Perfect Pain Control

IV Short-Acting Opioids as First-Line Therapy for Pain

With 100% bioavailability and peak effect within 15-30 minutes after intravenous administration, short-acting opioids have become the preferred first-line therapy in the management of moderate to severe pain.1,2 No longer reserved for the end-stage cancer patient, IV opioids are now used to effect rapid pain relief for a variety of conditions often seen by hospitalists. Below, the some common conditions for which IV opioids may be indicated. (Pain management specialists indicate that IV opioids are now used for many causes of severe pain.)

Non-malignant pain:

• Pancreatitis;
• Intense back pain;
• Sickle cell disease;
• Small bowel obstruction; and
• Perioperative pain.

Malignant pain:

• Metastases to the bone;
• New diagnosis of metastatic disease; and
• Dyspnea and other discomfort at the end of life.

With proper training and experience, hospitalists can utilize short-acting opioids effectively to gain rapid control of patients’ pain. Because IV opioids reach their peak effect within 15-30 minutes, patients may initially be reassessed and then re-dosed at this interval until adequate pain control is achieved and an effective dose is determined. The patient may then be placed on scheduled- or as-needed doses every two to three hours, or, alternatively, on a PCA pump. Doses may then be titrated by 25% for mild pain, by 50% for moderate pain, and by 100% for severe pain.

Choice of drug and starting doses must be individualized to each patient, taking into account his or her prior drug exposure—is the patient opioid-naïve or opioid-tolerant?—prior response to previous doses, age, liver and renal function, pain severity, anticipated pain duration, and co-morbidities such as renal or pulmonary disease.3 —GH

References

1. Gordon DB, Stevenson KK, Griffie J, et al. Opioid equianalgesic calculations. J Palliat Med. 1999;2:209-218.
2. National Comprehensive Cancer Network Practice Guidelines in Oncology. Adult cancer pain. Available at: www.nccn.org/professionals/physician_gls/PDF/pain.pdf. Last accessed January 28, 2007.
3. Gordon DB. Fast fact and concept #70: PRN range analgesic orders. Available at: www.eperc.mcw.edu/fastFact/ff_70.htm. Last accessed January 28, 2007.