99 Pain Management Guidelines (NCCN)

1. Use a multidrug approach. Combine opioids with nonopioids and adjuvant medications.
2. Base administration schedule on the analgesic’s duration of effect. Best to use sustained-release opioids for scheduled dosing and immediate-release opioids for rescue or breakthrough dosing.
3. In opioid-naïve patients, start with low-dose, short-acting opioids and titrate for effect.
4. Avoid meperidine (Demerol), propoxyphene (Darvon), and the mixed agonistantagonist opioids (eg, Stadol, Nubain, Talwin). Do not exceed 4000 mg of acetaminophen (APAP) in 24 hours.
5. Noninvasive routes preferred. For severe pain or rapidly escalating pain, it may be necessary to provide IV analgesics until the pain is managed. If oral or transdermal dosing is no longer practical or appropriate, continuous subQ or IV infusions are indicated.
6. Mild pain (rating 1-3): Start with simple analgesics, APAP or NSAIDS, with adjuvant analgesics as appropriate.
7. Moderate to severe pain (rating 4-10): When pain does not respond to nonopioid analgesics and adjuvants, consider adding an opioid. Drugs with APAP, ASA, or NSAIDS in combination with opioids limit flexibility of dosing.
8. Titration: Increase by 25% to 50% for moderate pain; increase by 50% to 100% for severe pain. Or calculate the average dose of breakthrough medication per day and add to the sustained-release medication dose (except when breakthrough is taken for incident pain).
9. Breakthrough: Scheduled dosing will maintain stable serum drug levels and provide consistent relief. Patients receiving long-acting opioids or continuous parenteral infusions must have an order for breakthrough pain medication. Frequent breakthrough dosing requires a change in the sustained-release drug dose. Oral breakthrough dose is 10% to 20% of the oral 24-hour baseline dose. Peak effect of immediate-release opioid is ~ 1 hour; may repeat dose every hour if patient is not sedated. IV/SQ breakthrough dose is 50% to 100% of the hourly IV/SQ rate. Peak effect of IV opioids is 10-15 minutes; may repeat dose every 15 minutes if patient not sedated. Peak effect of SQ opioids is 30 minutes; may repeat dose every 30 minutes if patient not sedated. Intramuscular dosing not recommended.
10. When changing drug or route of administration, use equianalgesic doses. If changing from one drug to another, the new drug may be more effective because of differences of potency or drug availability. Start at 2/3 to 3/4 of the amount calculated by using equianalgesic tables. Make sure breakthrough medication is available and titrate dose according to individual response.

Manage opioid adverse effects. Patients never become tolerant to the constipating effects of opioids. Always start stimulant laxative/softener combination with opioids