Registered Nurses´ Association of Ontario
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Practice Recommendations:
Part B: Management
i. Management
ii. Pharmacological Management of Pain Recommendations
- Selecting appropriate Analgesics
- Optimizing Pain Relief with Opioids
- Monitoring for Safety and Efficacy
- Anticipate and Prevent Common Side Effects of Opioids
- Anticipate and Prevent Procedural Pain Recommendation
- Patient and Family Education
- Effective Documentation
iii. Non–Pharmacological Management of Pain Recommendations
i. Management
Establishing a Plan for Pain Management
Recommendation 19
Establish a plan for management in collaboration with interdisciplinary team members that is consistent with individual and family goals for pain relief, taking into consideration the following factors:
- assessment findings;
- baseline characteristics of pain
- physical, psychological, and sociocultural factors shaping the experience of pain;
- etiology;
- most effective pharmacological and non-pharmacological strategies;
- management interventions; and
- current and future primary treatment plans.
Grade of Recommendation = C
Recommendation 20
Provide individuals and families/care providers with a written copy of the treatment plan to promote their decision-making and active involvement in the management of pain. The plan will be adjusted according to the results of assessment and reassessment.
Changes to the treatment plan will be documented and communicated to everyone involved in the implementation of the plan.
Grade of Recommendation = A
ii. Pharmacological Management of Pain Recommendations
Selecting Appropriate Analgesics
Recommendation 21
Ensure that the selection of analgesics is individualized to the person, taking into account:
- the type of pain (acute or chronic, nociceptive and/or neuropathic);
- intensity of pain;
- potential for analgesic toxicity (age, renal impairment, peptic ulcer disease, thrombocytopenia);
- general condition of the person;
- concurrent medical conditions;
- response to prior or present medications;
- cost to the person and family; and
- the setting of care.
Grade of Recommendation = A
Recommendation 22
Advocate for use of the simplest analgesic dosage schedules and least invasive pain management modalities:
- The oral route is the preferred route for chronic pain and for acute pain as healing occurs.
- Tailor the route to the individual pain situation and the care setting.
- Intravenous administration is the parenteral route of choice after major surgery, usually via bolus and continuous infusion.
Grade of Recommendation = C
- The intramuscular route is not recommended for adults or infants⁄children because it is painful and not reliable.
Grade of Recommendation = B
Recommendation 23
Use a step-wise approach in making recommendations for the selection of analgesics which are appropriate to match the intensity of pain:
- The use of the WHO Analgesic Ladder is recommended for the treatment of chronic cancer pain.
- Pharmacological management of mild to moderate postoperative pain begins with acetaminophen or NSAIDS. However, moderate to severe pain should be treated initially with an opioid analgesic.
Grade of Recommendation = B
Recommendation 24
Advocate for consultation with a pain management expert for complex pain situations which include, but are not limited to:
- pain unresponsive to standard treatment;
- multiple sources of pain;
- mix of neuropathic and nociceptive pain; and
- history of substance abuse.
Grade of Recommendation = C
Recommendation 25
Recognize that acetaminophen or nonsteroidal, anti-inflammatory drugs (NSAIDS) are used for the treatment of mild pain and for specific types of pain as adjuvant analgesics unless contraindicated.
Grade of Recommendation = A
Recommendation 26
Recognize that adjuvant drugs are important adjuncts in the treatment of specific types of pain.
- Adjuvant drugs such as anticonvulsants and antidepressants provide independent analgesia for specific types of pain.
- Extra caution is needed in administering antidepressant and anticonvulsant drugs to the elderly who may experience significant anticholinergic and sedative side effects.
Grade of Recommendation = B
Recommendation 27
Recognize that opioids are used for the treatment of moderate to severe pain, unless contraindicated, taking into consideration:
- previous dose of analgesics;
- prior opioid history;
- frequency of administration;
- route of administration;
- incidence and severity of side effects;
- potential for age related adverse effects; and
- renal function.
Grade of Recommendation = A
Recommendation 28
Consider the following pharmacological principles in the use of opioids for the treatment of severe pain:
- Mixed agonist-antagonists (eg. pentazocine) are not administered with opioids because the combination may precipitate a withdrawal syndrome and increase pain.
