geriatric Fellow called by NP:
nursing home patient with pain
Fentanyl patch applied
Next day patient still in pain
Another Fentanyl patch added
Next day patient still in pain
Another Fentanyl patch added
2 days later Pt obtunded
Opioid Choices
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Morphine - IV, SQ, IM, PO, PR, SL
Dilaudid - IV, SQ, IM, PO, SL
Oxycodone - PO, SL
Fentanyl - IV, transQ, transmucosal
Levorphanol - IV
Methadone – PO, SL, IV, SQ
Hydrocodone - PO
Discharge to Outpatient
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Around the Clock
“An ounce of prevention is worth a
pound of cure”
Rules of thumb
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Rescue dose = 10% of 24 hr dose PRN q 4
hrs
Call if use more than 2 PRN dose or use
more than 2 days
Narcan?
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87 yo small Japanese lady
S/p TAH/BSO, POD # 2
Allergy to morphine
MD orders Dilaudid 0.5 mg q 2 hrs
RN gives in error Dilaudid 5 mg IVP
RR 10, Pt sleeping – arousable
What should the RN do?
Side-effects
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Acute
All resolve within 3-5 days
 Respiratory depression (rare) - hours
 Sedation – 1-2 days
 Nausea/vomiting (33%) – 3-5 days
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Chronic - constipation
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“The hand that writes the opioid, writes the
laxative”
Indications for Narcan
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Not for mental status change
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Just hold – let wear off
Cause significant acute withdraw pain
RR < 6
Oxygen saturation <90%
If respond then
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Narcan drip & transfer to ICU
Because duration <2 hrs
Summary
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Titration
PCA best
 short acting
 convert to long acting
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NO DEMEROL
Monitor side-effects