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Acute Pain Management

Introduction

Management of acute pain does not mask causes and prevent diagnosis.

The analgesic stepladder

mild (1-3): NSAIDs, ASA +/- adjuvants

moderate (4-6): mild, weak opioids: codiene, tramadol

severe (7-10): potent opioids: morphine, hydromorphone, fentanyl,

unresponsive severe pain: interventional

upper dose is determined by the presence of toxicity

adjuvants may be used for pain but first optimize the opioid dose, and avoid polypharmacy if possible.

Titrate every three days; if after a week or two, move on and pick another drug

no one should be in pain for more than an hour; breakthrough doses are 10% of the total daily

if more that 3 prns/day implies the baseline dose is not high enough

pick a route of administration

oral is preferred because of ease

Tricyclic antidepressants: nortryptiline, amitripyline

Anticonvulsants: gabapentin, pregabalin, carbamazepine

Opiates

SNRIs

tramadol

mexiletine

topical agents

Opioids

Can be given sc, IM, IV, PO

onset of action of morphine

fentanyl

side effects

NSAIDS

smooth muscle inhibitor; can be useful