- The elderly generally receive greater peak and longer duration of action from analgesics than younger individuals, thus dosing should be initiated at lower doses and increased more slowly ("careful titration(").
- Special precautions are needed in the use of opioids with neonates and infants under the age of six months. Drug doses, including those for local anaesthetics, should be calculated carefully based on the current or most appropriate weight of the neonate. Initial doses should not exceed maximum recommended amounts.
Grade of Recommendation = B
Recommendation 29
Recognize that meperidine is contraindicated
for the treatment of chronic pain.
- Meperidine is not recommended for the treatment of chronic pain due to the build-up of the toxic metabolite normeperidene, which can cause seizures and dysphoria.
- Meperidine may be used in acute pain situations for very brief courses in otherwise healthy individuals who have not demonstrated an unusual reaction (ie. local histamine release at the infusion site) or allergic response to other opioids such as morphine or hydromorphone.
- Meperidine is contraindicated in patients with impaired renal function.
Grade of Recommendation = A
Optimizing Pain Relief with Opioids
Recommendation 30
Ensure that the timing of analgesics is appropriate according to personal characteristics of the individual, pharmacology (ie. duration of action, peak-effect and half-life) and route of the drug.
Grade of Recommendation = A
Recommendation 31
Recognize that opioids should be administered on a regular time schedule according to the duration of action and depending on the expectation regarding the duration of severe pain.
- If severe pain is expected for 48 hours post-operatively, routine administration may be needed for that period of time. Late in the post-operative course, analgesics may be effective given on an "as needed" basis.
- In chronic cancer pain, opioids are administered on an “around-the-clock” basis, according to their duration of action.
- Long-acting opioids are more appropriate when dose requirements are stable.
Grade of Recommendation = A
Recommendation 32
Use principles of dose titration specific to the type of pain to reach the analgesic dose that relieves pain with a minimum of side effects, according to:
- cause of the pain;
- individual’s response to therapy;
- clinical condition;
- concomitant drug use;
- onset and peak effect;
- duration of the analgesic effect;
- age; and
- known pharmacokinetics and pharmacodynamics of the drugs administered. Doses are usually increased every 24 hours for persons with chronic pain on immediate release preparations, and every 48 hours for persons on controlled release opioids. The exception to this is transdermal fentanyl, which can be adjusted every 3 days.
Grade of Recommendation = B
Recommendation 33
Promptly treat pain that occurs between regular doses of analgesic (breakthrough pain) using the following principles:
- Breakthrough doses of analgesic in the post-operative situation are dependent on the routine dose of analgesic, the individual’s respiratory rate, and the type of surgery, and are usually administered as bolus medications through PCA pumps.
- Breakthrough doses of analgesic should be administered to the person on an “as needed” basis according to the peak effect of the drug (po/pr = q1h; SC/IM = q 30 min; IV = q 10-15 min).
- It is most effective to use the same opioid for breakthrough pain as that being given for “around-the-clock” dosing.
- Individuals with chronic pain should have:
- An immediate release opioid available for pain (breakthrough pain) that occurs between the regular administration times of the “aroundthe- clock” medication.
- Breakthrough doses of analgesic for continuous cancer pain should be calculated as 10-15 per cent of the total 24-hour dose of the routine “around-the-clock” analgesic.
- Breakthrough analgesic doses should be adjusted when the regular “around-the-clock” medication is increased.
- Adjustment to the “around-the-clock” dose is necessary if more than 2-3 doses of breakthrough analgesic are required in a 24-hour period, and pain is not controlled.
Grade of Recommendation = C
Recommendation 34
Use an equianalgesic table to ensure equivalency between analgesics when switching analgesics. Recognize that the safest method when switching from one analgesic to another is to reduce the dose of the new analgesic by one-half in a stable pain situation.
Grade of Recommendation = C
Recommendation 35
Ensure that alternate routes of administration are prescribed when medications cannot be taken orally, taking into consideration individual preferences and the most efficacious and least invasive route.
- The indications for transdermal routes of medication include allergy to morphine, refractory nausea and vomiting, and difficulty swallowing.
- Consider using continuous subcutaneous infusion of opioids in individuals with cancer who are experiencing refractory nausea and vomiting, inability to swallow, or require this route to avoid continuous peaks and valleys in pain control.
