Principles of Pain Management

There are certain principles that guide the management of acute and chronic pain.  Following these principles helps to improve the quality of care patients receive.  Assessing and evaluating pain is the first key principle for effective management.

The PQRST pneumonic can be used to help remember components of an assessment.

• Provokes: What makes it worse? What makes it better?
• Quality: What does it feel like? How is it described?
• Radiates: does it radiate? This can help identify neuropathic pain.
• Severity: use a pain scale appropriate to patient ability
• Time: When does the patient experience pain?

Principles of Pain Management

Mild Pain

(Level 0-3)

Principles of therapy

1. If bone pain is present, use of an NSAID should be routine.**
2. Always dose a medication to its maximum before reverting to the next step, unless pain is totally out of control.
3. If pain is constant or recurring, always dose around-the-clock (ATC).
4. If medication is not tolerated, take with food, milk, or antacid, or switch to acetaminophen

**CAUTION:  NSAID’S may increase edema and cause acute heart failure in susceptible patients: renal disease, advanced cardiac or CHF, ascites, liver disease.

Mild/Moderate Pain (Level 4-5)

Principles of therapy

1. Assess the frequency/duration/occurrence/ etiology/ sites of the pain.
2. Neuropathic pain may require use of specific medications effective for this type of pain.
3. Whenever bone pain is present, use of an NSAID or corticosteroid should be routine.**
4. Pain management needs to take precedence over other therapies.
5. Accurate assessment and history of reported opiate allergy are important. A differentiation between allergy sensitivity and side effect needs to be made.
6. Always dose to the maximum of each agent before reverting to the next step.
7. If pain is constant or recurring, always dose ATC.

Moderate/Severe Pain

(Level 6-7)

Principles of therapy

1. Always dose ATC.
2. Special situations of sudden onset/sudden resolution pain, especially along a nerve track, or neuralgias, may require an adjunct of an anticonvulsant (Neurontin).
3. Trial of appropriate adjuncts should be attempted before reverting to the next step.
4. Need to revert to next step when there are no intervals of adequate control or breakthrough occurs at maximum dose sooner than 3 hrs.
5. Pain resulting from inflammation of neural tissue in CNS (nerve-root compression of CNS metastasis) may require dexamethasone in high dose, 16 mg or more per 24 hr. Other steroids do not reach the CNS.
6. Any time nonpharmacologic options of radiation, chemotherapy, surgical debulking, neurological interventions are used, a total re-evaulation of all drug treatment needs to be made.

Severe Pain

(Level 8-10)

Principles of therapy

1. Morphine is the drug of choice in this category: (1) multiple products available; (2) multiple route of administration options, such as oral, rectal, IM, SC, IV, epidural and intrathecal; and (3) known equipotency between these routes allows a much easier transition.
2. No real practical dosage limits; can be titrated to patient response.
3. Management should be ATC dosing only.
4. Utilize all possible adjuncts to minimize increases in dose.
5. Initial control may require dosages higher than those needed in maintenance.
6. Sustained-release morphine should be used when possible.

-Michelle Huber, RPH, PharmD, BCGP

Clinical Pharmacist