© 2013 UPMC All Rights Reserved
UPMC
POLICY AND PROCEDURE MANUAL
POLICY: HS-NA0408
INDEX TITLE: Nursing
SUBJECT: Pain Management Guidelines
DATE: May 31, 2013
I. POLICY
It is the policy of UPMC to provide excellence in patient care throughout the life span.
The relief of pain is inherent in patient care and includes relief of physical and
psychosocial symptoms associated with pain. Pain management is a vital part of patient
care and all patients have a right to pain relief. The prevention and relief of pain is
contingent upon pain assessment and reassessment, medication and non-medication
interventions, and the treatment of side effects that may be associated with analgesia.
The commitment of UPMC to prevent and treat pain is based on a body of scientific
knowledge derived from publications such as those of the World Health Organization
(WHO)11
, the American Pain Society (APS)2, Practice Guidelines for Acute pain
Management in the Perioperative Setting 3, and Guideline for the Management of Cancer
Pain in Adults and Children 4
. UPMC endorses the American Nurses Association Code of
Ethics for Nurses5, the American Hospital Association Patient’s Bill of Rights
6, and the
American Nurses Association Position Statement on Pain Management and Control of
Distressing Symptoms in Dying Patients7.
Links to policies referenced within this policy can be found in Section XII.
II. PURPOSE
The purpose of this policy is to provide direction to health care providers regarding the
assessment and management of pain across the lifespan and to:
Inform patients at the time of their initial evaluation that relief of pain is an important
part of their care and respond quickly to reports of pain to maximize comfort.
On initial evaluation and at regular intervals, assess for the presence, quality, and
intensity of pain and use patients’ self report as the primary indicator of pain.
Collaborate with the patient, responsible others, and healthcare providers to establish
a goal for pain relief and develop and implement a plan of care to achieve that goal.
Review and modify the plan of care for patients who have unrelieved pain, on a
regular basis.
Educate themselves and patient/family/caregiver about pain management.
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III. SCOPE
This policy applies to all United States based UPMC inpatient and outpatient facilities.
IV. DEFINITION (S)
PAIN:
“Pain is an unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage. It is unquestionably a
sensation in a part or parts of the body but it is also always unpleasant and therefore an
emotional experience.”8
“Pain is whatever the experiencing person says it is, existing whenever he/she says it
does.”9
ACUTE PAIN:
“A complex constellation of unpleasant sensory, perceptual, and emotional experiences
associated with autonomic, psychological, emotional, and behavioral responses.”10
CHRONIC NONMALIGNANT PAIN:
“Pain that persists a month or more beyond the usual course of acute disease or a
reasonable time for an injury to heal or that is associated with a chronic pathologic
process that causes continuous pain or the pain recurs at intervals for months or years.”10
CANCER PAIN:
Cancer pain can be chronic or acute and typically is caused by one or more of the
following:
1. Tumor involvement: local, regional, and metastatic spread of the disease
2. Cancer-related procedures and treatment effects
3. Causes unrelated to cancer such as back pain, diabetic neuropathy, and
rheumatoid arthritis experienced by patients with cancer.11
V. ASSESSMENT
All patients will be screened for the presence of pain upon admission, at regular intervals
and prior to and following an invasive procedure. If present, pain shall be assessed. The
assessment will include a pain severity scale (see Appendix A), location, description, and
level of sedation, using an age appropriate sedation scale defined by your hospital. All
patients should be assessed related to the administration of opioids whether they are
opoid naïve or opiod tolerant.
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Adult Sedation Scale to assess unintentional sedation related to opioid medication
administration:
0 = none (alert)
1 = mild (occasionally drowsy, easy to arouse
2 = moderate (frequently drowsy, easy to arouse)
3 = severe (somnolent, difficult to arouse)
S = normal sleep
Children’s Hospital of Pittsburgh uses the University of Michigan Sedation Scale
(UMSS)
Additional detail such as alleviating and aggravating factors may be included when
warranted by the patient’s condition.
A. For the patients receiving care and treatment in an outpatient setting, pain
screening and assessment, if necessary, will occur on initial evaluation and then as
indicated by the patient’s condition. Consider referral to appropriate resources.
B. The pain rating scale used will be appropriate to the patient’s age and ability to
communicate. Pain rating scales recommended for use include but are not limited
to (see Appendix A):
(1) Zero to ten (0-10) Numeric Pain Intensity Scale (8 years and older,
approximately)*
(2) Wong-Baker FACES Pain Rating Scale (3 – 7 years and older,
approximately)*
(3) Word Descriptors (4 years and older)
Omitting PIPPS
(4) Cries CRIES Scale (birth – 6 months, approximately)
(5) FLACC Behavioral Pain Assessment Scale – 2 months and older,
approximately
(6) Neonatal Infant Pain Scale (NIPPS) - <37 weeks gestation and full term
infants until 6 weeks.
(7) N-PASS - Neonatal Pain, Agitation & Sedation Scale
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*Self-report pain assessment scales may also contain word descriptors
A hierarchy of assessment measures including (1) self-report, (2) pathological
condition (disease process), (3) behavior and (4) family/caregiver input shall be
considered as warranted by the patient’s condition.
If the patient is unable to verbally communicate the presence of pain, the
assessment will include observations: that may include (a) facial responses (i.e.:
grimace, frown, clenched teeth, etc); (b) verbal response (i.e.: moaning,
whimpering, crying); and (c) body movement (rigid, arching, withdrawing,
splinting, etc).
C. Reassessment for the presence of pain following pain-relieving interventions is
essential for effective pain management. Reassessment will include intensity,
using an appropriate pain scale or description of behaviors level of sedation (per
age appropriate sedation scale), and outcome. For those patients unable to
communicate verbally, the reassessment may include observations. Frequency of
reassessment will be determined by individual patient care needs and
environment.
VI. RECOMMENDATIONS CONCERNING CARE OF THE PATIENT WITH NON
OBSTETRICAL PAIN
Accept the patient’s report of pain and act on it, per physician order when required.
i.e. non-pharmacological interventions, medications, etc
Use the WHO1 analgesic ladder.
1
The American Pain Society endorses the WHO analgesic ladder. It focuses on
selecting analgesics on the basis of the intensity of pain using analgesics from
each of the analgesic groups (non-opioids, opioids for mild to moderate pain,
opioids for moderate to severe pain). Individualize the opioid dose for the very
young and the very old.
Oral route preferred; intramuscular injections discouraged (unpredictable absorption,
injections cause pain to relieve pain).
Around the clock analgesic administration is preferred over PRN administration for
persistent pain.
Provide rescue or “clinician bolus” doses as appropriate, and following physician
order (e.g. patients receiving pump-controlled analgesia therapy who experience
breakthrough pain.)
