Prepared by Sunil Sapru, MD, and Ashish D. Parikh, MD, Saint Barnabas Medical Center, Livingston, NJ

1. Do not forget to ask all patients about the presence of pain. Pain should be considered the “fifth vital sign.” Believe the patient’s report of pain.

2. Use pain scales to objectively quantify the pain. Special scales are available for pediatric or cognitively impaired patients. Perform repeat assessments using the same pain scale.

3. Use exact dosages and intervals for analgesic orders. Avoid ranges and/or vague instructions that can lead to variations based on the medical staff’s interpretation of the written order.

4. Use the most effective and comfortable route of administration for any pain medication. Avoid using intramuscular injections, as they can be a source of pain.

5. Be familiar with the equianalgesic doses and varying intervals of dosing of the various pain medications. Remember, however, that individual patient responses to the same doses may vary.

6. A fixed-dose regimen should be used for baseline pain control. Titrate the dose up if the pain is not adequately controlled. In addition, an as-needed dose should be available for breakthrough pain.

7. Remember to avoid and treat the common side effects associated with opioids, including pruritus, nausea, somnolence, and respiratory depression. Constipation is a predictable side effect and all patients should be given a bowel regimen at the start of opioid therapy.

8. Be aware of the following precautions for common analgesics:

• Meperidine should not be used for more than 48 hours or in patients with renal impairment because of the potential accumulation of normeperidine, a neuroexcitatory metabolite.
• Methadone may antagonize the analgesic effects of other opioids.
• Tramadol should only be used with extreme caution in patients receiving drugs that may lower seizure threshold or in patients with a risk of developing seizures.
• Propoxyphene has no proven efficacy and is possibly toxic to the elderly. Consensus committees have recommended against the use of propoxyphene in geriatric patients.

9. Neuropathic pain is not well-controlled with opioids and usually requires other drugs, such as antiepileptic agents and antidepressants.

10. Consider adjuvant and complementary measures to improve pain control. Adjuvant medications may include corticosteroids, bisphosphonates, calcitonin, and octreotide. Nonpharmaceuticaltherapies include: radiation therapy, cognitive behavioral therapy, acupuncture, electrical stimulation, therapeutic exercise programs, and massage.