Acute Pain

Acute Pain
2016-03-27, 10:14 PM
Acute Pain
Benoit Bailey, MD, MSc, FRCPC
Date of Revision: July 2015
Introduction
Pain is one of the most common symptoms experienced by patients. Acute pain is temporary and may last for minutes
or up to several weeks. It needs to be recognized, assessed for cause and treated appropriately as soon as possible.
The absence of treatment can lead to physiological and psychological adverse effects. Treatment should be tailored to
the level and type of pain. The absence of a diagnosis, including for patients with abdominal pain, should not delay
measures to relieve pain.
Goals of Therapy
Recognize that the patient is experiencing pain
Relieve the pain until the cause is treated
Identify and treat the cause of pain
Investigations
Observe the patient for behavioural signs of pain, e.g., agitation, anxiety, crying, gritting of teeth, withdrawal from
activities
Solicit self-reports of the pain
Inquire about the medical history and perform a physical examination to determine the cause and severity of the
pain
Inquire about medication self-treatment history and possible allergy or adverse reactions to analgesics
Use laboratory investigations as appropriate to determine the cause of the pain
Use a pain scale to measure and assess pain
Frequently evaluate response to treatment
Note: The use of a pain scale can help reduce oligoanalgesia (undertreatment of pain).1 Record the results of this
assessment as for a vital sign, and use it to judge the efficacy of interventions. The easy-to-use verbal numeric scale,
also known as the numeric rating scale, asks the patient to grade pain from 0 (no pain) to 10 (worst pain) and is
validated in adults and children 8 years.2 Other pain scales such as the standardized colour analogue scale or the
Wong-Baker Faces Pain Rating Scale can be used in children as young as 45 years or 36 years, respectively.3 The
PAINAD tool was developed to assess pain in adults with cognitive impairment.4
Therapeutic Choices
Nonpharmacologic Choices
Assess patients presenting with acute pain quickly, calmly and with empathy. Provide reassurance and encourage
patients to verbalize their pain at all stages of treatment. Initiate immediate measures to decrease pain (e.g.,
immobilize a fracture, apply dressings to burns, employ cold or heat or other techniques such as relaxation,
imagery and distraction) until pharmacologic treatment is started and takes effect. Do not wait until a full
assessment is made to start pharmacologic treatment.
Pharmacologic Choices
Table 3 provides a list of opioid and non-opioid medications for the treatment of acute pain.
Oral Analgesics
https://www.e-therapeutics.ca/print/new/documents/CHAPTER/en/c0011
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As a first step for mild to moderate pain, initiate treatment with a nonopioid analgesic (i.e., acetaminophen or
nonsteroidal anti-inflammatory drug [NSAID]), either alone or in combination with an oral opioid depending on
the nature/severity of the pain and the patient's medical and medication history. If pain persists and is still
moderate or worsening, consider adding an oral opioid to thefirst-step drug if not already tried. For patients
with severe acute pain, starting a parenteral opioid is usually more appropriate (Figure 1).
Nonopioid Analgesics
Acetaminophen can be used for mild to moderate pain. Compared to full-dose NSAIDs, acetaminophen
has fewer adverse effects and drug interactions but is less effective and has no anti-inflammatory action.5
Acetaminophen can be used with oral opioids for additive analgesic effect.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are a heterogeneous group of medications with
analgesic, antipyretic and anti-inflammatory properties. Medications from all 5 classes of nonselective
NSAIDs (i.e., salicylates, fenamates, propionic acid derivatives, oxicams, acetic acid derivatives) are
effective for mild to moderate pain. Prescribing information for all classes of NSAIDs can be found in