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Consider the KISS principle – Keep It Simple and the Same:
i.e. sustained release morphine and immediate release morphine
Consider adjuvant medications such as non-steroidal anti-inflammatory medications
(NSAIDs), tricyclic antidepressants, anticonvulsants
Titrate to effect.
All analgesic doses must be titrated to optimize the balance between analgesia and
negative or undesirable side effects. For IV opioids, titration may occur as often as
every 5 minutes, whereas titration of a tricyclic antidepressant may occur only every 4
to 5 days. Generally, the goal is to use the smallest dose that relieves the maximum
amount of pain with the fewest negative or undesirable side effects. The prescriber
must indicate the specific titration parameters, if used. Orders such as “titrate to
comfort” are not acceptable. The prescriber must also indicate specific doses and
frequency of dosing.
Use equianalgesic doses when changing route of administration and opioid.
(Appendix B) Refer to the Pediatric Drug Therapy Handbook & Formulary,
Department of Pharmacy, and Children’s Hospital of Pittsburgh of UPMC for
pediatric dosing. Refer to Neofax for neonatal dosing.
Recognize and treat side effects vigorously (i.e. sedation, nausea, vomiting,
constipation, itching and respiratory depression).
Incorporate non-pharmacological modalities as indicated to supplement treatment
regimens (i.e. heat, cold, back rubs with change in position, TENS unit, oral sucrose with
non-nutritive sucking (pacifier) for infants).
Consider using complementary modalities. (Appendix C)
Use pain prevention techniques to facilitate activity such as turning, deep breathing,
coughing and ambulation.
Consider that opioid doses are individualized to the patient; therefore the dosing range
can be wide. A ceiling effect is reached when increasing the dose does not provide
additional analgesia. The analgesic effects of mu agonist opioids have no ceiling effect.
The maximum dose of opioids analgesics is related to patient tolerance of the medication
and patient tolerance of side effects. NSAIDs and acetaminophen have a ceiling effect.
The ceiling effect is reached when increasing the dose does not provide additional
analgesia.
Do not use placebos to assess the nature of pain or treat pain. (see UPMC Policy HS-
HD-CP-02, Placebo)
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Monitor for the development of tolerance and treat appropriately.
Tolerance to the analgesic effects of an opioid is a state of adaptation in which
exposure to a drug induces changes that result in a diminution of the drug’s
effectiveness over time. Opioid tolerance is defined as a decrease in the
effectiveness of a medication, particularly opioids, and the need for escalating
doses to achieve pain relief.
Opioid tolerant may be defined as: patients who are taking, for 1 week or longer, at least:
60 mg oral morphine/day;
25 mcg transdermal fentanyl/hour;
30 mg oral oxycodone/day;
8 mg oral hydromorphone/day;
25 mg oral oxymorphone/day; or
An equianalgesic dose of any other opioid.
Expect physical dependence and prevent withdrawal.
Physical dependence is not the disease of addiction. It is a state of adaptation that
is manifested by a drug-class specific withdrawal syndrome produced by abrupt
cessation, rapid dose reduction, decreasing level of medication in the blood,
and/or administration of an antagonist. This syndrome is characterized by
anxiety, irritability, chills alternating with hot flashes, salivation, lacrimation,
rhinorrhea, diaphoresis, piloerection, nausea, vomiting, abdominal cramps, and
insomnia.
Do not label a patient with the disease of addiction if you mean physically dependent
on, or tolerant to, opioids.
Addiction is defined as a primary, chronic, neurobiologic disease with genetic,
psychosocial, and environmental factors influencing its development and
manifestations. It is characterized by behaviors that include one or more of the
following: impaired control over drug use, compulsive use, continued use despite
harm, and craving. The exact prevalence of iatrogenic addiction in acute and
cancer pain in not known.
Be alert to the psychological state of the patient. The presence of anxiety intensifies
the pain experience.
Multimodal therapies may be used to optimize analgesic efficacy while minimizing
the risk of adverse events. Multimodal analgesia is achieved by combining different
analgesics that act by different mechanisms (e.g., opioids, NSAIDs, and local
anesthetics), resulting in additive or synergistic analgesia, lower total doses of
analgesics, and fewer side effects.
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It is the standard of care to administer a topical local anesthetic for children who must undergo
the following invasive procedures:
1. Venipuncture (blood draw)
2. Percutaneous intravenous cannulation (IV)
3. Totally implantable central venous port access
4. Subcutaneous catheter insertion
5. Percutaneous inserted central catheter (PICC) placement
The following clinical effectiveness guideline and policy should guide nursing practice.
http://intranet.chp.edu/04policies/04gce/04gce_misc/603-00.pdf
http://intranet.chp.edu/04policies/04ptcare/04ptcare_5/860.doc
Examples of Multimodal Therapy
Combination of Agents Example
Systemic NSAIDa plus systemic opioid PO Ibuprofen plus PO Hydromorphone
Systemic NSAID plus epidural opioid and
local anesthetic
IV ketorolac plus epidural fentaNYL and
bupivacaine
Systemic NSAID plus local infiltration of
anesthetic plus systemic opioid
IV ketorolac plus lidocaine infiltration of surgical
site plus IV PCA morphine
Regional block plus systemic NSAID plus
epidural opioid and local anesthetic
Intraoperative anesthetic plus IV ketorolac plus
postoperative fentaNYL and bupivacaine epidural
Continuous regional local anesthetic
infusion plus systemic opioid
Post-operative ropivacaine nerve plexus infusion
plus IV PCA morphine
Source: Reference 6 (adapted). McCaffery M, Portenoy RK. Overview of three groups of
analgesics. In: McCaffery M, Pasero C, eds. Pain Clinical Manual. 2nd ed. St. Louis, MO: Mosby
Inc; 1999a:103-128.
a NSAIDs need to be used with care in surgical patients due to the risk of bleeding (“anti-
platelet” effect).
IV: intravenous; NSAID: nonsteroidal anti-inflammatory drugs; PCA: patient-controlled
analgesia; PO: per os (oral).
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VII. PATIENT AND FAMILY EDUCATION
A. Essential to effective pain management is involvement and education of the
patient and/or family.
1. The health care provider will communicate that pain management is an
important part of the patient’s care while taking into consideration
personal, cultural, spiritual, and/or ethical beliefs of the patient/family.
2. Education will include (as appropriate):
a. Understanding pain and its risks
b. The importance of effective pain management
c. The pain assessment process
d. Methods for pain management, including pharmacological and non-
pharmacological methods
e. The patient’s/family’s roles in managing pain
f. Potential side effects of pain medication
g. Patient-specific goal-setting
3. Instructions provided to the patient and/or family shall be recorded in the
patient’s medical record.
4. The effectiveness of education will be evaluated on an on-going basis.
VIII. DOCUMENTATION
A. Inpatient Population
1. The initial screening and assessment of pain, if indicated, will be
documented on admission.
