Review of Pharmacological

Pain Management

CHAMP Activities are possible with generous support from The Atlantic Philanthropies and The John A. Hartford
Foundation
 The WHO Pain Ladder

The World Health Organization Pain Ladder outlines an

overall strategy for pharmacological pain management
as follows:
Step 3: Severe pain (rated 7-10’):
 Requires treatment with strong
opioids, with or without the addition
of a non-opioid or adjuvant
medication.

Step 2: Moderate pain (rated 4-6’):

 May be treated with an opioid only,
or an opioid combined with a non-
opioid.

Step 1: Mild pain (rated 1-3’):

 Can typically be treated with non-
opioids.

* on a scale of 0-10
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 Principles of Pharmacological Pain
Management

Key Points to Remember About the WHO Pain Ladder

At each step in the pain ladder:
 The appropriate medication and dose is the one that controls
pain with the fewest side effects.
 Medication choice is based on type and severity of pain and
action and duration of medication(s).
 Frequent dose adjustment may be necessary to arrive at the
appropriate dose to relieve pain.
Around-the-Clock Dosing
 Around-the-clock dosing is required with pain that is constant.
If pain medication has to be administered every 4 hours, it is
usually best to switch to long-acting formulations (like MS
Contin) so the patient can sleep through the night without
breakthrough.
 PRN dosing with short-acting, rapid-onset medications may be
used along with around-the-clock dosing for breakthrough
pain or activity-related pain.
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 Non-Opioid Analgesics

Best Choice for Mild to Mild-Moderate Pain

 Non-opioid analgesics are the best choice for mild pain, or for mild
to moderate pain, alone or in combination with opioids.

 The most common non-opioid pain relievers are acetaminophen,

aspirin, and other non-steroidal anti-inflammatory drugs (NSAIDs)

 Use of these drugs is limited by a ceiling effect—higher doses

do not relieve pain beyond a certain dose level.

 Older patients taking NSAIDs should be monitored for adverse

effects, including renal and hepatic dysfunction, bleeding, and
gastric ulceration
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 Non-Opioid Analgesics

Using Non-Opioids in Older Adults

 Many non-opioid analgesics carry a risk of toxicity above the

recommended maximum daily dose.

 The recommended daily dose is further reduced in older

adults, particularly those with hepatic dysfunction, or those at
risk for GI bleeding and cardiovascular problems.

 For example, the maximum daily dose of acetaminophen for

healthy younger adults is 4000 mg; in older adults with hepatic
dysfunction it may need to be reduced by 50-75%.

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 Non-Opioid Analgesics

NSAIDs: Monitor for Complications

Teach the patient to:

 Promptly report blood in vomit, urine or stool; or black tarry

stools.

 Report signs/symptoms of liver toxicity, including nausea,

lethargy, itching, jaundice, RUQ tenderness and flu-like
symptoms.

 Check with his or her physician or home care nurse before

taking additional medication.

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 Opioid Medications

Best Choice for Moderate to Severe Pain

 Moderate pain (rated 4-6 on a scale of 0-10) may be treated with

an opioid.

 Moderate pain may also require an opioid combined with a

non-opioid, but remember, combination regimens may be
limited because of the maximum daily dose of the non-opioid.
Examples: Hydrocodone, Oxycodone

 Severe pain (rated 7 and above on a scale of 0-10) requires

treatment with strong opioids.
Examples: Morphine, Hydromorphone, Oxycodone, Fentanyl

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 Opioid Medications

Opioid Medications to Avoid with Older Adults (3.2)

 Meperidine (Demerol): A metobolite produces CNS toxicity that

may cause tremor, irritability, cognitive changes and seizures;
other opioids are safer and more effective.

 Propoxyphene (Darvon, Darvocet): Long half-life, metabolite

cause CNS and cardiac toxicity; can cause renal injury;
analgesia equal to aspirin or acetaminophen; other opioids are
safer and more effective.

 Pentazocine (Talwin®): Causes delirium and agitation in older

patients, potential for renal injury; other opioids are safer and
more effective.
8 3.2: www.geronurseonline.org. Assessment for High Risk Medications in the Elderly
 Opioid Medications

A Peripheral Analgesic: Lidocaine Patches

 Although not technically an opioid medication, a newer agent,

the topical lidocaine patch 5% (Lidoderm), may be useful for
older patients with postherpetic neuralgia (PHN). PHN is a
chronic pain syndrome that presents as continuous burning or
intense paroxysmal pain which may be severe and disabling.

 The lidocaine patch is targeted peripheral analgesic, so it does

not have the same adverse systematic effects possible with
opioids and other medications. It also has a minimal risk of
drug/drug interactions.

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 Opioid Side Effects

Start Low, Go Slow

Opioids should be started at low doses and titrated up gradually to

reach the point of maximum pain relief with minimum side effects.
In older patients, the starting dose is usually lowered. You may
have heard this approach described as “Start low, go slow”.

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 Opioid Side Effects

Tolerance
 Tolerance usually develops to many of the side effects of opioids in a few
days.
 Tolerance to the analgesic effect can also develop and may require
additional medication over time. If a patient with previously-controlled pain
is no longer getting adequate relief, an assessment of worsening pain and
disease progression should also be considered.

Physical Dependence
 Physical dependence (as opposed to addiction) is a normal and expected
response to continuous opioid therapy
 Physical dependence is characterized by withdrawal symptoms
experienced when an opioid is discontinued. Symptoms may include
agitation, insomnia, diarrhea, sweating, and rapid heart beat.
 If pain is resolved, physical dependence is easily treated by gradually
decreased the opioid dose.
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 Opioid Side Effects

Common Side Effects and Monitoring for Complications

Drowsiness and Nausea

 Drowsiness and nausea typically resolve in 1-3 days without
treatment. Patients and their families should be instructed that these
may occur.
 Rarely, patients may experience confusion or “fuzzy thinking,” which
can be persistent. This can continue to delirium for reasons that are
not clearly understood. Any change in mental status with a new
opioid or change in opioid dose should be reported to the physician.

Respiratory Depression
 It is the first dose of an opioid that puts the patient at most risk for
developing a respiratory event. After that, there is rapid central
nervous system tolerance to the respiratory depressive effects of
opioids. However, patients with other respiratory risk factors
(including alcohol use and pre-existing respiratory disease) should
also be monitored closely with opioid dose increases.
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 Opioid Side Effects

Common Side Effects and Monitoring for Complications con’t

Constipation
 While many of the side effects of opioids resolve in a few days, constipation
almost never resolves on its own while the patient is still taking an opioid.
Constipation usually occurs after several days of taking opioids, can be
quite painful, and may require hospitalization. Constipation should always
be anticipated and treated aggressively.
 All patients taking around-the-clock opioids should have a prophylactic
bowel management plan, including appropriate medications. Stool
softeners, by themselves, are usually insufficient. In the absence of
adequate fluid intake, bulk laxatives such as psyllium (Metamucil) can
cause fecal impaction and should be avoided.

Pseudo-addiction
 In pseudo-addiction, patients with severe unrelieved pain can become
intensely focused on obtaining relief, and their behavior can mimic aspects
of drug seeking behavior. This behavior should resolve when adequate
pain relief is provided, without the evidence of loss of control, escalating,
and binging that is characteristic of addiction,

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