Osteoarthritis. Full single doses of most NSAIDs provide more effective analgesia than full doses of ASA or
acetaminophen.5 Choosing an NSAID can be difficult; some patients respond well to a certain class but not
to others and cost can be an important factor.
Adverse effects associated with single (or a few) doses of nonselective NSAIDs are limited and are
qualitatively similar to those of ASA. Chronic use is associated with GI effects (ulceration, bleeding and
perforation) and renal failure. Combining a proton-pump inhibitor (PPI) once daily or misoprostol 200 g QID
po with an NSAID effectively provides protection from GI toxicity.6 Some combinations are commercially
available in Canada (e.g., naproxen/esomeprazole, Vimovo; diclofenac/misoprostol, Arthrotec). Unlike other
NSAIDs, ASA irreversibly inhibits platelet function for the lifetime of the platelet (810 days) even after a
single therapeutic dose. In contrast, platelet function returns to normal when other NSAIDs have been
eliminated from the body (within approximately 24 hours for most NSAIDs). NSAIDs can precipitate asthma
in ASA-sensitive patients. Avoid NSAIDs in patients with a history of peptic ulcer disease, renal failure or
heart failure.
COX-2 selective NSAIDs such as celecoxib may cause less severe GI toxicity than nonselective NSAIDs,
but are more expensive and have a poorly-defined role and unstudied adverse effect profile in the treatment
of acute pain.
ASA can be given with opioids for additive analgesic effect. Avoid using ASA in children less than 18 years
of age if they have a fever or viral illness such as flu or chickenpox or any unidentified infection, because of
a possible increased risk of Reye's syndromea rare but serious condition that causes brain and liver
damage. ASA can also precipitate asthma in ASA-sensitive patients.
Ibuprofen 200 mg provides equivalent analgesia to ASA 650 mg or acetaminophen 650 mg; a dose of 400
mg is superior and longer acting, and provides comparable analgesia to the combination of
acetaminophen/codeine.5,7 A 10 mg/kg dose of ibuprofen is as safe as a 15 mg/kg dose of acetaminophen,
although GI bleeding has been reported with ibuprofen.8
Naproxen has a longer duration of action than ASA.5 Compared to ASA 650 mg, naproxen 250 mg is
equally effective and naproxen 500 mg is superior.9 Naproxen is available as oral tablets or rectal
suppositories. Naproxen sodium 220 mg (equivalent to naproxen 200 mg) is available as an oral
nonprescription analgesic.
Opioids
Oral opioids can be used for the treatment of moderate to severe pain. The parenteral route may be
preferred for severe pain due to a faster onset of action. Opioids are included in the list of medications
described as high-alertif not used appropriately they have a high risk of causing harm to the patient.10
Adverse effects include constipation, nausea, sedation, respiratory depression and (if used for a long period
of time) tolerance, dependence and withdrawal symptoms. Skin reactions (i.e., hives) and itching are
common and are usually not due to allergy; symptoms are often relieved with administration of an
antihistamine. Use the lowest recommended dose when treating opioid-nave, frail or elderly patients. Use
caution when switching among opioids and consider the equipotent doses (see Table 1) of each drug,
particularly when substituting to the highly potent hydromorphone. Depending on the duration of therapy, it
may be necessary to halve the equipotent dose when initiating an opioid switch and titrate the dose
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may be necessary to halve the equipotent dose when initiating an opioid switch and titrate the dose
carefully.
Due to its adverse effect profile, meperidine (pethidine) should not be used for pain that will last more than 3
hours (see Parenteral Analgesics).
Table 1: Equianalgesic Doses for Opioids in Acute Pain
Drug
Dose (mg) Approximately Equivalent to Morphine 10 mg IV

