Pain Assessment Grid Drugs

UCLA Pharmaceutical Services

Pain Management Medications - Dosing and Pharmacodynamic Chart Pain Assessment Considerations The following are considerations to guide pain assessment General Considerations Tolerance • The pain experience should be considered a clinical emergency and • If a patient is receiving a narcotic for >7days, evaluate for tolerance as patient may require increased doses. treated in a timely fashion. • Whenever a pain medication is administered its effect should be Withdrawal Side Effects evaluated • Prevention of withdrawal is essential if doses are reduced/stopped • Unresolved pain (ie: after a fall, intervention, or procedure) is a for any reason. warning sign and is a high priority for assessment and treatment. Reassess dose for efficacy. Adjunctive Therapy • Unresolved escalating pain requires detailed assessment. This can • Assess benefit of adjuvant therapy such as ice, heat, position indicate other etiologies such as nerve pain that is typically change, massage, relaxation techniques, etc. unresponsive to an opioid and needs a pain consult. • Orders with variable dose/frequency (e.g., Vicodin 1-2 tabs every 4High Risk 6 hours) may be used only when there are acceptable objective • Patients with a past medical history of drug abuse will require modifiers (e.g., for mild, moderate or severe pain) for each dose or greater dosing than less. dosage interval specified. • Patients with a history of PVD or neuropathic pain (e.g., chronic pain) with new onset acute pain may have additional needs. PCA • Patients with a history of depression, anxiety or psychosis may be at • If the # of attempts far exceeds the number of injections dose may increased risk for poor coping. Alternative/additional medication need to increased. choices should be considered. • If patient awakens in severe pain-evaluate for the addition of a basal dose. Route Change • When changing route from IV/oral and epidural to oral it is essential to utilize equinalgesic doses.

2/10/03 Approved by P&T Committee

UCLA Pharmaceutical Services

Pain Management Medications - Dosing and Pharmacodynamic Chart Medication

Onset of action

Peak Effect1

Duration of Action1

Route/Rate of Administration

Dose (D)

Comments

Oral

D: 30-60mg codeine (e.g. 1-2 tablets) every 4-6 hours. Maximum 12 tablets/day

Drowsiness, sedation, lightheadedness, dizziness, nausea/vomiting, constipation, dose related respiratory depression. Excess acetaminophen can cause hepatotoxicity. Do not exceed 4gm acetaminophen/day. Drowsiness, sedation, lightheadedness, dizziness, nausea/vomiting, constipation, dose related respiratory depression. Excess acetaminophen can cause hepatotoxicity. Do not exceed 4gm acetaminophen/day.

Oral Medications Acetaminophen 325mg/codeine 30mg (Tylenol #3)

30-45 minutes

1-2 hours

4-6 hours

10-30 minutes

0.5-1 hour

4–6 hours

Oral

D: 5-10mg hydrocodone (e.g. 1-2 tablets) every 4 – 6 hours. Maximum 8 tablets/day

30 minutes

1.5-2 hours

4 hours

Oral

D: 2 mg every 3-6 hours

Drowsiness, sedation, lightheadedness, dizziness, nausea/vomiting, constipation, dose related respiratory depression.

Methadone

30-60 minutes

1.5-2 hours

6 hours2

Oral

D: 5-20mg every 6-8 hours

Drowsiness, sedation, lightheadedness, dizziness, nausea/vomiting, constipation, dose related respiratory depression.

Morphine, immediate release (MSIR)

30-60 minutes

1-2 hours

4-5 hours

Oral

D: 10-30 mg every 4 hours

Drowsiness, sedation, lightheadedness, dizziness, nausea/vomiting, constipation, dose related respiratory depression.

Oral

D: Give half the total daily dose of MSIR every 12 hours; or give 1/3 the total daily dose of MSIR every 8 hours.

Drowsiness, sedation, lightheadedness, dizziness, nausea/vomiting, constipation, dose related respiratory depression. Sustained release formulations not for acute pain relief. Immediate release products should be used for breakthrough pain.

Hydrocodone 5mg /acetaminophen 500mg (Vicodin)

Hydromorphone

Morphine, sustained release (MS Contin)

N/A3

3-8 hours

8-12 hours

2/10/03 Approved by P&T Committee

UCLA Pharmaceutical Services

Pain Management Medications - Dosing and Pharmacodynamic Chart

Medication

Onset of action

Peak Effect1

Duration of Action1

Oxycodone, immediate release

-

1-1.5 hours

3-4 hours

Oxycodone, sustained release (Oxycontin)

Oxycodone 5mg / acetaminophen 325mg (Percocet 5mg/325mg)

Propoxyphene 65mg/ acetaminophen 650mg

1. 2. 3.

N/A3

-

15-60 minutes

3 hours

1-1.5 hours

2 hours

12 hours

3-6 hours

4-6 hours

Route/Rate of Administration

Oral

Oral

Oral

Oral

Dose (D)

Comments

D: 5-15 mg every 4-6 hours

Drowsiness, sedation, lightheadedness, dizziness, nausea/vomiting, constipation, dose related respiratory depression.

D: give half the total daily dose of immediate release oxycodone every 12 hours

Drowsiness, sedation, lightheadedness, dizziness, nausea/vomiting, constipation, dose related respiratory depression. Sustained release formulations not for acute pain relief. Immediate release products should be used for breakthrough pain

D: 2.5-10mg oxycodone every 6 hours.

