pain assessment grid drugs

UCLA Pharmaceutical Services Pain Management Medications - Dosing and Pharmacodynamic Chart

Pain Assessment Considerations

The following are considerations to guide pain assessment General Considerations • The pain experience should be considered a clinical emergency and

treated in a timely fashion. • Whenever a pain medication is administered its effect should be

evaluated • Unresolved pain (ie: after a fall, intervention, or procedure) is a

warning sign and is a high priority for assessment and treatment. Reassess dose for efficacy.

• Unresolved escalating pain requires detailed assessment. This can indicate other etiologies such as nerve pain that is typically unresponsive to an opioid and needs a pain consult.

• Orders with variable dose/frequency (e.g., Vicodin 1-2 tabs every 4-6 hours) may be used only when there are acceptable objective modifiers (e.g., for mild, moderate or severe pain) for each dose or dosage interval specified.

PCA • If the # of attempts far exceeds the number of injections dose may

need to increased. • If patient awakens in severe pain-evaluate for the addition of a basal

dose. Route Change • When changing route from IV/oral and epidural to oral it is essential

to utilize equinalgesic doses.

Tolerance • If a patient is receiving a narcotic for >7days, evaluate for tolerance

as patient may require increased doses. Withdrawal Side Effects • Prevention of withdrawal is essential if doses are reduced/stopped

for any reason. Adjunctive Therapy • Assess benefit of adjuvant therapy such as ice, heat, position

change, massage, relaxation techniques, etc. High Risk • Patients with a past medical history of drug abuse will require

greater dosing than less. • Patients with a history of PVD or neuropathic pain (e.g., chronic

pain) with new onset acute pain may have additional needs. • Patients with a history of depression, anxiety or psychosis may be at

increased risk for poor coping. Alternative/additional medication choices should be considered.

2/10/03 Approved by P&T Committee


Medication Onset of

action Peak Effect1 Duration of Action1

Route/Rate of Administration Dose (D) Comments

Oral Medications

Acetaminophen 325mg/codeine 30mg (Tylenol #3)

30-45 minutes 1-2 hours 4-6 hours Oral

D: 30-60mg codeine (e.g. 1-2 tablets) every 4-6 hours. Maximum 12 tablets/day

Drowsiness, sedation, lightheadedness, dizziness, nausea/vomiting, constipation, dose related respiratory depression. Excess acetaminophen can cause hepatotoxicity. Do not exceed 4gm acetaminophen/day.

Hydrocodone 5mg /acetaminophen 500mg (Vicodin)

10-30 minutes 0.5-1 hour 4–6 hours Oral

D: 5-10mg hydrocodone (e.g. 1-2 tablets) every 4 – 6 hours. Maximum 8 tablets/day


Hydromorphone 30 minutes 1.5-2 hours 4 hours Oral D: 2 mg every 3-6 hours Drowsiness, sedation, lightheadedness, dizziness, nausea/vomiting, constipation, dose related respiratory depression.

Methadone 30-60 minutes 1.5-2 hours 6 hours2 Oral D: 5-20mg every 6-8 hours

Drowsiness, sedation, lightheadedness, dizziness, nausea/vomiting, constipation, dose related respiratory depression.

Morphine, immediate release (MSIR)

30-60 minutes 1-2 hours 4-5 hours Oral D: 10-30 mg every 4 hours


Morphine, sustained release (MS Contin)

N/A3 3-8 hours 8-12 hours Oral

D: Give half the total daily dose of MSIR every 12 hours; or give 1/3 the total daily dose of MSIR every 8 hours.

Drowsiness, sedation, lightheadedness, dizziness, nausea/vomiting, constipation, dose related respiratory depression. Sustained release formulations not for acute pain relief. Immediate release products should be used for breakthrough pain.



Medication Onset of action Peak Effect1 Duration of

Action1 Route/Rate of

Administration Dose (D) Comments

Oxycodone, immediate release - 1-1.5 hours 3-4 hours Oral D: 5-15 mg every 4-6

hours


Oxycodone, sustained release (Oxycontin) N/A3 3 hours 12 hours Oral

D: give half the total daily dose of immediate release oxycodone every 12 hours

Drowsiness, sedation, lightheadedness, dizziness, nausea/vomiting, constipation, dose related respiratory depression. Sustained release formulations not for acute pain relief. Immediate release products should be used for breakthrough pain

Oxycodone 5mg / acetaminophen 325mg (Percocet 5mg/325mg)

- 1-1.5 hours 3-6 hours Oral D: 2.5-10mg oxycodone every 6 hours.