2. Reassessment will be recorded with the intensity documented using the
pain scale, sedation scale, quality descriptors and outcome parameters
defined per the scale(s) defined for specific patient populations.
Observations and further assessment details are to be documented in the
Medical Record.
3. The plan for patient care will be developed and/or revised based on
specific patient needs.
B. Procedural and Outpatient Departments
1. Assessment and reassessment for presence of pain will occur in procedural
and outpatient departments and documented on the appropriate
departmental record. Patients being seen in ambulatory clinics will be
assessed for the presence of pain appropriate to the context of their visit.
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When pain is present, the assessment will include intensity, location, and
onset.
2. Based on the patient’s response to the assessment, the provider will
conduct a further assessment and determine appropriate intervention or the
need for referral.
3. The plan for patient care will be developed and/or revised based on
specific patient needs.
IX. STAFF EDUCATION
A. Education in pain assessment and management will be provided for appropriate
clinical staff during orientation and on an ongoing basis.
B. Many clinical departments have specially educated staff (Pain Management
Resource Nurses/Clinicians) who serve as on-site resources and educators for the
clinical staff.
C. A variety of pain management resources are available throughout the UPMC.
These include advanced practice nurses, pain management resource nurses and
clinicians, pharmacists, and physicians.
X. OVERSIGHT AND EVALUATION
A. An interdisciplinary pain committee/team serves as a resource for clinical issues
surrounding pain management. The team reviews current clinical practice and
makes recommendations for change based on evidence and research.
B. Patient interviews and surveys are used to evaluate the appropriateness and
effectiveness of pain management.
C. Some organizations may benchmark pain assessment data (e.g., National Database
for Nursing Quality Indicators).
XI. ASSOCIATED POLICIES/PROCEDURES
Individual UPMC facilities may have institution specific policies related to pain
management techniques.
XII. POLICIES REFERENCED WITHIN THIS POLICY
HS-HD-CP-02 Placebo
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© 2013 UPMC All Rights Reserved
SIGNED: Holly Lorenz
Chief Nursing Executive
ORIGINAL: January 6, 2003
APPROVALS:
Policy Review Subcommittee: May 9, 2013
Executive Staff: May 31, 2013
PRECEDE: June 1, 2012
SPONSOR: Chief Nursing Executive
Attachments
Appendixes:
Appendix A Pain Rating Scale (Adult and Children’s)
Appendix B Analgesic Reference Guide
Appendix C Complementary Modalities for Pain Management
References:
1Cancer Pain Relief, 2
nd Ed. Geneva, World Health Organization, 1996.
2 American Pain Society (APS): Principles of analgesic use in the treatment of acute pain and
cancer pain, Ed 4, Glenview, Ill, 2008.
American Pain Society (APS): (2003) Principles of analgesic use in the treatment of acute and
cancer pain (5th
ed.). Glenview, IL: APS.
American Pain Society (APS): Guideline for the Management of Acute and Chronic Pain in
Sickle Cell Disease), Glenview, Ill, 1999.
3 American Society of Anesthesiologists (ASA): Practice Guidelines for Acute Pain
Management in the Perioperative Setting, Anesthesiology (2004;100:1573-81).
4
American Pain Society (APS): Guideline for the Management of Cancer Pain in Adults and
Children, Glenview, Ill, 2005.
5American Nurses’ Association (ANA) Code for Nurses published by American Nurses
Publishing, 600 Maryland Ave., SW, Suite 100W, Washington, D.C. 20024-2571. Copyright ©
1976, 1985 by the American Nurses Association. All rights reserved. G-56 7.5M 10/96.
6American Hospital Association (AHA) A Patient’s Bill of Rights copyrighted material 1992 by
the American Hospital Association, 840 North Lake Shore Drive, Chicago, Illinois 60611.
Printed in the USA. All rights reserved. Catalog number 157759.
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7American Nurses Association (ANA) Position Statement on Promotion of Comfort and Relief
of Pain in Dying Patients, American Nurses Association, 600 Maryland Ave., SW, Washington,
D.C. 20024. September 5, 1991, rev. 1995.
8 International Association for the Study of Pain. Subcommittee on Taxonomy. Pain Terms: a
list with definitions and notes on usage. Pain. 1979;6:250.
9 McCaffery, M. Nursing practice theories related to cognition, bodily pain, and man
environment interactions, Los Angeles, 1968, UCLA Students Store.
10 Bonica, JJ, Definitions and taxonomy of pain, in: Bonica, JJ, Ed. The Management of Pain.
2nd
ed. Philadelphia, PA: Lea & Febiger; 1990:18-27.
11
Pasero, C., & McCaffery, M., (2010) Management of Opioid-Induced Adverse Effects. In Pain
Assessment and Pharmacologic Management. Elsivier-Mosby: St.Louis. pp. 520-521.
12
Foster, R.L., Varni, J.W. Preliminary validation of instruments to measure child and parent
satisfaction with post-operative pain management. A poster presented at the 9th
World Congress
of Pain, Vienna, Austria, 1999.
13
Anand KJS. 2001. Consensus statement for the prevention and management of pain in the
newborn. Archives of Pediatric Adolescent Medicine, 155(2): 173-180.
14
Stevens, B, Yamada, J, Ohlsson, A. Sucrose for analgesia in newborn infants undergoing
painful procedures. Cochrane Database Syst Rev.
2010;(1):CD001069.doi:10.1002/14651858.CD001069.pub3. (more recent systematic review)
15
Pasek, TA, Huber, JM. Hospitalized infants who hurt: A sweet solution with oral sucrose.
Critical Care Nurse, 2012;32(1):1-9 (in press).
16
Thompson, DG. 2004. Utilizing an oral sucrose solution to minimize neonatal pain. Journal for
the Society of Pediatric Nurses, 10(1): 3-10.
17
Gray L, Watt L, Blass EM. 2000. Skin-to-skin contact is analgesic in healthy newborns.
Pediatrics. 105(1): e14.
18
Johnston CC, Stevens B, Pinelli J et al. 2003. Kangaroo care is effective in diminishing pain
response in preterm neonates. Archives of Pediatrics & Adolescent Medicine 157(11):1084-8.
19
Ludington-Hoe SM, Hosseini R, Torowizc DL. 2005. Skin-to-skin contact (Kangaroo Care)
analgesia for preterm infant heelstick. AACN Clinical Issues. 16(3):373-387.
20
O’Malley-Dafner, L., & Davies, P., (2000). Naloxone-induced pulmonary edema The American
Journal of Nursing, 100(11), 24AA-24JJ.
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21Malviya, S, Voepel-Lewis, T, Tait, AR, Merkel, S, Tremper, K, Naughton, N, Depth of
sedation in children undergoing computed tomography: validity and reliability of the University
of Michigan Sedation Scale (UMSS). British Journal of Anesthesia, 2002;88(2):241-245.