- The cost of medications and the technology necessary for delivery (e.g. pain pumps) should be taken into consideration in selecting certain alternative routes of administration.
- Consider using a butterfly injection system to administer intermittent subcutaneous analgesics.
- Epidural access must be managed by clinicians with appropriate
Grade of Recommendation = C
Recommendation 36
Recognize the difference between drug
addiction, tolerance and dependency to
prevent these from becoming barriers to
optimal pain relief.
Grade of Recommendation = A
Monitoring for safety and efficacy
Recommendation 37
Monitor persons taking opioids who are at
risk for respiratory depression recognizing
that opioids used for people not in pain, or
in doses larger than necessary to control
the pain, can slow or stop breathing.
- Respiratory depression develops less frequently in individuals who have their opioid doses titrated appropriately. Those who have been taking opioids for a period of time to control chronic or cancer pain are unlikely to develop this symptom.
- The risk of respiratory depression increases with intravenous or epidural administration of opioids, rapid dose escalation, or renal impairment.
Grade of Recommendation = A
Recommendation 38
Monitor persons taking opioids who are at
risk for respiratory depression recognizing
that opioids used for people not in pain, or
in doses larger than necessary to control
the pain, can slow or stop breathing.
Grade of Recommendation = C
Recommendation 39
Evaluate the efficacy of pain relief with
analgesics at regular intervals and following
a change in dose, route or timing of
administration. Advocate for changes in
analgesics when inadequate pain relief is
observed.
Grade of Recommendation = C
Recommendation 40
Seek referral to a pain specialist for individuals
who require increasing doses of
opioids that are ineffective in controlling
pain. Evaluation should include assessment
for residual pathology and other pain
causes, such as neuropathic pain.
Grade of Recommendation = C
Anticipate and Prevent Common Side Effects of Opioids
Recommendation 41
Anticipate and monitor individuals taking
opioids for common side effects such as
nausea and vomiting, constipation and
drowsiness, and institute prophylactic
treatment as appropriate.
Grade of Recommendation = B
Recommendation 42
Counsel patients that side effects to opioids
can be controlled to ensure adherence
with the medication regime.
Grade of Recommendation = C
Recommendation 43
Recognize and treat all potential causes of
side effects taking into consideration
medications that potentiate opioid side
effects:
- Sedation – sedatives, tranquilizers, antiemetics.
- Postural hypotension – antihypertensives, tricyclics.
- Confusion – phenothiazines, tricyclics, antihistamines and other anticholinergics.
Grade of Recommendation = A
Anticipate and Prevent Common Side Effects of Opioids –
Nausea and Vomiting
Recommendation 44
Assess all persons taking opioids for the presence of nausea and/or vomiting, paying particular attention to the relationship of the symptom to the timing of analgesic administration.
Grade of Recommendation = C
Recommendation 45
Ensure that persons taking opioid analgesics
are prescribed an antiemetic for use on an
“as needed” basis with routine administration
if nausea/vomiting persists.
Grade of Recommendation = C
Recommendation 46
Recognize that antiemetics have different
mechanisms of action and selection of the
right antiemetic is based on this understanding
and etiology of the symptom.
Grade of Recommendation = C
Recommendation 47
Assess the effect of the antiemetic on a
regular basis to determine relief of nausea/
vomiting and advocate for further
evaluation if the symptom persists in spite
of adequate treatment.
Grade of Recommendation = C
Recommendation 48
Consult with physician regarding switching
to a different antiemetic if nausea/vomiting
is determined to be related to the opioid,
and does not improve with adequate doses
of antiemetic.
Grade of Recommendation = C
Anticipate and Prevent Common Side Effects of Opioids –
Constipation
Recommendation 49
Institute prophylactic measures for the
treatment of constipation unless contraindicated,
and monitor constantly for
this side-effect.
- Laxatives should be prescribed and increased as needed to achieve the desired effect as a preventative measure for individuals receiving routine administration of opioids.
Grade of Recommendation = B
- Osmotic laxatives soften stool and promote peristalsis and may be an effective alternative for individuals who find it difficult to manage an increasing volume of pills.
Grade of Recommendation = B
- Stimulant laxatives may be contraindicated if there is impaction of stool. Enemas and suppositories may be needed to clear the impaction before resuming oral stimulants.