Parenteral
Oral
Codeine
120
200
Fentanyl
0.1
NA
Hydromorphone
46
Meperidinea (pethidine)
75
300
Morphine
10
60b
Oxycodone
NA
1015
Avoid meperidine in the elderly, patients with renal or hepatic insufficiency, or in patients with history of irreversible
MAOI use within the past 14 days.
b
For acute pain, the parenteral-to-oral ratio for a single dose of morphine is approximately 1:6; however, with chronic
dosing, the ratio is 1:23, i.e., 10 mg injectable 2030 mg oral.
Abbreviations: NA = not applicable
Codeine is available as single-entity formulations or in combination with acetaminophen or ASA 325 mg at

doses of 8, 15, 30 or 60 mg. Prescription and nonprescription products containing codeine are no longer
recommended for children under 12 years of age.11 Very rare cases of serious side effects and death in
children have been attributed to codeine, when given directly or ingested by infants via breast milk.
Individuals who are CYP2D6 ultra-rapid metabolizers convert codeine to morphine quickly, leading to
increased risk of adverse effects and potential overdose. Conversely, poor metabolizers or those who take
drugs that inhibit CYP2D6 will have inadequate analgesic effect with codeine.12 For these same reasons,
codeine as a single agent is not a reliable treatment for acute pain in adults.
Oral morphine is a better alternative for acute pain; an equipotent dose will be at least as effective as
codeine, with a more predictable adverse effect profile. Morphine is available in several immediate-release
dosage forms and sustained-release preparations but the longer-acting formulations should rarely be used
to treat acute pain. Because morphine's adverse effects are predictable, the dose can be titrated to achieve
pain-free status.
Hydromorphone is an alternative to morphine for acute pain. Due to its higher potency, lower doses are
needed. It is available as an oral liquid or tablets as well as parenteral formulations. Immediate-release
products such as liquid, tablets and iv solutions are preferable to controlled-release products in the
management of acute pain.
Oxycodone is available in single-entity immediate-release or controlled-release formulations and in
combination with acetaminophen. Immediate-release formulations with or without acetaminophen are an
effective alternative for acute pain management; use with caution since oxycodone is often a drug of choice
for patients with drug seeking behaviour or substance abuse disorders.
Tramadol is a unique analgesic. It is structurally related to morphine and codeine and acts through opioid
and nonopioid mechanisms. Although it appears to have less abuse potential and minimal effect on
respiratory function, tramadol causes more nausea compared to other opioids and may not be as effective
unless combined with another analgesic such as acetaminophen.13,14 Tramadol should not be used as a
first-line analgesic for acute pain.14,15,16
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Parenteral Analgesics
IV administration is less painful and has a more rapid and predictable onset of action compared with the sc and
im routes. The intranasal route is sometimes used with fentanyl.17
In case overdosage occurs, keep naloxone (Table 2) on hand when administering opioids parenterally.
Respiratory depression rarely occurs as long as the opioid is titrated to the level of pain.
Table 2: Treatment of Opioid-induced Respiratory Depression
Class
Drug
Dose
Opioid
Antagonists
naloxone
Adults and children >5 y or >20 kg weight: 0.42 mg Q23 min iv,
depending on response
generics
Children 5 y or 20 kg weight: 0.1 mg/kg Q23 min iv, depending on

response
Maximum dose: 10 mg. Note: May need to repeat in 12 h, depending on
half-life of opioid.
Continuous infusion may be used for overdoses of long-acting opiates.
Starting dose is 2/3 of the initial dose that was effective for the patient,
administered per hour by infusion or 0.40.8 mg/h in adults and
0.050.15 mg/kg/h in children. Titrate to effect.
NSAIDs
Ketorolac is an NSAID that can be given im or iv for the treatment of moderate to severe pain. A dose of 30
mg is comparable to approximately 12 mg of morphine.5 Ketorolac has the same adverse effect profile as
the oral nonselective NSAIDs. The pharmacologic effect cannot be titrated but the drug can be used when
opioids are contraindicated. Limit its use to 5 days' duration to minimize adverse effects. Ketorolac is
effective for the treatment of pain associated with renal colic.
Ibuprofen, at a dose of 400 mg or 800 mg administered as an iv infusion every 6 hours, significantly
decreased pain at rest and with movement when used adjunctively with iv opioids, for short-term
management of postoperative pain.18 The 800 mg dose, but not 400 mg, significantly reduced opioid
requirements.
Opioids
Morphine is the gold standard to which other opioids are compared. Its advantages (i.e., over meperidine)
include a longer duration of action, and metabolism that is not affected by liver and renal disease. It can be
administered as continuous infusion or as patient-controlled analgesia (PCA), a pump programmed to
deliver a preset amount of drug by continuous infusion or repeated boluses, as well as smaller bolus doses
for breakthrough pain.
Fentanyl is a synthetic opioid with a duration of action of only 3060 minutes, making it an ideal analgesic
for brief procedures. It can be administered by infusion, but this offers no advantage over morphine in terms
of efficacy, and is much more costly. Fentanyl has almost no hemodynamic effects and does not induce
histamine release, unlike morphine and meperidine. Rapid iv administration can lead to chest wall rigidity
that could interfere with ventilation. A single dose of intranasal fentanyl can be used to rapidly treat acute
pain when there is no iv access (such as on arrival to the emergency department).17 This requires an
atomizer device as well as established policy and procedures for administration. The intranasal dose should
be followed by administration of an iv opioid in all cases, where required.
Meperidine is not considered a first-line option in the treatment of acute pain and should not be given for
pain that is expected to last more than 3 hours where morphine is a better choice. Limit its use to short-term
(i.e., 2448 hours) due to the accumulation of normeperidine, a neurotoxic metabolite that can cause
seizures in some patients and CNS effects such as tremors, hyperreflexia, hallucinations. Avoid using
meperidine in patients with renal failure or liver disease and in those who have received MAOIs in the past
14 days. In some hospitals, meperidine has been removed from the formulary because of these concerns.
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Topical and Local Anesthesia

