Pain Guidelines & Range Dosing

PAIN MANAGEMENT GUIDELINE The University of Maryland Medical Center recognizes a patient’s right to pain relief and supports a multidisciplinary approach to assessment and management. Utilize this guideline along with associated policies and guidelines: PROE-005 Patient Rights and Organizational Code of Ethical Behavior Policy, PROE-013 Pain Management Policy, MED-003 Medication Administration Policy, MED-004 Controlled Substances Policy, PMT-002 Management of the Patient Receiving Analgesia via Catheter Technique Policy, PMT-001 Management of the Patient Receiving Analgesia via Catheter Technique Guideline, PMT-003 Patient Controlled Analgesia Policy, PMT-004 Patient Controlled Analgesia Guideline, COP-015, Conscious Sedation Policy, COP-027 Palliative/Supportive Care Policy, SPP-006 Palliative/Supportive Care Guideline. ASSESSMENT

RE-ASSESSMENT DOCUMENTATION

Inpatient complaints of pain are considered relevant to the visit and will be assessed. Pain assessment follows the PQRST acronym P = Palliative Factors Q = Quality R = Region, Radiation, Relief S = Severity, Symptoms, Side Effects T = Timing While the multiple dimensions of pain should be routinely considered, investigate spiritual and psychosocial dimensions of pain* when physical pain is not significantly reduced by analgesics. Refer and treat as needed. *May be manifested in a variety of ways including, but not limited to, issues with reconciliation, forgiveness, anxiety, alienation, anger, suffering, questioning the meaning of pain or implicating religious beliefs. Ideally, the same approved pain measurement tool is used for the same patient throughout an episode of care. See Table 1 • Contact PCA Service for appropriate pain measurement tool for non-English speaking patients. Obtain pain scores: • as frequently as clinically indicated. Recommended with routine (ie., every 4 hours) vital signs. • pre and post analgesic administration; with new pain reports; pre, during, and post procedure. Be alert for and report increasing pain scores, increasing analgesic use, persistent pain, intractable pain or new reports of pain which may be a signal of other medical problems such as abscess/hematoma formation (ie., compartment syndrome), or inappropriate use (ie., “gas” pain, recreational). Perform re-assessment at appropriate time intervals based on the analgesic and route. See Table 2 Do not disturb patient’s sleep for reassessment. Document patient is sleeping. Document pain screen on the Intake & Triage Form, Intake Sheet, or computerized data base (CDB). Document initial pain assessment on the Pain Management Assessment/History Form or CDB. Document pain score on the Patient Flow Sheet, Vital Sign Record, MAR, or Pain Management Flow Sheet (PMFS). Document significant changes in PQRST assessment in the medical record. Document PCA/PCEA assessment, pain score and pump settings on the PMFS. Document patient/family education on the Interdisciplinary Patient/Family Education Record.