22
Shields, CH, Styadi-Park, G, McCown, MY, Creamer, KM, Clinical utility of the bispectral
index score when compared to the University of Michigan Sedation Scale in assessing the depth
of outpatient pediatric sedation. Clinical Pediatrics, 2005;44:229-236.
23
Malviya, S, Voepel-Lewis, T, Tait, AR, A comparison of observational and objective measures
to differentiate the depth of sedation in children from birth to 18 years of age. Anesthesia
Analgesia, 2006;102:389-394.
24
Malviya, S, Voepel-Lewis, T, Ludomirsky, A, Marshall, J, Tait, AR, Can we improve the
assessment of discharge readiness? Anesthesiology, 2004;100:218-224.
© 2013 UPMC All Rights Reserved
APPENDIX A.1.
UPMC
PAIN RATING SCALES
“The single most reliable indicator of the existence and
intensity of pain is the patient’s self-report”….McCaffery and
Pasero in Pain: Clinical Manual, Mosby: 1999, p. 40.
The types of pain rating scales that are recommended for patients
5 years and older include:
Numeric Pain Intensity Scale
Word Descriptors
Wong-Baker FACES Pain Rating
Scale©
Zero to 10 Numeric Pain Intensity Scale:
The zero (0) to 10 scale is the easiest to use for patients
who are able to verbalize their subjective pain rating. Ask
the patient to rate their pain with zero (0) being “no pain”
and ten (10) being the “worst pain imaginable”. Document
the number as a fraction, e.g. 6/10.
Word Descriptors:
Ask the patient to describe their pain using one of the five
descriptors:
None Mild Moderate Severe Excruciating
(0) (2.5) (5) (7.5) (10)
Document the number as a fraction, e.g. 6/10.
Wong-Baker FACES Pain Rating Scale©
Explain to the patient that each face is for a person who feels
happy because he has no pain (hurt) or sad because he has some or
a lot of pain. Face 2 hurts just a little bit, face 4 hurts a
little bit more, face 6 hurts even more. Face 8 hurts a whole
lot. Face 10 hurts as much as you can imagine, although you don’t
have to be crying to feel this bad. Ask the person to choose the
face that best describes how he is feeling. This scale is
recommended for persons age 3 and older. Document the number as
a fraction, e.g. 6/10.
© 2013 UPMC All Rights Reserved
© 2013 UPMC All Rights Reserved
Appendix A.2
The N-PASS is a valid and reliable clinical pain/agitation and
sedation tool for neonates. Nurses find the N-PASS easy to use
clinically, facilitating documentation and management of pain and
sedation.
Information for the N-PASS scale may be obtained at:
http://www.n-pass.com/assesment_table.html
Appendix A.3.
Coding Tips for CRIES
Crying The characteristic cry of pain is high-pitched.
If there is no crying or it is not high-pitched. Score 0
If crying is high-pitched but the baby is easily consoled Score 1
If crying is high-pitched and the baby is inconsolable Score 2
Requires O2 for Oxygen
saturation >95%
(Consider other causes
of changes in
oxygenation: atelectasis,
pneumothorax,
oversedation, etc.)
Look for changes in oxygenation. Babies experiencing pain manifest decreases
in oxygenation as measure by TCO2 or oxygen saturation.
If no oxygen is required Score 0
If < 30% O2 is required Score 1
If > 30% O2 is required Score 2
Increased vital signs Note: Take blood pressure last, as this may wake the baby, making other
assessments difficult.
Use baseline preoperative parameters from a period free of stress.
Multiply baseline HR x 0.2, then, add this total to the baseline value to determine
whether the HR is 20% faster.
Do likewise for BP, using the same mean value.
If HR and BP are both either unchanged or less than at baseline Score 0
If either HR or BP is increased less than 20% of baseline Score 1
If either one is increased more than 20% from baseline Score 2
Expression The facial expression most often associated with pain is a grimace characterized
by a lowered brow, the eyes squeezed shut, a deepening of the nasolabial furrow,
and open lips and mouth.
If no grimace is present Score 0
If grimace alone is present Score 1
If grimace and a vocalization without crying (grunt) are present Score 2
Sleeplessness This parameter is scored according to the infant’s state during the preceding
hour.
If the baby has been continuously asleep Score 0
If the baby has awaken at frequent intervals Score 1
If the baby has been awake continuously Score 2
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HR=Heart Rate; BP=Blood Pressure; ↑=Increase; TCO2=Transcutaneous CO2
Source: Krechel SW, Bildner J. CRIES: a new neonatal postoperative pain measurement score. Initial
testing of validity and reliability. Paediatric Anaesth; 1995; 5(1):53-61. This neonatal pain assessment
tool was developed at the University of Missouri-Columbia.
Copyright 1995 S. W. Krechel and J. Bildner. Adopted with permission.
AJN. August 2002.Vol. 102.NO. 8. p.63
© 2012 UPMC All Rights Reserved
Appendix A.4.
The FLACC Behavioral Pain Assessment Scale Each of the five categories is scored from 0-2, resulting in a total score between 0 and 10
Reprinted with permission: Merkel SL, et al. The FLACC: a behavioral scale for scoring postoperative pain in young
children. Pediatr. Nur 1997;23(3):293-7. The FLACC scale was developed by Sandra Merkel, MS RN, Terri
Voepel-Lewis, MS RN and Shobha Malviya, MD at C. S. Mott Children’s Hospital, University of Michigan Health
System, Ann Arbor, MI.
How to use the FLACC In patients who are awake: observe for 1 to 5 minutes or longer. Observe legs and body uncovered. Reposition
patient or observe activity. Assess body for tenseness and tone. Initiate consoling interventions if needed.
In patients who are asleep: observe for 5 minutes or longer. Observe body and legs uncovered. If possible,
reposition the patient. Touch the body and assess for tenseness and tone.
Face
Score 0 if the patient has a relaxed face, makes eye contact, shows interest in surroundings
Score 1 if the patient has a worried facial expression, with eyebrows lowered, eyes partially closed, cheeks
raised, mouth pursed.
Score 2 if the patient has deep furrows in the forehead, closed eyes, an open mouth, deep lines around the
nose and lips.
Legs
Score 0 if the muscle tone and motion in the limbs are normal
Score 1 if patient has increased tone, rigidity, or tension; if there is intermittent flexion or extension of the
limbs
Score 2 if patient has hypertonicity, the legs are pulled tight, there is exaggerated flexion or extension of the
limbs, tremors
Activity
Score 0 if the patient moves easily and freely, normal activity or restrictions
Score 1 if the patients shifts positions, appears hesitant to move, demonstrates guarding, a tense torso,
pressure on a body part
Score 2 is the patient is in a fixed position, rocking; demonstrates side-to-side head movement or rubbing of
a body part.