Topical NSAIDs can be used to treat acute musculoskeletal conditions.19 They provide local pain relief with
fewer systemic effects compared to oral NSAIDs. See Osteoarthritis for information on topical NSAIDs
availability.
Infiltrative techniques using lidocaine are frequently used for minor procedures. A dose of 35 mg/kg
(maximum 300 mg) can be used for direct infiltration or regional nerve block. Coadministration of epinephrine
allows an increase of lidocaine dose to 57 mg/kg, unless epinephrine is contraindicated (e.g., if tissue
vascularity is poor or if distal vasculature is involved). If allergy to amide-type local anesthetics (e.g., lidocaine,
bupivacaine) is suspected, an ester (e.g., procaine, tetracaine, benzocaine) can be used because of the
absence of cross-reactivity.
For small facial lacerations, a mixture of tetracaine 0.51%, epinephrine (adrenaline) 0.250.5% and cocaine
14% (TAC) can be applied topically (volume 3 mL; maximum topical cocaine dose 6 mg/kg). The restricted
status of cocaine limits its usefulness. A mixture of lidocaine 0.4%, epinephrine 0.1% and tetracaine 0.05%
(LET), in a dose of 2 mL topically, is as effective as TAC.
Topical anesthetics such as eutectic mixture of local anesthetics (EMLA), amethocaine (tetracaine; Ametop) or
liposomal lidocaine (Maxilene) can be used to reduce pain associated with minor procedures such as needle
insertion on intact skin. EMLA, containing prilocaine and lidocaine, causes vasoconstriction potentially making
cannulation difficult. To be effective, a large amount should be applied and covered with an occlusive dressing
for at least 4560 minutes.
Amethocaine is superior to EMLA in preventing pain associated with needle insertion in children.20 It requires a
shorter application time (30 minutes) than EMLA (4560 minutes). Amethocaine causes vasodilation and may
induce hypersensitivity with repeated use. Liposomal lidocaine is as effective as EMLA in decreasing pain
associated with venipuncture or iv cannulation. It has minimal vasoactive properties and requires an application
time of 30 minutes. An occlusive dressing is not required, but it is recommended in young children.
Inhalation Pain Management

Inhaled nitrous oxide (N20) 3050% can be used as an analgesic.21 Advantages include rapid onset and short
duration of action. Contraindications include altered level of consciousness, severe maxillofacial injuries, chronic
obstructive pulmonary disease, acute pulmonary edema, pneumothorax, shock, decompression sickness, bowel
obstruction and major chest injury. It can produce lightheadedness, drowsiness, nausea, vomiting and
excitement.
Choices during Pregnancy and Breastfeeding

