Principles of Pharmacologic Management

    1. Base the initial choice of analgesic on the severity and type of pain: non-opioids for mild pain (rating 1-4); opioids, often in combination with a non-opioid, for moderate (rating 5-6) to severe (rating 7-10) pain. Neuropathic pain may require an antidepressant or anticonvulsant drug.

    2. Dose to therapeutic ceiling of non-opioid if side effects permit. There is no maximum dose or analgesic ceiling with opioids. Increase opi oid use until pain relief is achieved or side effects are unmanageable before changing medications.

    3. Administer drugs orally whenever possible. Avoid intramuscular injections.

    4. Administer analgesics "around the clock" rather than prn.

    5. Avoid using multiple opioids or multiple non-opioids (drugs from the same class at the same time) when possible.

    6. Anticipate and vigorously treat side effects.

    7. Avoid multiple dosing with meperidine (no more than 48 hours or at doses greater than 600 mg/24 hours). Accumulation of toxic metabolite normeperidine (half life,12-16 hours) can lead to CNS excitability and convulsions. Contraindicated in patients with impaired renal function or those receiving MAO inhibitors.

    8. Addiction occurs very rarely in patients who receive opioids for pain control. Drug addiction, when suspected should be investigated and ruled in or out but not implied and "left hanging" because it interferes with pain management. The hallmarks of addiction include: a) compulsive use, b) loss of control, and c) use in spite of harm.

    9. Do not use placebos to determine if the pain is "real."

    10. Assess pain, pain relief, and side effects frequently and adjust the dose accordingly. Change to another drug if side effects are unmanageable.

Reprinted with permission: Third Edition: Pain Patient Care Team, September 1996 copyright University of Wisconsin Board of Regents