Propoxyphene 65mg/ acetaminophen 650mg 15-60 minutes 2 hours 4-6 hours Oral D: 1 tablet every 4 hours,

maximum 6 tablets/day

Drowsiness, sedation, lightheadedness, dizziness, nausea/vomiting, dose related respiratory depression. Excess acetaminophen can cause hepatotoxicity. Do not exceed 4gm acetaminophen/day.

1. These parameters may be affected by the dose of the drug and/or the patient’s physical status, underlying pathology, body size, weight and age. 2. Methadone duration of action prolonged with repeat dosing. 3. Sustained release formulations not for acute pain relief. Immediate release products should be used for breakthrough pain



Medication Onset of

action Peak Effect1 Duration of Action1

Route/Rate of Administration Dose (D)2,3 Comments

Parenteral Medications

Morphine IV: 4-6 min

IM: 10-30 min

IV: 20 min SC: 50-90 min

IM: 30-60min

4-5 hours Give over 4-5 minutes; may be diluted to 4-5ml

D: (IV/SC) 1-10mg every 2-4 hours D: (IM) 5-20mg every 4 hours

Respiratory depression, tachycardia, bradycardia, nausea, vomiting, hypotension, miosis, dizziness, drowsiness, sedation, biliary or urinary tract spasm, histamine release

Hydromorphone (Dilaudid) IM: 10-15 min

IV:15-30 min

IM: 30-60 min

IV: 2-3 hrs

IM: 4-5 hrs

IV: administer slowly

D: (IV) 0.2-1 mg every 3 hours D: (SC/IM) 1-2 mg every 4-6 hours

Respiratory depression, tachycardia, bradycardia, nausea, vomiting, hypotension, miosis, dizziness, drowsiness, sedation, biliary or urinary tract spasm

Meperidine (Demerol) least preferred agent

IV: 1 minute

IM: 10-15 min

IV: 5-7 mins

IM: 30-50 min 2-4 hours

Give over 4-5 minutes; may dilute to 4 - 5ml

D: 50-100mg

Respiratory depression, tachycardia, bradycardia, nausea, vomiting, hypotension, miosis, dizziness, drowsiness, sedation, biliary or urinary tract spasm, histamine release **Administration with MAOIs may lead to fatal drug interaction - Avoid MAOIs within the last 15 days**

1. These parameters may be affected by the dose of the drug and/or the patient’s physical status, underlying pathology, body size, weight and age. 2. IM route of administration should be avoided 3. Doses at the lower or upper limits should prompt patient reassessment (e.g., step down to oral agents or increase to continuous infusion, PCA, etc.)



Patient Controlled Analgesia - Intravenous Medication Route Comments Opiates - PCA (morphine, fentanyl, hydromorphone)

IV (PCA) Respiratory depression, tachycardia, bradycardia, nausea, vomiting, hypotension, miosis, dizziness, drowsiness, sedation, biliary or urinary tract spasm, histamine release

Patient Controlled Analgesia – Epidural Medication Route CommentsLocal anesthetics + Opiates – epidural, PCEA (bupivacaine or ropivacaine + fentanyl, morphine, or hydro-morphone)

Epidural (PCEA)

Respiratory depression, tachycardia, bradycardia, nausea, vomiting, hypotension, orthostasis, miosis, dizziness, drowsiness, sedation, urinary retention, histamine release/pruritus Local anesthetics may cause CNS excitation or depression with excessive doses or inadvertant intravascular administration (e.g., catheter migration). Inadvertant intrathecal administration will cause decreased sensation in buttocks, paresis of legs, or absent knee jerk within a few minutes.




Naloxone (Narcan®) Administration Indication Route/Rate of

Administration Dose Comments

Mild – Moderate Respiratory Depression secondary to opiate treatment (not in extremus)

Dilute 1ml (0.4mg) naloxone in 9ml normal saline (total volume = 10ml ). May be given IV push (preferred), IM, or subcutaneously

IV: 0.5ml (=0.02mg) IVP q 2 minutes

Any patient receiving opioids for more than 7 days will be sensitive to antagonists (i.e., naloxone); the dose MUST be diluted and carefully titrated to avoid precipitation of acute withdrawal, severe pain, or seizures. Whenever naloxone is administered immediate and continued reassessment is required.

Severe Respiratory Depression – Respiratory arrest secondary to opiate treatment

IV push (preferred) May be given IM or subcutaneously

IV: 0.4mg – 2mg IV q 2 minutes; if no response after 10mg reassess cause

For severe, life-threatening situations naloxone is administered undiluted and immediately. Notify physician. Whenever naloxone is administered immediate and continued reassessment is required.

pain assessment grid drugs

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