Managing Pain Management Protocols

Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the pain type (acute surgical, acute medical, chronic non-cancer, cancer/palliative, neuropathic)? (Default: classify)
2. What is the current pain severity (NRS 0-10, functional assessment)? (Default: obtain pain assessment)
3. Is the patient opioid-naive or opioid-tolerant? (Default: determine—opioid-tolerant = ≥60 mg OME/day for ≥1 week)
4. What is the patient's renal and hepatic function? (Default: check labs for analgesic dosing)
5. What non-opioid therapies have been tried or are currently in use? (Default: review active orders)
6. Is the patient a candidate for regional anesthesia or nerve blocks? (Default: assess with anesthesiology)
7. What is the patient's opioid risk assessment (ORT, history of substance use disorder)? (Default: screen)
8. Is PCA being considered? If so, what are the patient's cognitive and physical requirements for self-administration? (Default: assess suitability)

Documents to Request

• Pain assessment documentation (NRS score, location, quality, temporal pattern)
• Current analgesic orders with doses, frequencies, and PRN utilization patterns
• Surgical/procedural details (type, expected pain duration and intensity)
• Opioid history (chronic use, prior prescriptions, PDMP query)
• Renal function (SCr, CrCl) and hepatic function (LFTs)
• Allergy and ADR history (specific to analgesics: NSAIDs, opioids, local anesthetics)
• Substance use history and opioid risk assessment tool scores
• Functional goals (target pain level for mobilization, PT participation)

Step 1: Apply the WHO Analgesic Ladder and Multimodal Framework

WHO Three-Step Analgesic Ladder:

Modern multimodal approach (layer non-opioid agents first):

Step 2: Opioid Selection and Dosing (When Indicated)

Opioid-naive patients (acute pain):

Key dosing principles:

• Start low, titrate to effect
• Use immediate-release formulations for acute pain; never initiate ER/LA in opioid-naive patients
• Maximum tramadol: 400 mg/day (300 mg/day if age >75)
• Avoid meperidine (normeperidine accumulation → seizures; no role in modern pain management)
• Avoid codeine in CYP2D6 ultra-rapid metabolizers (fatal respiratory depression reported)
• Codeine contraindicated in children <12 years and post-tonsillectomy in children <18

Step 3: Patient-Controlled Analgesia (PCA) Protocol

PCA eligibility criteria:

• Patient can understand PCA concept and self-administer (press button)
• Patient is alert enough to make dosing decisions
• No authorized agent dosing (family/nurse pressing button = unauthorized, unsafe)
• Appropriate for moderate-severe pain expected to last >24 hours (post-surgical, sickle cell crisis)

Standard PCA programming (opioid-naive adult):

Critical PCA safety requirements:

• Continuous pulse oximetry and/or capnography for all PCA patients
• Pasero Opioid-Induced Sedation Scale (POSS) assessment q1-2h
• Naloxone 0.4 mg IV at bedside (accessible to nursing)
• Independent double-check of PCA programming by two nurses before initiation
• Basal rate NOT recommended for opioid-naive patients (increased respiratory depression risk)
• PCA by proxy (family-controlled) is prohibited except in specific institutional protocols with safeguards

Step 4: Monitoring and Opioid Safety

Monitoring parameters:

Naloxone dosing for opioid-induced respiratory depression:

• Mild-moderate (RR 8-10, responsive to stimulation): Dilute naloxone 0.4 mg in 10 mL NS; give 1 mL (0.04 mg) IV q2-3 min until RR >12
• Severe (RR <8, unresponsive): Naloxone 0.4 mg IV bolus; repeat q2-3 min; consider infusion (2/3 of response dose per hour)
• Duration: Naloxone half-life (30-90 min) is shorter than most opioids; monitor for re-sedation

Step 5: Opioid Tapering and Transition

Acute pain opioid taper (post-surgical):

• Reduce opioid by 25-50% per day as pain improves and non-opioid agents provide adequate relief
• Convert IV to oral when patient meets conversion criteria
• Target opioid discontinuation by post-operative day 3-5 for most surgeries
• At discharge, prescribe the minimum quantity needed (3-7 days typical)

Discharge prescribing principles per CDC guidelines:

• Prescribe lowest effective dose of immediate-release opioid
• Limit initial supply to 3-7 days for acute pain
• Counsel on safe storage and disposal (drug take-back, disposal pouches)
• Co-prescribe naloxone if ≥50 MME/day or concurrent benzodiazepine
• Document pain management follow-up plan

Chronic opioid taper (when indicated):

• Reduce by 10% of total daily dose per week (slow taper)
• Reduce by 10% per month for long-term high-dose therapy
• Collaborate with pain management and addiction medicine
• Monitor for withdrawal symptoms (COWS scale) and provide symptomatic management

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Were non-opioid therapies optimized before initiating or escalating opioids?
2. Is the selected opioid dose appropriate for opioid-naive vs. opioid-tolerant status?
3. Is PCA programming verified with independent double-check and appropriate safety monitoring?
4. Are opioid monitoring parameters (sedation, respiratory rate, O2 sat) ordered with appropriate frequency?
5. Is a taper/discontinuation plan documented for acute pain patients?

Quality Audit

• Pain type classified (acute, chronic, neuropathic, cancer) and assessed with validated tool
• Multimodal non-opioid agents initiated before or concurrently with opioids
• Acetaminophen and/or NSAID scheduled (not PRN) as foundational agents
• Opioid selected appropriately for organ function (avoid morphine in renal failure)
• Opioid-naive patients started on immediate-release formulations at lowest effective dose
• PCA programming independently double-checked by two clinicians
• Basal rate NOT used for opioid-naive PCA patients
• Continuous monitoring ordered for PCA patients (pulse oximetry, sedation scale)
• Naloxone available at bedside for all opioid-receiving patients
• Bowel regimen initiated with opioid start (senna + docusate prophylaxis)
• MME/day calculated and CDC thresholds applied (50 MME, 90 MME triggers)
• PDMP queried for patients receiving opioid prescriptions at discharge
• Discharge opioid quantity limited to 3-7 days with disposal instructions
• Taper plan documented for patients expected to discontinue opioids
• Functional goals documented (not just pain score targets)

Guidelines

• Multimodal analgesia is the standard of care: always optimize non-opioid agents before escalating to opioids
• The WHO analgesic ladder remains valid as a framework; apply it bidirectionally (step up for increasing pain, step down as pain resolves)
• PCA by proxy (family members pressing the button) is unsafe and prohibited in standard practice; only the patient should activate doses
• Never initiate extended-release or long-acting opioids in opioid-naive patients (FDA black box warning)
• Meperidine has no role in modern pain management; normeperidine accumulation causes seizures
• Functional goals (ability to mobilize, participate in PT) are more meaningful outcome measures than pain scores alone
• Co-prescribe naloxone for patients at elevated overdose risk: ≥50 MME/day, concurrent benzodiazepines, history of overdose, substance use disorder
• Pain management is iterative: reassess, adjust, and document at every clinical encounter