Acute pain is a common occurrence during pregnancy and in breastfeeding mothers. These conditions need not
preclude the use of analgesics. However, prescribing the safest alternative for the fetus or newborn is paramount.
Pregnancy
For mild pain, the drug of choice is usually acetaminophen. During pregnancy, the use of NSAIDs should be
restricted to the first or second trimester; even short-term NSAID use after 32 weeks is associated with a
substantial increase in the risk of premature closure of the ductus arteriosus, and is not recommended.22 For more
severe pain, opioids can be used at all stages of pregnancy. If opioids are used during the late stage of labour, the
newborn should be monitored for signs of respiratory depression. When opioids are used at high doses or more
than sporadically in late pregnancy, monitor the newborn for signs of withdrawal. Neonatal withdrawal can occur
when therapeutic doses of opioids are used in late pregnancy.23
Breastfeeding
For mild pain, the drug of choice is acetaminophen. NSAIDs can be used safely during breastfeeding. Generally,
most immediate-release opioids taken while breastfeeding are safe if limited to therapeutic doses and relatively
short-term use. Because of potential toxicity, codeine12,24 or meperidine are not recommended if safer
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short-term use. Because of potential toxicity, codeine12,24 or meperidine are not recommended if safer
alternatives are available. When possible, it is advisable to wait at least 2 hours after taking an opioid before
breastfeeding.25 With exposure to more than a few doses of any opioid, particularly high doses, the breastfed child
needs to be monitored for signs of respiratory depression.
A discussion of general principles on the use of medications during pregnancy and breastfeeding can be found in
Drug Use during Pregnancy and Drug Use during Breastfeeding. Other specialized reference sources are also
provided in these appendices.
Therapeutic Tips
Choose the medication and route of administration according to the severity of the pain and the desired onset and
duration of action.
Opioid analgesics can be safely given before full assessment and diagnosis in acute abdominal pain, without
increasing the risk of errors in diagnosis or treatment.26,27
Consider adding sedatives to analgesics, particularly for painful procedures. However, sedative use should not
replace analgesics.
Choose the most appropriate analgesic for elderly patients, considering hepatic and renal function and concurrent
medications.
Allow an adequate amount of time (according to the analgesic's onset of action), before performing a painful
procedure or assessing whether an analgesic is effective.
Monitor the patient's level of consciousness and for the presence of adverse effects after administering an
analgesic.
Reassess the need for analgesics frequently, using a pain scale.
Avoid administering opioids on an as-needed basis. A regular schedule of administration is more effective.
Consult specialized acute pain services as needed.
Algorithm
Figure 1: Management of Acute Pain
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Drug Table
Table 3: Analgesics for the Treatment of Acute Pain
Class
Drug
Dosage
Adverse
Effects
Drug
Interactions
Costa
Analgesics,
nonopioid
acetaminophen
Atasol
Preparations,
Tempra,
Tylenol,
generics
Children:
1015 mg/kg/dose
Q4H po; oral
suspension available
Hepatotoxicity in
overdose or
supratherapeutic
dosing.
Chronic alcohol
use increases the
risk of
hepatotoxicity.
Acetaminophen
has been
reported to
increase INR in
warfarin-treated
patients.28 Check
INR if
acetaminophen
2 g/day is used
for 3
consecutive
days. Adjust
warfarin dosage
as required.
GI upset. Avoid
in patients with
renal failure,
Warfarin:
increased
anticoagulant
1520 mg/kg/dose
Q4H pr
Maximum: 5
doses/day
Adults: 325650 mg
Q4H po or pr
Maximum: 4 g/day
