Pain Management Regimens: Mild, Moderate, Severe Pain with Breakthrough Pain Options

Mild Pain

• Acetaminophen (Tylenol):
  • PRN: 650 mg q4hr or 1000 mg q6hr as needed.
  • Scheduled: Consider for patients with uncontrolled mild pain.
  • Max Doses:
    • 4g/day in patients with normal liver function.
    • 2g/day in those with liver dysfunction or cirrhosis.
  • Routes: Oral or rectal preferred; IV is available but expensive.
• NSAIDs:
  • Use cautiously in patients at risk for GI bleeding or acute kidney injury.
  • Ibuprofen: 400 mg PO every 6–8 hours.
  • Naproxen: 250–500 mg PO every 12 hours.
  • Ketorolac (IV/IM): 10–15 mg q6hr (limit use to 48 hours to reduce risks).
  • Consider topical NSAIDs (e.g., Diclofenac gel) for localized musculoskeletal pain.

Moderate Pain

• Combination Therapy:

  • Acetaminophen ± NSAIDs for additive effects.

• Topical Analgesics:

  • Lidocaine Patch: Apply up to 3 patches; remove after 12 hours.
  • Capsaicin Cream: Effective for neuropathic and osteoarthritis pain.

• Low-Potency Opioids:

  • Tramadol: 50 mg PO q4–6hr PRN.
    • Avoid in patients with seizure history.
  • Consider consultation for opioid-sparing strategies if chronic pain.

Severe Pain

• Opioid Therapy:

  • Short-acting Opioids: First-line for acute severe pain.
    • Oxycodone: 5 mg PO q4–6hr PRN.
    • Hydromorphone (Dilaudid): 1–2 mg IV q4–6hr PRN.
    • Morphine: IV or PO options; adjust for renal impairment.
    • Fentanyl (IV): Short half-life, for acute episodes.
  • Use conversion charts for switching opioids; start at 75% of equianalgesic dose when rotating.

• Adjuncts:

  • Ketamine: Consult pain service. Useful for opioid-sparing.
  • Methadone: Requires specialist involvement for titration.

• Neuropathic Pain:

  • Duloxetine or Venlafaxine.
  • Gabapentin: Start at 100–300 mg PO nightly, titrate.

Breakthrough Pain

• PRN Opioids:
  • 10–15% of total daily opioid dose, every 2–4 hours as needed.
  • Ensure opioid conversion and rescue dosing are appropriately calculated.

General Considerations

• Prevent Constipation with Opioids:
  • Prophylaxis: Senna and docusate or polyethylene glycol (Miralax).
• Multimodal Pain Control:
  • Combine pharmacologic and non-pharmacologic options (e.g., warm compresses, physical therapy).
• Consult Services:
  • Pain management or palliative care for complex cases or refractory pain.

Summary: Management of Vaso-Occlusive Crisis in Sickle Cell Disease

Nonnarcotic Analgesics for Mild Pain

• Acetaminophen (Tylenol): 500–1,000 mg q4–6 hours (Max < 4,000 mg/day).
• Aspirin: 650–1,000 mg q4–6 hours (Max < 4,000 mg/day).
• NSAIDs:
  • Ibuprofen: 200–400 mg q4–6 hours.
  • Naproxen: 500 mg initially, then 250 mg q6–8 hours.
  • Ketoprofen: 25–75 mg q6–8 hours (Max < 300 mg/day).

Narcotic Analgesics for Moderate Pain

• Weak opioids like codeine and oxycodone can be titrated for moderate pain control.
• Avoid prolonged use due to dose-limiting side effects (e.g., sedation, nausea, vomiting).

Opioids for Severe Pain

• Administer stronger opioids parenterally or via patient-controlled analgesia (PCA) for severe pain:
  • Morphine:
    • Oral: 15–30 mg q4 hours.
    • IV: 0.1–0.15 mg/kg q3–4 hours.
  • Hydromorphone (Dilaudid):
    • Oral: 2–4 mg q4–6 hours.
    • IV: 1–2 mg q4–6 hours.
  • Avoid Meperidine due to short half-life, risk of neurotoxicity, and complications with repetitive dosing.