Cry
Score 0 if the patient has no cry or moan, awake or asleep
Score 1 if the patient has occasional moans, cries, whimpers or sighs
Score 2 if the patient has frequent or continuous moans, cries, grunts
Consolability
Score 0 if the patient is calm and does not require consoling
Score 1 if the patient responds to comfort by touching or talking in 30 seconds to 1 minute
Score 2 if the patient requires constant comforting or is inconsolable. Whenever feasible, behavioral measurement of pain should be used in conjunction with self-report. When self-report
is not possible, interpretation of pain behaviors and decisions regarding treatment of pain require careful
consideration of the context in which the pain behaviors are observed.
Each category is scored on the 0-2 scale, which results in a total score of 0-10.
Interpreting the Behavioral Score
0= Relaxed and comfortable
1-3= Mild discomfort
4-6= Moderate pain
7-10= Severe discomfort or pain or both
AJN.October 2002.Vol.102.NO.10.p.55
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Appendix A5.
NIPS assessment includes five behavioral items (facial expression, crying, arms, legs, and state of
arousal) and one physiological indicator (breathing pattern).
Scored at 1-minute intervals before, during, and after a procedure.
Total score ranges from 0 to 7. NIPS was researched in preterm and full-term infants who required capillary, venous, or arterial
punctures and is ideal for newborns not on cardiorespiratory monitoring. Pain scores must be interpreted in light
of the pattern of how total scores change between pain and non pain situations and whether risk factors for pain
are present.
References:
(Lawrence, Alcock, McGrath, Kay, MacMurray, & Dulberg, 1993. The development of a tool to assess neonatal
pain. Neonatal Network. 12(6).59-66. Figure 1. page 60.
Reprinted with permission from The Children’s Hospital of Eastern Ontario (CHEO) from Lawrence, J., Alcock.D.,
McGrath, P., Kay, J., MacMurray.S., & Dulberg, C. (1993)
1 2 1 2 3 4 5 1 2
Facial expression
0-Relaxed; 1-Grimace
Cry
0-No cry; 1-Whimper;
2-Vigorous
Breathing patterns
0-Relaxed
1-Change in breathing
Arms
0-Relaxed/restrained
1-Flexed/extended
Legs
0-Relaxed/restrained
1-Flexed/extended
State of Arousal
0-Sleeping/awake
1-Fussy
Total
Before During After
Neonatal Infant Pain Scale (NIPS)
Before During After
© 2013 UPMC All Rights Reserved
Appendix B: Analgesic Reference Guide (Refer to the Pediatric Drug Therapy Handbook & Formulary, Department of
Pharmacy, Children’s Hospital of Pittsburgh of UPMC for pediatric dosing. Refer to Neofax for neonatal dosing.)
Nonopioid Analgesics Maximum Starting Dose *Starting doses are can often be given less frequently than cited below.
Commentsa,b,c
(MDD) = Maximum Daily Dose
Acetaminophenc
650 mg PO/PR Q4hr Lacks anti-inflammatory effect of NSAIDs
MDD for healthy patients = 3,000mg
MDD for alcoholics, or G6PD deficiency and & elderly = 2,000 mg
CrCL 10-50 ml/min: dose Q6hr; CrCL <10 ml/min: dose Q8hr
Avoid chronic use in Hepatic Impairment (See Warnings – Footnotes)
Avoid use in acute liver disease
Acetaminophen Injection
(Ofirmev®)
1000mg IV Q6hr MDD for healthy patients = 3000mg (higher doses in hospitalized patients)
For pts unable to take PO/NG with post-op pain, mild/mod pain, or critically
ill pt with fever
Automatic interchange to oral therapy by pharmacy after 24hrs (4doses)
For additional comments see above
Aspirinb
650 mg PO Q4hr MDD for healthy patients = 3.9g
Do Not Use in patients (especially in children <16 y/o) with suspected viral
illness due to risk of Reye’s Syndrome
Inhibits platelet function for life of platelet ( 7 days)
CrCL <10 ml/min: avoid use (See Warnings –Footnotes)
Avoid use in patients with severe liver disease
Ibuprofen (Motrin®)b
400 mg PO Q8hr MDD for healthy patients = 3,200mg
Avoid use in patients with severe hepatic impairment
Avoid use in patients with renal impairment
Naproxen Sodium (Anaprox®)b
275 - 550 mg PO initially, then
275 mg PO Q6hr MDD for healthy patients = 1,375 mg
MDD (geriatric) = 400mg/day (200mg q12h)
CrCL <30 ml/min: use is not recommended
Use lowest possible dose in patients with advanced liver disease
Nabumetone (Relafen®)b
500mg -– 1000 mg PO daily in
one or two divided doses
(max 2000mg daily)
Limit use to 7 – 14 days
MDD for healthy patients = 2000 mg
CrCL 30-50 mL/min: 750 mg daily; max 1500 mg /day
CrCL < 30 mL/min: 500 mg daily; max 750-1000mg/day
Not for use perioperatively post CABG (true for all NSAIDs)
Meloxicam (Mobic®)b
Non-formulary
7.5 mg PO daily MDD = 15 mg; CrCL ≤ 20 ml/min: use is not recommended
Celecoxib (CeleBREX®)2
400 mg PO in one dose on day
one; 200 mg BID MDD in otherwise healthy patients = 400 mg
Use is not recommended in patients with severe renal or hepatic dysfunction
For patients with moderate hepatic impairment decrease the dose by 50%
Ideal for patients on anticoagulation therapy or antiplatelet therapy and
patients with GI ulcers or irritation due to the COX-2 selective nature
Indomethacin (Indocin®)b
25-50 mg PO Q8hr MDD for otherwise healthy patient = 200 mg
Generally not first line agent due to high incidence of CNS & GI side effects,
except in pain associated with gout Generally not recommended in elderly
patients due to safety issues
Not for use in patients with advanced renal disease
Ketorolac (Toradol®)b
15-30 mg IM / IV Q6hr
Pt age 17-64: 20mg PO once,
then 10mg q4-6H prn
Elderly, renally impaired, and/or weight <50kg dose = 10-15 mg PO/IM/ IV
Q4-6 hr
MDD (normal, healthy) = 120 mg IM / IV, 40mg/day PO
MDD ( age > 65 years or < 50kg) = 60mg IM/IV, 40mg/day PO
Limit duration to maximum of 5 days; automatic stop of 3 days of therapy
Can precipitate renal failure in dehydrated / renally compromised patients.