Analgesics,
nonopioid
ASA
Aspirin, Coated
Aspirin,
Children:
1015 mg/kg/dose
Q4H po
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Aspirin,
generics
Q4H po
Maximum: 5
doses/day
Adults: 325650 mg
Q4H po
renal failure,
peptic ulcer
disease, heart
failure and ASAsensitive
asthma.
Maximum: 4 g/day
anticoagulant
effect.
Antihypertensives
(diuretics, betablockers, ACE
inhibitors, alphablockers):
possible
reduction in
antihypertensive
effect; may
require additional
antihypertensive
therapy.
Lithium may
interfere with
sodium/water
balance. Monitor
lithium levels
when NSAID
added.
Increased risk of
GI bleeding with
SSRIs.
Analgesics,
nonopioid
ibuprofen, oral
Advil, Motrin,
Motrin
(Children's),
generics
Children:
10 mg/kg/dose Q68H
po; oral suspension
available
Maximum:
40 mg/kg/day, not to
exceed adult dose
Adults: 200400 mg
Q68H po
GI upset. Avoid
in patients with
renal failure,
peptic ulcer
disease, heart
asthma.
Maximum: 1.2 g/day
Warfarin:
increased
anticoagulant
effect.
Antihypertensives
possible
reduction in
antihypertensive
effect; may
require additional
antihypertensive
therapy.
Lithium may
interfere with
sodium/water
balance. Monitor
lithium levels
when NSAID
added.
Increased risk of
GI bleeding with
SSRIs.
Analgesics,
nonopioid
ibuprofen,
parenteral
Caldolor
Adults: For
postoperative pain in
conjunction with iv
opioids, in patients
undergoing general
anesthesia:
400800 mg Q6H iv
Dilute each dose in
250 mL compatible
fluid and administer
GI upset. Avoid
in patients with
renal failure,
peptic ulcer
disease, heart
asthma.
Warfarin:
increased
anticoagulant
effect.
Antihypertensives
possible
reduction in
$$$$$/ 800
mg vial
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reduction in
antihypertensive
effect; may
require additional
antihypertensive
therapy.
over 30 min
Usual maximum:
2400 mg/24 h 1 day;
do not exceed 3200
mg in 24 h
Lithium may
interfere with
sodium/water
balance. Monitor
lithium levels
when NSAID
added.
Increased risk of
GI bleeding with
SSRIs.
Analgesics,
nonopioid
ketorolac,
parenteral
Toradol,
generics
Children:
0.21 mg/kg/dose Q4
6H im or iv
Maximum: 30 mg/dose
Adults: 1030 mg
Q46H im or iv
Maximum: 120 mg/day
GI upset. Avoid
in patients with
renal failure,
peptic ulcer
disease, heart
asthma.
Warfarin:
increased
anticoagulant
effect.
Antihypertensives
possible
reduction in
antihypertensive
effect; may
require additional
antihypertensive
therapy.
$$
Lithium may
interfere with
sodium/water
balance. Monitor
lithium levels
when NSAID
added.
Increased risk of
GI bleeding with
SSRIs.
Analgesics,
nonopioid
naproxen
Naprosyn,
Pediapharm
Naproxen
Suspension,
generics
Children:
57 mg/kg/dose
Q812H po; oral
suspension available
Maximum:
1000 mg/day
Adults: 500 mg
initially, then 250 mg
Q68H po
Maximum:
1250 mg/day
GI upset. Avoid
in patients with
renal failure,
peptic ulcer
disease, heart
asthma.
Warfarin:
increased
anticoagulant
effect.
Antihypertensives
possible
reduction in
antihypertensive
effect; may
require additional
antihypertensive
therapy.
Lithium may
interfere with
sodium/water
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sodium/water
balance. Monitor
lithium levels
when NSAID
added.
Increased risk of
GI bleeding with
SSRIs.
Analgesics,
nonopioid
naproxen
sodium
Aleve (220 mg),
, Anaprox (275
mg; 550 mg),
generics
Adults: 220550 mg
Q812H po
Maximum: 1375
mg/day (maximum
dose for
nonprescription use is
440 mg/day)
GI upset. Avoid
in patients with
renal failure,
peptic ulcer
disease, heart
asthma.
Warfarin:
increased
anticoagulant
effect.
Antihypertensives
possible
reduction in
antihypertensive
effect; may
require additional
antihypertensive
therapy.
Lithium may
interfere with
sodium/water
balance. Monitor
lithium levels
when NSAID
added.
Increased risk of
GI bleeding with
SSRIs.
Analgesics,
opioid
fentanyl
generics
Children:
0.53 g/kg/dose Q1
2H iv
All opioids:
sedation,
constipation.
All opioids:
