Meeting the Challenges of Acute Pain Management: Medication Choices for Acute Pain

                    

                    Acute Pain Management

                                                

Medication choices for pain should reflect the reported intensity of the pain and any confounding factors, such as comorbidities and other medications being used concurrently, such as sedatives, sleeping pills, and antiemetics -- which can have a contributory sedating effect when used with opioids. The World Health Organization (WHO) Ladder is one of the best methods of selecting an appropriate medication on the basis of severity of the pain; this is a stepwise approach that can provide direction for prescribers when choosing a medication for the patient's pain intensity:
                                   

Step 1. Pain Intensity 1-3, Mild Pain

  • Acetaminophen -- daily limit, 4000 mg;
  • Nonsteroidal anti-inflammatory drugs (NSAIDs); both cyclooxygenase (COX)-2 (celecoxib); and nonselective NSAIDs, such as ibuprofen and ketorolac; and
  • Adjuvant medications, such as antidepressants, antiseizure medications, muscle relaxants, etc.

Step 2. Pain Intensity 4-6, Moderate Pain

  • Combination medications with codeine and acetaminophen, such as Tylenol#3;
  • Combination medications with hydrocodone and acetaminophen, such as Vicodin/Lortab);
  • Combination medications with oxycodone and acetaminophen/acetylsalicylic acid, such as Percocet/Percodan, or oxycodone alone, and as an extended-release formulation, Oxycontin;
  • Tramadol (Ultram) a mixed mu-agonist selective serotonin reuptake inhibitor medication that can be used as a short-acting medication or as an extended-release formulation (Ultram ER); and
  • Continue any adjuvant medication being used for added pain relief.

Step 3. Pain Intensity 7-10, Severe Pain

  • Morphine oral -- both short-acting morphine and extended-release MS Contin/intravenous (IV);
  • Hydromorphone (Dilaudid) used as oral or IV medication;
  • Fentanyl used as IV/subcutaneous (Duragesic) (not recommended for acute pain) or buccal Fentora or fentanyl oralets (only for use with opioid-tolerant patients);
  • Methadone (Dolophine), for experienced prescribers only on the basis of extended half-life and monitoring requirements; and
  • Continue adjuvant medications being used for added pain relief.
                                            

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