Drowsiness, sedation, lightheadedness, dizziness, nausea/vomiting, constipation, dose related respiratory depression. Excess acetaminophen can cause hepatotoxicity. Do not exceed 4gm acetaminophen/day.

D: 1 tablet every 4 hours, maximum 6 tablets/day

Drowsiness, sedation, lightheadedness, dizziness, nausea/vomiting, dose related respiratory depression. Excess acetaminophen can cause hepatotoxicity. Do not exceed 4gm acetaminophen/day.

These parameters may be affected by the dose of the drug and/or the patient’s physical status, underlying pathology, body size, weight and age. Methadone duration of action prolonged with repeat dosing. Sustained release formulations not for acute pain relief. Immediate release products should be used for breakthrough pain

2/10/03 Approved by P&T Committee

UCLA Pharmaceutical Services

Pain Management Medications - Dosing and Pharmacodynamic Chart

Medication

Onset of action

Peak Effect1

IV: 4-6 min

IV: 20 min SC: 50-90 min

Duration of Action1

Route/Rate of Administration

Dose (D)2,3

Comments

Parenteral Medications

Morphine IM: 10-30 min

Hydromorphone (Dilaudid)

Meperidine (Demerol) least preferred agent

1. 2. 3.

4-5 hours

IM: 30-60min

IV:15-30 min

IV: 2-3 hrs

IM: 30-60 min

IM: 4-5 hrs

IM: 10-15 min

IV: 1 minute

IV: 5-7 mins 2-4 hours

IM: 10-15 min

IM: 30-50 min

Give over 4-5 minutes; may be diluted to 4-5ml

D: (IV/SC) 1-10mg every 2-4 hours D: (IM) 5-20mg every 4 hours D: (IV) 0.2-1 mg every 3 hours

IV: administer slowly

Give over 4-5 minutes; may dilute to 4 - 5ml

D: (SC/IM) 1-2 mg every 4-6 hours

D: 50-100mg

Respiratory depression, tachycardia, bradycardia, nausea, vomiting, hypotension, miosis, dizziness, drowsiness, sedation, biliary or urinary tract spasm, histamine release

Respiratory depression, tachycardia, bradycardia, nausea, vomiting, hypotension, miosis, dizziness, drowsiness, sedation, biliary or urinary tract spasm Respiratory depression, tachycardia, bradycardia, nausea, vomiting, hypotension, miosis, dizziness, drowsiness, sedation, biliary or urinary tract spasm, histamine release **Administration with MAOIs may lead to fatal drug interaction - Avoid MAOIs within the last 15 days**

These parameters may be affected by the dose of the drug and/or the patient’s physical status, underlying pathology, body size, weight and age. IM route of administration should be avoided Doses at the lower or upper limits should prompt patient reassessment (e.g., step down to oral agents or increase to continuous infusion, PCA, etc.)

2/10/03 Approved by P&T Committee

UCLA Pharmaceutical Services

Pain Management Medications - Dosing and Pharmacodynamic Chart Patient Controlled Analgesia - Intravenous Medication Opiates - PCA (morphine, fentanyl, hydromorphone)

Route IV (PCA)

Comments Respiratory depression, tachycardia, bradycardia, nausea, vomiting, hypotension, miosis, dizziness, drowsiness, sedation, biliary or urinary tract spasm, histamine release

Patient Controlled Analgesia – Epidural Medication Local anesthetics + Opiates – epidural, PCEA (bupivacaine or ropivacaine + fentanyl, morphine, or hydromorphone)

Route Epidural (PCEA)

Comments Respiratory depression, tachycardia, bradycardia, nausea, vomiting, hypotension, orthostasis, miosis, dizziness, drowsiness, sedation, urinary retention, histamine release/pruritus Local anesthetics may cause CNS excitation or depression with excessive doses or inadvertant intravascular administration (e.g., catheter migration). Inadvertant intrathecal administration will cause decreased sensation in buttocks, paresis of legs, or absent knee jerk within a few minutes.

2/10/03 Approved by P&T Committee

UCLA Pharmaceutical Services

Pain Management Medications - Dosing and Pharmacodynamic Chart

Naloxone (Narcan®) Administration Indication Mild – Moderate Respiratory Depression secondary to opiate treatment (not in extremus)

Severe Respiratory Depression – Respiratory arrest secondary to opiate treatment

Route/Rate of Administration Dilute 1ml (0.4mg) naloxone in 9ml normal saline (total volume = 10ml ). May be given IV push (preferred), IM, or subcutaneously

Dose

Comments

IV: 0.5ml (=0.02mg) IVP q 2 minutes

IV push (preferred) May be given IM or subcutaneously

IV: 0.4mg – 2mg IV q 2 minutes; if no response after 10mg reassess cause

Any patient receiving opioids for more than 7 days will be sensitive to antagonists (i.e., naloxone); the dose MUST be diluted and carefully titrated to avoid precipitation of acute withdrawal, severe pain, or seizures. Whenever naloxone is administered immediate and continued reassessment is required. For severe, life-threatening situations naloxone is administered undiluted and immediately. Notify physician. Whenever naloxone is administered immediate and continued reassessment is required.

2/10/03 Approved by P&T Committee