If creatinine elevated, use ½ of the recommended dose (MDD = 60 mg/day)
Use cautiously in patients with hepatic impairment as use can result in
elevation of liver enzymes
May be considered first-line in cases of bone pain due to metastasis
The Intramuscular route is not a preferred route of administration
© 2013 UPMC All Rights Reserved
a (MDD) = Maximum Daily Dose
b ASPIRIN / NSAIDS: Chronic use is associated with dose-related increases in gastric mucosa damage/erosions/peptic ulcer disease;
bleeding from inhibition of platelet function typical of most NSAIDs (irreversible for life of platelet with Aspirin), fluid retention and impairments
to renal function. Hypersensitivity reaction triad symptomatology includes rhinitis, asthma, and nasal polyps. Other signs of hypersensitivity
include hypotension, shock, and syncope within minutes. To reduce the risks associated with NSAIDs, avoid alcohol and administration while
fasting and always use lowest effective dose. COX-2 selective NSAIDs (CeleBREX) may be more appropriate for patients who may be at
greatest risk for bleeding or GI problems, but haves been associated with an increase risk of MI, stroke, and hypertension.
c ACETAMINOPHEN: Chronic alcohol use, liver disease, and a fasting state can predispose patients to hepatic toxicity, even at therapeutic
doses. Doses > 4000 mg /daily (max) can lead to hepatic necrosis. Use caution not to exceed maximum daily doses of acetaminophen,
especially when combining acetaminophen tablets with combination products that contain acetaminophen, such as Percocet®, / Ultracet® or
Vicodin.®. Doses > 1500 mg daily can enhance anticoagulant effects of warfarin.
Appendix B: Analgesic Reference Guide (Refer to the Pediatric Drug Therapy Handbook & Formulary, Department of
Pharmacy, Children’s Hospital of Pittsburgh of UPMC for pediatric dosing; Refer to Neofax for Neonatal dosing)
Nonopioid Analgesics (continued) Maximum Starting Dose *Starting doses are can often be given less frequently than cited below.
Commentsa,b,c
(MDD) = Maximum Daily Dose
Duloxetine (Cymbalta®)
60 mg PO once daily MDD for healthy patients = 60 mg daily
Patients with renal impairment: initiate lower dose and increase
gradually
CrCl < 30 ml/min: not recommended for use
Do not use in patients with hepatic insufficiency
Pregabalin (Lyrica®) 150 mg/day PO in divided doses MDD for healthy patients = 600mg/day. Doses must be increased by
no more than 150 mg/day every 7 days.
CrCl 30-60 ml/min: MDD 300mg/day CrCl 15-30 ml/min: MDD
150mg/day CrCl < 15 ml/min: MDD 75mg/day HD: 25-150mg
supplement
Gabapentin (Neurontin®)
300 mg/day PO DO NOT interchange with once-daily formulation
MDD for healthy patients = 3600 mg/day
CrCl 30-59 ml/min: MDD 1400 mg/day in 2 divided doses; CrCl 15-
29 ml/min 700mg/day once daily; CrCl 15ml/min: 300mg/day once
daily; CrCl < 15 ml/min: ↓ dose in proportion to CrCl HD: give 125-
350mg supplement
Gabapentin – Extended Release
(Gralise®) Non-Formulary
300 mg/day PO NOT interchangeable with other gabapentin products
MDD for healthy patients = 1800 mg/day
CrCl < 30 ml/min and HD: avoid use
Ketamine
Starting dose:
Low-dose analgesia (AIPPS:
PUH/SHY/Pass/Mercy):
4-10mg/hr (general units);
patients must be in ICU to receive
doses >10mg/hr; 48-hour
automatic stop on infusion
duration;
Chronic pain: doses up to
30mg/hr
Palliative care: doses up to
42mg/hr
Consider dose reduction in patients with liver impairment
AIPPS low-dose analgesia, chronic pain, or palliative care protocol
must be approved by institution P&T Committee prior to
implementation
o AIPPS: No IV push or bolus doses should be given
Must be infused via a locked device as a continuous infusion, on the
non-ICU unit
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Medication Opioid agonistsd Starting dose *Starting doses can often be given less
frequently than cited below
Equi-analgesic dosee Commentsd Opiate Agents (See Warnings – Footnotes)
Morphine – Immediate Release
15-30 mg PO Q3hr or 2.5-10 mg IV/IM/SQ Q2-6hr
30 mg PO 10 mg IV/IM/SQ
M-6G (active metabolite) enhances sedative effects of morphine; especially in renal dysfunction; If CrCL 10-50 ml/min: use 75% of normal dose; If CrCL <10
ml/min: use 50% of normal dose; dose 25-50% for age > 70
(Loading Dose) Morphine IV 0.03 mg/kg Q 10 mins
- repeat until 50% in pain score or patient is satisfied (Maintenance Dose) Est. Hourly Maintenance Dose = Loading Dose T1/2 (hrs) x 2
Morphine – Extended Release
MS Contin® -15mg PO Q8hr Kadian® - 10-20mg PO Q12-24hr
Avinza® - 30mg PO Q24hr
Oramorph SR® - 15-30mg PO Q8-12hr
Roxanol® - 10-30mg PO Q4hr
Do not crush/chew/dissolve caps or content
Kadian and Avinza may sprinkle on applesauce immediately prior to use
Renal Dosing: CrCl 10-50 ml/min: use 75% of the normal dose, CrCl <10 ml/min: use 50% of the normal dose
Oramorph®, Avinza®, Kadian® and MS Contin® Black Box Warning: swallow tabs whole due to risk of rapid release and absorption of potentially fatal morphine dose
Kadian® tablet strength restriciton: 100/200mg ER for opioid tolerant pts only
Codeine
15-30mg PO Q3hr or 30 mg IM/SQ Q4hr
120 mg IM/SQ (parenteral) 200mg PO (Not recommended at this dose.)
Greater risk of nausea and constipation than other opioids narcotics
If CrCL 10-50 ml/min: use 75% of the normal dose
If CrCL <10 ml/min: use 50% of the normal dose
10% of Caucasians lack enzyme to metabolically activate Codeine
FentaNYL (Sublimaze®)
20 – 75 mcg IV Q1hr 0.1 mg IV ** Note typical doses are in micrograms (not milligrams !).
Maximum dose on monitored unit (non-ICU): 25mcg (Mercy: 50 mcg) IV no greater than q2hr
FentaNYL (Transdermal - Duragesic®)
Opiate Opioid naïve: Start with 25 mcg/hr patch Q72h
100 mcg/hr IV/SQ or transdermally = 4 mg/hr of IV/SQ Morphine Sulfate 1mcg/hr transdermally = 2 mg/day of Morphine Sulfate PO
Start w/ no more than 25 mcg/hr of Duragesic transdermal system patches (opiate opioid naïve)
Not for acute pain – delay in onset of analgesia from patch is approx 12 –18 hrs. Opioid effects persist > 18 hrs after patch removal.
