Acute Pain Management Pearls: A Focused Review for the Hospital Clinician
Abstract
:1. Introduction
- Uncontrolled pain worsens patient outcomes and healthcare costs—adopt a consistent, systematic, and holistic approach to acute pain management.
- Not every patient is an ideal candidate for every medication, but every patient in pain is a candidate for multimodal analgesia optimization.
- There are tremendous benefits to employing anti-inflammatories and few good reasons to withhold them in the management of acute pain.
- Gabapentinoids have a complex risk/benefit ratio and decision-making should be nuanced.
- Low-dose ketamine is a powerful analgesic even in opioid-tolerant patients and is generally well-tolerated with appropriate institutional protocols.
- Empiric opioid regimens should include consideration of optimal agent selection, dosing, route of administration, and supportive therapies.
- Pain regimens should be evaluated and adjusted at least daily through multidimensional pain assessments to optimize efficacy and safety endpoints.
- Patients with opioid tolerance, chronic pain, and/or opioid use disorder require higher opioid doses and more supportive therapies.
- When used for acute pain, patient-specific plans for opioid tapering and harm reduction should be developed and supported across the care continuum.
- Methadone and buprenorphine should almost always be continued throughout acute pain episodes, but naltrexone must be stopped.
2. Clinical Pearl #1: Uncontrolled Pain Worsens Patient Outcomes and Healthcare Costs—Adopt a Consistent, Systematic, and Holistic Approach to Acute Pain Management
KEY CONSIDERATION: Opioid avoidance in acute painful conditions is an ill-advised goal as it is neither patient-centered nor evidenced-based; rather, multimodal analgesia and opioid stewardship should integrate into a patient-specific, data-driven approach to inpatient acute pain management.
3. Clinical Pearl #2: Not Every Patient Is an Ideal Candidate for Every Medication, but Every Patient in Pain Is a Candidate for Multimodal Analgesia Optimization
KEY CONSIDERATION: Multimodal analgesia should be balanced and thoughtful, utilizing complementary mechanisms to improve pain control with less high-risk drug exposure, as opposed to overmedicating without regard to cumulative risks or patient-specific factors.
- Acetaminophen
- Anti-inflammatories
- Neuropathic agents- gabapentinoids, serotonin reuptake inhibitors, anticonvulsants
- Corticosteroids
- NMDA antagonists
- Central alpha adrenergic agonists
- Systemic anesthetics (e.g., intravenous lidocaine, inhaled anesthetics)
- Topical agents- lidocaine, anti-inflammatories, capsaicin
- Regional anesthetic modalities in concert with a specialist pain service (e.g., peripheral nerve blocks, neuraxial blocks)
- Physical therapy, cognitive/behavioral therapies, thermotherapies, and other nonpharmacologic modalities
4. Clinical Pearl #3: There Are Tremendous Benefits to Employing Anti-Inflammatories and Few Good Reasons to Withhold Them in the Management of Acute Pain
KEY CONSIDERATION: NSAIDs target an important source of pain instead of just interfering with the perception of pain, making them among the most effective and important analgesics available in acute pain management.
5. Clinical Pearl #4: Gabapentinoids Have a Complex Risk/Benefit Ratio and Decision-Making Should Be Nuanced
KEY CONSIDERATION: Gabapentanioids are heavily renally eliminated and require dose adjustment in altered kidney function. Patients undergoing dialysis who are apt to miss appointments or who are unable to tolerate a complete hemodialysis session are at risk for drug accumulation and adverse events.
KEY CONSIDERATION: Gabapentinoids are narcotics with dose-dependent adverse effects, which may include respiratory depression, especially with concomitant CNS depressants or in high-risk patients.
6. Clinical Pearl #5: Low-Dose Ketamine Is a Powerful Analgesic even in Opioid-Tolerant Patients and Is Generally Well-Tolerated with Appropriate Institutional Protocols
KEY CONSIDERATION: Among available nonopioid analgesics, ketamine has the strongest evidence supporting improved pain control and opioid-sparing properties in patients with preexisting opioid tolerance. It may also interrupt the pathological processes of central sensitization and opioid-induced hyperalgesia, conferring benefit in severe or difficult-to-treat pain.
KEY CONSIDERATION: Collaborative, evidence-based institutional protocols and prescriber/staff education are essential to the safe use of analgesic-dose ketamine in hospitalized patients. With appropriate provider knowledge (and/or availability of specialist consultation) and standardized procedures, low-dose ketamine can be safely employed for acute pain management by general practitioners on general medical/surgical inpatient units.
7. Clinical Pearl #6: Empiric Opioid Regimens should include Consideration of Optimal Agent Selection, Dosing, Route of Administration, and Supportive Therapies
7.1. Opioid Agent Selection
7.2. Empiric Opioid Dosing
7.3. Opioid Routes of Administration
KEY CONSIDERATION: The route of opioid administration should be tailored to patient status and degree of need for rapid onset, with the enteral route being the safest and easiest when possible. The sublingual route of administration also offers a fast onset of action.