Grade of Recommendation = C
Recommendation 50
Counsel individuals on dietary adjustments
that enhance bowel peristalsis recognizing
personal circumstances (seriously ill individuals
may not tolerate) and preferences.
Grade of Recommendation = C
Recommendation 51
Urgently refer persons with refractory constipation accompanied by abdominal pain and/or vomiting to the physician.
Grade of Recommendation = C
Anticipate and Prevent Common Side Effects of Opioids –
Drowsiness/Sedation
Recommendation 52
Recognize that transitory sedation is common and counsel the person and family/care provider that drowsiness is common upon initiation of opioid analgesics and with subsequent dosage increases.
Grade of Recommendation = C
Recommendation 53
Evaluate drowsiness which continues beyond 72 hours to determine the underlying cause and notify the physician of confusion or hallucinations that accompany drowsiness.
Grade of Recommendation = C
Anticipate and Prevent Procedural Pain
Recommendation 54
Anticipate pain that may occur during
procedures such as medical tests and
dressing changes, and combine pharmacologic
and non-pharmacologic options
for prevention.
Grade of Recommendation = C
Recommendation 55
Recognize that analgesics and/or local
anaesthetics are the foundation for pharmacological
management of painful
procedures. Anxiolytics and sedatives are
specifically for the reduction of associated
anxiety. If used alone, anxiolytics and
sedatives blunt behavioural responses
without relieving pain.
Grade of Recommendation = C
Recommendation 56
Ensure that skilled supervision and appropriate
monitoring procedures are instituted
when conscious sedation is used.
Grade of Recommendation = C
Patient and family education
Recommendation 57
Provide the person and their family/care
providers with information about their
pain and the measures used to treat it,
with particular attention focused on
correction of myths and strategies for the
prevention and treatment of side effects.
Grade of Recommendation = A
Recommendation 58
Ensure that individuals understand the
importance of promptly reporting unrelieved
pain, changes in their pain, new
sources or types of pain and side effects
from analgesics.
Grade of Recommendation = C
Recommendation 59
Clarify the differences between addiction,
tolerance, and physical dependence to
alleviate misbeliefs that can prevent optimal
use of pharmacological methods for
pain management.
- Addiction (psychological dependence) is not physical dependence or tolerance and is rare with persons taking opioids for chronic pain.
- Persons using opioids on a chronic basis for pain control can exhibit signs of tolerance requiring upward adjustments of dosage. However, tolerance is usually not a problem and people can be on the same dose for years.
- Persons who no longer need an opioid after long-term use need to reduce their dose slowly over several weeks to prevent withdrawal symptoms because of physical dependence.
Grade of Recommendation = A
Effective Documentation
Recommendation 60
Document all pharmacological interventions
on a systematic pain record that
clearly identifies the effect of analgesic on
pain relief. Utilize this record to communicate
with interdisciplinary colleagues in
the titration of analgesic. The date, time,
severity, location and type of pain should
all be documented.
Grade of Recommendation = C
Recommendation 61
Provide the individual and family in the
home setting with a simple strategy for
documenting the effect of analgesics.
Grade of Recommendation = C
iii. Effective Non–Pharmacological Management of Pain
Recommendation 62
Combine pharmacological methods with
non-pharmacological methods to achieve
effective pain management.
- Non-pharmacological methods of treatment should not be used to substitute for adequate pharmacological management.
- The selection of non-pharmacological methods of treatment should be based on individual preference and the goal of treatment.
- Any potential contraindications to non-pharmacological methods should be considered prior to application.
Grade of Recommendation = C
Recommendation 63
Institute specific strategies known to be
effective for specific types of pain, such as
superficial heat and cold, massage, relaxation,
imagery and pressure or vibration,
unless contraindicated.
Grade of Recommendation = C
Recommendation 64
Implement psychosocial interventions
that facilitate coping of the individual and
family early in the course of treatment.
Grade of Recommendation = B
Recommendation 65
Institute psycho-educational interventions
as part of the overall plan of treatment
for pain management.
Grade of Recommendation = A
Recommendation 66
Recognize that cognitive-behavioural
strategies combined with a multidisciplinary
rehabilitative approach are important
strategies for treatment of chronic
non-malignant pain.
Grade of Recommendation = A