PRINCIPLES OF PHARMACOLOGIC MANAGEMENT

Goal is maximal pain relief with minimal side effects and minimal patient/family burden. Individualize the pain management plan: • Consider patient’s clinical condition and individual response to analgesic therapy (ie., onset of action, time to peak effect, length of action, side effects). • Opioid tolerant individuals often require larger doses of opioids than the opioid naive person. Prevent/minimize pain whenever possible: • If pain does or is expected to return, administer analgesics “around the clock” (ATC). • Consider rapid-acting prn rescue analgesic to manage pain that breaks through the ATC regimen. • Consider a long-acting analgesic as the ATC analgesic if pain is expected to continue for several days. Administer long-acting analgesics ATC, not prn. • Consider upward titration of the long-acting analgesic if patient uses rescue dose > 2 times/day. • May administer short-acting and long-acting analgesics at the same time if peak effect differs. See Table 2 • May use alternating analgesic administration times, but consider patient/family burden for outpatients. • Pre-treat expected procedure and activity-related pain; consider time to peak effect. See Table 2 Utilize analgesic and modality appropriate to the type and severity of pain as well as patient’s clinical condition. • Non-opioids for mild pain (pain score 1-3/10) • Combination products (opioids + acetaminophen or NSAID) for moderate pain (4–6/10). See Table 3 • Opioids for severe pain (7-10/10). See Table 3 • Treat severe pain promptly with rapid-acting analgesics. See Table 2 • Consider use of opioid sparing/synergistic co-analgesics (NSAIDs, acetaminophen). See Table 4 • Consider NSAID for muscular, joint, and bony pain; antidepressant, anticonvulsant, or specialized analgesic therapy for neuropathic pain; special co-analgesics for uncontrolled visceral pain. Consider APMS Consult for the latter two categories. • Select analgesic route based on patient’s clinical condition. Oral route is preferred and IM route should be avoided. When parenteral route is required, IV route is preferred. Titrate medication to clinical response. With dose range orders (ie., 2-4 mg. every 2-4 hours), the dose may be repeated or increased at time of peak effect as long as physician order limits are not exceeded . Consider patient’s clinical condition and pharmacologic dose limitations (ie., combination products{upper dose limits of non-opioid}, mixed opioid agonists antagonists, tramadol, meperidine). Streamline patient analgesic regimen (ie., use one long-acting opioid, one short-acting opioid, and one NSAID). Polypharmacy is confusing and increases patient risk. Transition analgesics using equianalgesic conversions. See Table 3 Use of opioids and partial agonists (ie., nalbuphine, butorphanol, buprenorphine) may result in ineffective analgesia or trigger withdrawal symptoms. See Table 3 and Table 5 For patients receiving an opioid or benzodiazepine > 5-10 days or longer, consider a taper instead of markedly decreasing the dose or abruptly discontinuing these medications to prevent or minimize symptoms of withdrawal.

SIDE EFFECT MANAGEMENT NON-PHARMACOLOGIC MANAGEMENT PATIENT EDUCATION

DISCHARGE PLAN PATIENT ADVOCACY IV or SubQ PATIENT CONTROLLED ANALGESIA

EPIDURAL/ INTRATHECAL ANALGESIA

See Table 6 During active phases of dying, opioids are continued and doses are not withheld or reduced. Anticipate and aggressively manage side effects. Consider treating prophylactically. See Table 7 Consider non-pharmacological pain management strategies.

See Table 8

It may not always be possible to obtain the optimal goal of a pain score of zero. Instruct the patient accordingly (ie., activity related pain scores < than the midpoint of the scale are to be expected). Allay fears related to overmedication, addiction, and inadequate analgesia. While important for all modalities, these are particularly important points for patients utilizing patient controlled modalities. Instruct patient to use physician ordered medications/drugs only. Include pain management plan, patient education and a resource to call if plan is ineffective. Health care providers are vigilant to the possibility of pain and advocate for patients. This is especially important in patients who cannot self-report and where pain is anticipated or suspected. In such instances an analgesic trial (ie., assessment, analgesic intervention, reassessment) is used. Two licensed health care professionals familiar with the specialty analgesic pump will double check the solution being infused and the pump settings at initial set-up, when the pump is reprogrammed, upon transfer, and every shift change. Assess respiratory rate, sedation score and pain score every 30 min. x 2, then every 2 hrs. x 6, then every 4 hrs. Document on PMFS. Notify APMS for ↓ respiratory rate (RR) &/or ↑ sedation, RR < age specific RR, O2 saturation < 95% on O2, sedation score of 3. See Table 7 Discontinue all other pain medication and sedation orders except those ordered by PCA Service/APMS. Analgesics and sedatives must be ordered or approved by the Pain Service until Pain Service therapy is discontinued. Two licensed health care professionals familiar with the specialty analgesic pump will double check the solution being infused and the pump settings at initial set-up, when the pump is reprogrammed, upon transfer, and every shift change. Assess respiratory rate and sedation score every hr. x 12 hrs., then every 2 hrs. x 12 hrs. then every 4 hrs. Assess pain score and presence of side effects every 2 hrs. x 12 then every 4 hrs. Document on PMFS. Keep head of the bed > to 30 degrees except for 15 min. intervals. Notify APMS for ↓ respiratory rate (RR) &/or ↑ sedation, RR < age specific RR, O2 saturation < 95% on O2, sedation score of 3, patient has not voided in 6 hours, catheter disconnects, or dressing integrity disturbed. See Table 7 Discontinue all other pain medication and sedation orders except those ordered by the APMS.

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