additive sedation
with other CNS
depressants,
e.g., alcohol;
potential
enhancement of
opioid effects
with lidocaine.
Fentanyl:
inhibitors of
CYP3A4 (e.g.,
cimetidine,
efavirenz,
erythromycin,
itraconazole,
ketoconazole,
ritonavir) may
potentiate
fentanyl's opioid
effects.
$$
All opioids:
sedation,
constipation.
All opioids:
additive sedation
with other CNS
depressants,
e.g., alcohol;
po: $
iv: $$
Adults: 50100 g
Q12H iv
Titrate to effect
Analgesics,
opioid
hydromorphone
Dilaudid,
generics
Adults: 12 mg Q4H
po
0.250.5 mg Q1H iv
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e.g., alcohol;
potential
enhancement of
opioid effects
with lidocaine.
Analgesics,
opioid
morphine
M.O.S., MS-IR,
Statex,
generics
Titrate to effect.
Immediate-release
oral:
All opioids:
sedation,
constipation.
All opioids:
additive sedation
with other CNS
depressants,
e.g., alcohol;
potential
enhancement of
opioid effects
with lidocaine.
All opioids:
sedation,
constipation.
Seizures can
occur when
used in renal
failure. May
cause tremors,
hyperreflexia,
hallucinations.
Avoid in liver
disease and
those who have
received MAOIs
within the last 14
days.
All opioids:
additive sedation
with other CNS
depressants,
e.g., alcohol;
potential
enhancement of
opioid effects
with lidocaine.
Meperidine:
potentially lifethreatening
serotonin
syndrome with
nonselective
MAOIs.
$$
All opioids:
sedation,
constipation.
All opioids:
additive sedation
with other CNS
depressants,
e.g., alcohol;
potential
enhancement of
opioid effects
with lidocaine.
Children:
0.20.5 mg/kg/dose
Q46H
Adults: 1030 mg
Q46H
IV: Children:
Intermittent:
0.10.2 mg/kg/dose
Q24H
Continuous infusion:
0.010.05 mg/kg/h
Breakthrough pain
during infusion:
0.010.05 mg/kg/dose
Adults: Intermittent:
2.510 mg Q24H iv
Continuous infusion:
110 mg/h
Breakthrough pain
during infusion:
2.55 mg/dose
Analgesics,
opioid
meperidine
(pethidine)
generics
Parenteral:
Children:
11.5 mg/kg/dose
Q34H iv
Maximum:
100 mg/dose; not
recommended for
ongoing use
Adults: 50100 mg
Q34H iv
Maximum:
100 mg/dose; not
recommended for
ongoing use
Analgesics,
opioid
oxycodone
Oxy-IR,
generics
Adults: 2.55 mg
Q4H po
Cost per dose (based on body weights of 20 kg for children and 70 kg for adults); includes drug cost only.
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Dosage adjustment may be required in renal impairment; see Dosage Adjustment in Renal Impairment.
Legend:
$ <$1
$$ $13
$$$ $36
$$$$ $69
$$$$$ $912
Suggested Readings
Drugs for pain. Treat Guidel Med Lett 2013;11(128):31-42.
Macintyre PE, Scott DA, Schug SA et al. Acute pain management: scientific evidence. 3rd ed. Melbourne (AU):
Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine; 2010. p. 491. Available from:
www.anzca.edu.au/resources/books-and-publications/acutepain.pdf.
Moore ND. In search of an ideal analgesic for common acute pain. Acute Pain 2009;11(3):129-37.
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proceduresa systematic review. Dan Med J 2013;60(6):A4627.

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CPhA assumes no responsibility for or liability in connection with the use of this information. For clinical use only and not intended for for use by
patients. Once printed there is no quarantee the information is up-to-date. [Printed on: 03-28-2016 01:14 AM]
RxTx, Compendium of Therapeutic Choices Canadian Pharmacists Association, 2016. All rights reserved
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Dose (mg) Approximately Equivalent to Morphine 10 mg IV

Codeine is available as single-entity formulations or in combination with acetaminophen or ASA 325 mg at

Children 5 y or 20 kg weight: 0.1 mg/kg Q23 min iv, depending on

Topical and Local Anesthesia

Inhalation Pain Management

Choices during Pregnancy and Breastfeeding

Maximum: 1.2 g/day

proceduresa systematic review. Dan Med J 2013;60(6):A4627.

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