KEY CONSIDERATION: The subcutaneous route of administration for opioids is a valued option in unique situations; the intramuscular route of administration should be avoided.
7.4. Supportive Therapies to Be Co-Prescribed with Opioids
KEY CONSIDERATION: Always begin a scheduled stimulant bowel regimen when initiating opioid therapy; as-needed laxatives or docusate alone are not sufficient to prevent opioid-induced bowel dysfunction.
8. Clinical Pearl #7: Pain Regimens Should Be Evaluated and Adjusted at Least Daily through Multidimensional Pain Assessments to Optimize Efficacy and Safety Endpoints
KEY CONSIDERATION: Assessing for drug efficacy and adverse effects at the expected time to peak after drug administration is the best way to determine whether the selected dose is right for the patient. Carefully assess the nature of breakthrough pain in order to determine the best approach to regimen adjustments.
9. Clinical Pearl #8: Patients with Opioid Tolerance, Chronic Pain, and/or Opioid Use Disorder Require Higher Opioid Doses and More Supportive Therapies to Achieve Positive Outcomes
KEY CONSIDERATION: A relationship of mutual trust and respect is vital to manage the patient’s pain. Chronic pain comes with complex psychological impacts that can inform the patient’s physical pain experience and can affect treatment response.
10. Clinical Pearl #9: When Used for Acute Pain, Patient-Specific Plans for Opioid Tapering and Harm Reduction Should Be Developed and Supported across the Care Continuum
KEY CONSIDERATION: Opioid tapering goals and regimens must be patient-specific and prospectively, collaboratively discussed with the patient and other care team members in order to be safe and successful. Pre-discharge patient counseling on the pain management plan and opioid safety are essential.
KEY CONSIDERATION: Co-prescribing take-home naloxone is evidenced-based harm reduction and should be widely considered by hospital providers prescribing opioids at discharge, alongside appropriate educational and continuity of care efforts.
11. Clinical Pearl #10: Methadone and Buprenorphine Should Almost Always Be Continued throughout Acute Pain Episodes, but Naltrexone Must Be Stopped
KEY CONSIDERATION: Buprenorphine/naloxone combination products DO NOT have to be changed to buprenorphine-only products during acute painful episodes due to the low bioavailability of naloxone.
KEY CONSIDERATION: Methadone and buprenorphine should be continued during acute painful episodes, including surgical encounters, alongside opioid-tolerant doses of as-needed pain medications within multimodal analgesic regimens.
KEY CONSIDERATION: The duration of analgesia from buprenorphine and methadone is shorter than their duration of reducing cravings and withdrawal symptoms- splitting the home dose throughout the day should be considered as part of the multimodal analgesic regimen during periods of acute pain. The patient’s usual dosing regimen can then be resumed once acute pain has subsided and/or at hospital discharge.
KEY CONSIDERATION: Naltrexone-containing products must be stopped prior to any scheduled elective procedures to ensure adequate pain management for patients. Patients who have naltrexone interrupted will rapidly lose their tolerance to opioids and should be monitored closely when opioid therapies are needed.
12. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Concern | Evidence | Recommendation |
---|---|---|
Bleeding/antiplatelet effects | Bleeding times and perioperative bleeding events are not significantly affected by NSAIDs at usual doses; GI complications from NSAID-induced prostaglandin inhibition are not increased by short-term use (<7 days); These risks may be further mitigated by using a COX-2 selective agent since antiplatelet effects are mediated by COX-1 inhibition | Do not withhold NSAIDs in acute pain due to bleeding concerns as long as usual analgesic doses and short-term durations are employed; selective COX-2 inhibitors or concomitant gastroprotective agents may be considered in patients at high GI bleed risk |
Wound healing issues or orthopedic/spinal nonunion after fracture or fusion surgery | Older data from animal and limited retrospective studies suggested these concerns, however more recent and higher quality prospective studies have not replicated | NSAIDs, especially COX-2 selective agents, appear efficacious and safe for short-term use in orthopedic and spinal surgery and should be routinely considered based on risks/benefits |
Anastomotic leak after GI surgery | Some studies have suggested increased risk of anastomotic leakage with nonselective NSAIDS, but selective COX-2 inhibitors were not associated with this risk in recent meta-analyses | Do not withhold COX-2 selective NSAIDs in GI surgery patients |
MACE after cardiac surgery | COX-2 selective inhibitors have been associated with increased rates of MACE after cardiac surgery, likely due to an unfavorable effect on pro-thrombotic pathways | COX-2 selective agents should be avoided in cardiac surgery, however, nonselective NSAIDs have been used safely in cardiac surgery, and COX-2 selective agents have been used safely in patients with cardiac disease undergoing noncardiac surgery |