Breakthrough Pain

• Administer 1/4 to 1/2 of the maintenance dose based on sedation level.
• If 3+ rescue doses are needed in 24 hours, increase maintenance dose by 25–50%.

Supportive Care

• Fluids:
  • Oral hydration for mild crises; IV fluids for severe dehydration or vomiting.
  • Use balanced solutions (e.g., 5% dextrose in 0.25% normal saline) after correcting deficits.
• Oxygen:
  • Only for hypoxemia; unnecessary in normoxic patients.
  • Use arterial blood gas if pulse oximetry is unreliable.

Hydroxyurea

• Indicated for patients with severe recurrent crises.
• Dosage: Start at 500 mg/day, titrate to 1,000–2,000 mg/day.
• Monitor blood counts every 4–6 weeks.

Nonpharmacologic Strategies

• Heat application, physical therapy, TENS, distraction techniques, and self-hypnosis.

Key Management Principles

• Avoid delays in analgesia.
• Prefer scheduled dosing over PRN.
• Regular reassessment of pain, sedation, and vital signs.
• Transition to oral analgesics as pain resolves and taper doses gradually.
• Provide a prescription for pain control upon discharge if needed.

Opioid Overdose Order Set

1. Monitoring and Initial Assessment

• Vitals Monitoring:

  • Continuous pulse oximetry, cardiac telemetry.
  • Capnography if available (preferred for assessing hypoventilation).
  • Measure respiratory rate and mental status every 15 minutes until stable, then every hour.

• Labs:

  • Arterial blood gas (ABG) or venous blood gas (VBG) to assess CO2 retention.
  • Basic metabolic panel (BMP) to check for acidosis or hyperkalemia.
  • Serum glucose to rule out hypoglycemia as a contributor.
  • Urine toxicology screen.
  • Blood ethanol level if history or suspicion of concurrent alcohol ingestion.

2. Airway and Breathing

• Airway Support:

  • Ensure airway patency; initiate bag-mask ventilation if respiratory rate < 8/min or oxygen saturation < 92% despite oxygen.

• Supplemental Oxygen:

  • Administer 2–6 L/min via nasal cannula or non-rebreather mask as needed to maintain oxygen saturation > 92%.

3. Naloxone Administration

• Initial Dosing:

  • Naloxone (Narcan):
    • IV Route: 0.04 mg IV bolus initially; repeat every 2–3 minutes, titrate up to 2 mg as needed for adequate respiratory effort.
    • IM/SC Route: 0.4 mg; may repeat every 2–3 minutes.
    • Intranasal Route: 4 mg in one nostril, may repeat after 3–5 minutes if no response.

• Consider Infusion:

  • For long-acting opioid overdoses or recurrent respiratory depression:
    • Naloxone Infusion: Start at 0.02–0.1 mg/hour; titrate to effect (based on respiratory rate and oxygenation).

4. Supportive Measures

• IV Fluids:

  • Start Normal Saline (0.9% NaCl) 1 L bolus if hypotension is present.

• Hypoglycemia Management:

  • If blood glucose < 70 mg/dL, administer:
    • Dextrose 50% (D50): 1 amp (25–50 mL) IV push, repeat as needed.

• Bicarbonate Therapy:

  • If severe acidosis (pH < 7.2):
    • Sodium bicarbonate: 1 amp IV, repeat based on ABG results.

5. Observation and Tapering

• Observe patients for at least 2–4 hours after last naloxone dose for signs of recurrent respiratory depression.
• Extend observation to 6–12 hours for long-acting opioids (e.g., methadone, extended-release formulations).

6. Education and Prevention

• Assess for opioid use disorder (OUD) and consider initiating treatment:
  • Buprenorphine for withdrawal management.
  • Referral to addiction medicine or pain management.
• Prescribe a naloxone kit for discharge with education on overdose prevention and response.

7. Documentation

• Record time, dose, and route of naloxone administration.
• Document patient’s response to treatment, including changes in respiratory rate, oxygenation, and mental status.
• Note any complications (e.g., withdrawal symptoms, agitation).