Do not cut, chew or alter patch; Rotate placement site
FentaNYL (Transmucosal – Actiq®)
200mcg x 1-2, 30 minutes apart for breakthrough pain; no more than 6/day initially
Dissolve in mouth / cheek
Do not chew or swallow
FentaNYL (Buccal Tablet – Fentora®)
100 mcg x 1; re-dosing of same amount may occur 30 minutes after initial dose
Indicated for cancer patients who experience breakthrough pain on their current opioidate regimen (i.e.,; opioidate-tolerant)
Dissolve in mouth / cheek; Do not chew or swallow.
More than 4 tablets simultaneously has not been studied.
HYDROmorphone (Dilaudid®)
2-4 mg PO Q3hr or 0.2-0.6 mg IV/SQ Q3hr
7.5 mg PO 1.5 mg IV/SQ
Shorter duration of action than Morphine
Safe medication practice: Use brand name in order to avoid mix-ups with other opioid analgesics.
Dilaudid® IV is approximately 7 times more potent than morphine IV per mg!
OxyCODONE
5-15mg PO Q4hr
20 mg PO
Percocet® & Tylox® contain acetaminophen
Percodan® (w/ aspirin); Combinox® (w/ ibuprofen)
If CrCL 10-50 ml/min: use 75% of the normal dose
If CrCL <10 ml/min: use 50% of the normal dose
Hepatic impairment use 50% of usual dose
Methadone
5-10 mg PO Q6hr or 2.5-5 mg IV/IM/SQ Q8hr
Acute: 20 mg PO; 10 mg IV/IM/SQ Chronic: 2-4 mg PO; 2-4 mg IV/IMSQ
Effect accumulates over 2-5 days leading to need for reduction in dose size and frequency
Use caution in the elderly
CrCl <10 ml/min: decrease dose by 25-50%
Oxymorphone – Immediate Release (Opana® injection and tablets)
0.5mg initially Q2-4hr. Up to 1.5mg may be required Opioid naïve(usual dose): 10 mg PO Q6H
1 mg IV/SQ 10 mg rectal (cant find rectal formulation)
CrCL < 50 mL/min – decrease start dose. Titrate slowly.
Mild Hepatic dysfunction– Start 5mg Q 4-6 hr PRN
Contraindicated in Moderate to – Severe Hepatic Dysfunction.
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Opioid agonistsdMedication Starting Dose Equi-analgesic dose Commentd
Oxymorphone - Extended Release (Opana ER® tablets)
Opioid naïve: 5 mg PO Q12hr Conversion to ER: Use ½ the dose of immediate release oxymorphone Q12hr (i.e. oxymorphone 40mg/day = Opana ER 20 mg Q12hr)
10 mg PO Indicated for management of moderate to severe pain when continuous, around the clock opioid analgesia is needed for an extended period of time (several days).
Concurrent alcohol can cause increased levels and a potentially fatal overdose due to dose dumping.
Administer 1 hour before or 2 hours after meal.
Use 1/3 to 1/2 of normal dose if on other CNS depressants due to risk of respiratory depression, hypotension, and profound sedation
Contraindicated in pts w/ moderate to- severe hepatic dysfunction
CrCL < 50 mL/min – decrease start dose. Titrate slowly.
Do not crush or chew; only swallow whole
Meperidine (Demerol®) (Use of meperidine Demerol is restricted at UPMC)
Adults: 100 mg IV/ Q3hr *Oral administration not recommended due to high risk of GI side effects *IM painful
300 mg PO 75 mg IV/
Toxic metabolite (normeperidine) accumulates with chronic dosing in elderly and/or renal impairment - leading to excessive CNS excitation and seizures.
Risk of serotonin syndrome increases when used with MAOIs & other serotonergic agonists.
Meperidine may be less likely to promote histamine release and should be reserved for patients who may experience allergic-like reactions to other narcotics.
HYDROcodone Combination
Adults: 5-10 mg PO Q3hr 30 mg PO
Norco®, Vicodin® products & Lortab® contain acetaminophen
Opioid/APAP- combination products should have < 325mg of acetaminophen per dosage unit. Products will be automatically switched to the <325mg APAP-containing product by the inpatient pharmacist.
Vicoprofen® (contains w/ ibuprofen)
TraMADol (Ultram®)
Adults: 25 mg/day ORALLY every morning, titrated in 25 mg increments as separate doses every 3 days to reach 25 mg four times daily; then, may increase total daily dose by 50 mg as tolerated to reach 50 mg four times daily; after titration, 50 to 100 mg ORALLY every 4hr as needed can be used
120 mg PO
MDD = 400 mg (healthy) ; for patients <75 y/o = 300 mg; for pts w/ renal impairment = 200 mg
TraMADol lowers seizure threshold
Immediate Release: If CrCL is <30 ml/min, use dose no higher than 50-100 mg Q12hr (maximum of 200 mg/day)
Extended Release: avoid use if CrCL <30 ml/min; max 300mg daily
Useful adjunct to NSAIDs when treating pain associated with osteoarthritis
Cirrhosis: recommended dose is 50mg PO q12h (immediate-release); extended-release should be avoided.
TraMADol (TraMADol Ultracet® 25 mg/ Acetaminophen 325 g)
2 tablets Q4hr prn for pain relief (maximum of 8 tablets/day)
Combination accounts for synergistic analgesic effects
CrCL <30 ml/min: max 2 tab Q12hr; no more than 5days
Hepatic impairment: use not recommended
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dOPIOIDS:
When assessing acute pain, consider the following symptoms:
1) Sympathetic stimulation invokes hypertension, tachycardia, tachypnea, mydriasis, diaphoresis and pallor.
2) Other symptoms include decreased activity, fearful expression, grimacing, teeth grinding, crying, striking out,
bracing, guarding, rubbing, wincing with movement, irritability, restlessness, abnormal gait, unwillingness to
move, and apathy.
In selecting an initial opioid dose, attention should be given to the following factors:
1) The total daily dose, potency and specific characteristics of the opioid the patient has been taking previously
2) The relative potency estimate used to calculate the equivalent dose needed
3) The patient’s degree of opioid tolerance
4) The age, general condition, and medical status of the patient
5) Concurrent non-opioid analgesic and other medications
6) The type and severity of the patient’s pain
7) The balance between pain control and adverse experiences
Opioid agonistsdMedication Starting Dose Equi-analgesic dose Commentd
Mixed opioid agonist-antagonists – all mixed agonist-antagonists can precipitate withdrawal in opiate-tolerant patients. For this reason, the drugs in this class should only be used
in patients without a history of recent or concomitant opioid use.