Sulfa allergy | While some NSAIDs contain a sulfur-containing moiety, these are not structurally the same as sulfa antibiotics; patients with sulfa allergies have been found to be no more likely to have allergic reactions to NSAIDs than patients without sulfa allergies | Do not withhold NSAIDs, including celecoxib, in patients with sulfa (sulfonamide antibiotic) allergies |
Gastritis/pouchitis in patients s/p bariatric surgery | Patients s/p bariatric surgery should avoid chronic NSAID exposure, however, short-term use is supported by current guidelines as safe and beneficial | Do not withhold short-term NSAIDs in acute pain in patients s/p bariatric surgery; use of a COX-2 selective agent and/or temporary PPI therapy may be considered to decrease GI risk |
Kidney injury | NSAIDs inhibit prostaglandin-dependent mechanisms of preserving renal perfusion and GFR in times of decreased renal blood flow, increasing risk for acute and chronic kidney injury in at-risk populations | All NSAIDs and COX-2 inhibitors should generally be avoided in patients with AKI or CKD |
Large doses must be used for analgesia | The maximum effective analgesic dose of ketorolac is approximately 10–15 mg and is approximately 400 mg for ibuprofen based on available dose-finding studies, though higher doses may confer additional anti-inflammatory benefit | When using NSAIDs primarily to treat pain, doses should generally not exceed their analgesic ceiling in order to limit adverse effects |
Pain Scale 1 | Description | Intended Population |
---|---|---|
Visual Analog Scale | numerical scale rating 1–10 | adults who are able to self-report pain |
Wong-Baker Faces | scale utilizing facial expressions linked to pain severity | patients age 3 and above |
Pain Assessment in Advanced Dementia (PAINAD) | utilizes non-verbal cues to assess pain | patients with dementia, unable to self-report |
Behavioral Pain Scale | observational assessment | critically ill, sedated patients |
Defense and Veterans Pain Rating Scale (DVPRS) | combination graphic and numerical tool | adults who are able to self-report pain |
Formulation/Route of Administration | Time to Peak1—Assess for Efficacy and Adverse Effects | Additional Considerations |
---|---|---|
Intravenous | 10–15 min | |
Subcutaneous | 30 min | |
Immediate release oral | 60 min | |
Immediate release sublingual | 15–30 min | Assess patient ability to hold medication under the tongue |
Regimen Component | Approach for Opioid-Naïve | Approach for Opioid-Tolerant |
---|---|---|
Goals of opioid tapering | Limit excess exposure to opioids and opioid-related adverse events once pain is improving, limit conversion to persistent opioid use if not otherwise indicated by patient condition, limit quantity of unused opioids | More complex and patient-specific, may entail tapering back to previous chronic pain or MOUD regimen (or reevaluating chronic regimen in concert with applicable prescriber), limiting opioid-related adverse events, avoiding relapse of OUD, limiting long-term adverse events related to chronic opioid exposure |
Dose reduction at each step of taper | Consider decreasing daily dose by 20–25% | More gradual reductions may be needed at each step |
Frequency of tapering | Every 1–2 days once pain is improving | Less frequent reductions are likely to be needed, consider every 2–7 days once acute pain improving |
Total duration of taper | Most patients can successfully taper off opioids within 3–7 days after a major scheduled surgery, assuming multimodal and enhanced recovery techniques are used concurrently | Longer tapers will be needed, may take weeks to months to be successful depending on patient-specific circumstances |
Other considerations | Consider reducing dose before lengthening dosing interval to help maintain smoother pain control without large peaks/valleys of analgesic effect | More multimodal therapies, psychosocial support, monitoring, and coordination of care often needed |
Medication | Mechanism of Action | Acute Pain Strategies |
---|---|---|
Buprenorphine | Partial mu-opioid agonist, kappa-opioid antagonist | Continue home regimen; Split home regimen into TID dosing for same TDD |
Methadone | Full mu-opioid agonist, NMDA antagonist | Continue home regimen; Split home regimen into TID dosing for same TDD |
Naltrexone (IM) | Mu-opioid antagonist | Stop IM dose 30 days prior to painful procedure and until patient has been opioid-free for 3 days afterward; Multimodal therapies to treat painful crisis, consider ketamine and regional anesthesia |
Naltrexone (PO) | Mu-opioid antagonist | Stop therapy 72 h prior to painful and until patient has been opioid-free for 3 days afterward; Multimodal therapies to treat painful crisis, consider ketamine and regional anesthesia |
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Hyland, S.J.; Wetshtein, A.M.; Grable, S.J.; Jackson, M.P. Acute Pain Management Pearls: A Focused Review for the Hospital Clinician. Healthcare 2023, 11, 34. https://doi.org/10.3390/healthcare11010034
Hyland SJ, Wetshtein AM, Grable SJ, Jackson MP. Acute Pain Management Pearls: A Focused Review for the Hospital Clinician. Healthcare. 2023; 11(1):34. https://doi.org/10.3390/healthcare11010034
Chicago/Turabian StyleHyland, Sara J., Andrea M. Wetshtein, Samantha J. Grable, and Michelle P. Jackson. 2023. "Acute Pain Management Pearls: A Focused Review for the Hospital Clinician" Healthcare 11, no. 1: 34. https://doi.org/10.3390/healthcare11010034