Butorphanol (Stadol®)
1mg spray in one nostril Q3hr OR
1-2 mg IV Q3hr
2 mg IV/SQ
If renal or hepatic dysfunction, use ½ typical IV dose & space doses 6 hours apart
In renal or hepatic dysfunction: initial dose of nasal spray should not exceed 1 mg. 2nd dose should be given no less than 90-120 minutes after
Effective for pain associated with migraines; pain associated with labor; pain assoc w/ gallstones
Nasal spray convenient for patients unable to swallow
Buprenorphine (Buprenex®)
300 mcg/dose IV/IM q6hr 300mcg IV/IM ↓ dose by 50% if respiratory disease or elderly/debilitated patient
Dose of IM may be increased to 600mg/dose (IM ONLY)
Caution in advised in patients with moderate/severe hepatic impairment
Long-term use is not recommended
Buprenorphine – Transdermal (Butrans®)
5 mcg/hr patch Q7days See Comments Do not alter/cut patch
MDD = 20mcg/hr patch
Replace patch every 7 days
Dose may be changed after a minimum of 72 hr
TTD of PO morphine dose or equivalent of < 30mg, start with 5mcg/hr patch
TTD of PO morphine between 30-80mg, start with 10mcg/patch
TTD of PO morphine or equivalent of > 80mg, 20mcg/hr patch may not provide adequate pain control
Not studies in severe hepatic impairment
Nalbuphine (Nubain®)
10 mg/ 70 kg IV/SQ Q3hr 10 mg/ 70 kg IV/SQ Similar to butorphanol; Less psychomimetic effects than Pentazocine
Use reduced dose and monitor patients with renal or hepatic impairment
Maximum: 20mg as single dose & 160mg/day
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8) Risk factors for abuse, addiction or diversion, including a prior history of abuse, addiction or diversion
9) Allergies and drug to drug interactions based on the patient’s medication profile.
Reduce opioid doses and monitor more closely in patients with the following conditions: frail (< 50 kg),
elderly (age > 70: reduce dose by 25 to 50%), sleep apnea, pulmonary fibrosis, O2 dependency, obesity, asthma,
COPD or other types of respiratory dysfunction. Caution in patients with increased intracranial pressure, pregnancy,
liver or renal insufficiency. Use can lead to orthostatic hypotension due to histamine release and peripheral
vasodilation.
Drug Interactions: Opioid analgesics should be started at 25 to 33 percent (1/3 to ½) of the usual dose in patients
who are concurrently receiving other central CNS depressants including sedatives or hypnotics, general anesthetics,
phenothiazines, tranquilizers, or alcohol because respiratory depression, hypotension, and profound sedation or
coma may result.
Treatment of opioid overdose: Usual initial adult naloxone dose = 0.04 mg IV every minute until a change in
alertness is observed.
Cessation of opioid therapy: When the patient no longer requires opioid therapy, doses should be tapered
gradually to prevent signs and symptoms of withdrawal.
e Approximate equivalent dose of opioid for moderate to severe pain.
References:
1) American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. (5th eEd.). Glenview, IL:
American Pain Society, Glenview, IL; 2003.
2) McEvoy GK (ed). AHFS Drug information.; McEvoy GK (ed); American Society of Health-System Pharmacists; Bethesda MD:
American Society of Health-System Pharmacists. 2007.
3) Cohen M, et al. An omnipresent risk of morphine HYDROmorphone mix-ups. ISMP Newsletter 2004, July 1.
http://www.ismp.org/Newsletters/acutecare/articles/20040701.asp?ptr=y (Accessed 2007, July)
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Appendix C
Non-pharmacological/Complementary Modalities for Pain Management
Complementary modalities are used to treat pain, anxiety, fear, ineffective coping, restlessness,
and sleep disturbances. Independent modalities do not require formal training, while dependent
or formal modalities require specialty training, while dependent or formal modalities require
specialty training.
Independent Non-pharmacological and Complementary Modalities
A. Presence
The single most important aspect of promoting comfort is the underlying relationship
between the patient and his or her care provider.
Refers to both physically “being there” and psychologically “being with” the patient.
B. Progressive Relaxation and Deep Breathing
Assess pain level. If pain is present, consider intervening accordingly with pain
medication. Pain relief improves the ability to follow directions and participate in the
relaxation process.
Relaxation is a method of behavioral control in which a person performs techniques
that will reduce or eliminate pain. This modality can interrupt the cycle of pain,
anxiety, and muscle tension that often develops with unrelieved pain.
Several forms of relaxation techniques have been suggested for use in pain
management. (e.g. deep-breathing exercises, muscle relaxation, Lamaze therapy and
visual imagery.)
As patient begins to exhale, the healthcare provider may instruct the patient to
progressively begin relaxing groups of muscles in a head to toe approach. (e.g. begin
with facial muscles to neck and shoulder muscles, etc.) The body tends to relax
naturally on exhalation.
Practice with the patient during non-stressful periods to augment efficacy.
C. Prayer / Meditation
Can be used as a way to connect to the spiritual core of healing and foster hope.
Prayer or meditation can evoke deep states of relaxation.
Offer Pastoral Care support to the patient and family.
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D. Distraction Techniques
Distraction produces analgesic effects by sending intense stimuli through the brain
that can increase the release of endorphins.
The brain can process only a limited amount of signals at any given time.
Forms of distraction include; music, conversation, reading, poetry, crafts, television
viewing, laughter and deep breathing for relaxation.
Techniques should be appropriate to patient’s energy level and are most effective
when the activities interest the patient or when they involved multiple senses such as
hearing, vision, touch and movement.
E. Imagery
Alters the perception of pain stimuli within the brain, helps promote relaxation and
can increase the production of endorphins.
This technique has been found to be helpful when used with planned invasive
procedures.
Patients can use imagery independently or with the assistance of another person. A
care provider or friend can help guide the patient in “painting” an imaginary picture.
The more details that can be pictured with the image the more effective the technique.
Using multiple sensations during the imagery can be helpful, similar to distraction
techniques.
Strategies to help guide the patient include using details to describe the imaginary
scene. (e.g. “Smell the fresh scent of the ocean air; listen to the seagulls overhead.)
F. Sucrose
A 24% oral sucrose solution (Sweet-Ease®
) may decrease crying episodes and cry
duration in response to pain. It provides safe, effective non-pharmacologic analgesia
to infants before and during painful procedures. It may reduce crying-related energy
expenditure and soothe infants. 24% oral sucrose solution (Sweet-Ease®) may be used
in conjunction with opioids and non-pharmacologic interventions such as non-
nutritive sucking (pacifier), positioning, swaddling and kangaroo care, thereby
mimicking endogenous non-opioid & opioid systems. Age dependency of oral sucrose
analgesia may be the result of developmental changes in the interaction between
gustatory and pain pathways.
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G. Infant and Child Massage by Parent
Kangaroo Care
Kangaroo care provides a method of patient care in which a term or pre-term infant is
placed in direct skin-to-skin contact with a primary family caregiver such as mother or
father. This contact is to support parental attachment, infant development and pain
management.