Treatment of Pain

Mild (pain score 1)

-Stabilize with bolus of IV opioids +/- ketorelac or immediate release potent oral opioids in patients without IV access
Maintenance of analgesia with a combination of sustained release oral opioids and immediate release potent opioid and non narcotic analgesics
Consider treating neuropathic component
Wean to weak opioids

Moderate (pain score 2-3)

Stabilize with bolus of IV opioids until comfortable
Maintain analgesia by using either PCA or intermittent boluses on an ATC schedule. PRN doses should be ordered in addition to ATC for rescue.
Consider treating neuropathic component
Consider transfusion for prolonged symptoms
Wean to PO sustained release opioids plus IV or immediate release opioids as rescue. Wean to all PO opioids prior to discharge.

Severe (pain score 3-4)

Stabilize with bolus of IV opioids. Note: these patients often require very large doses of opioids. Consider IMU or ICU monitoring for first few days.
Consider epidural analgesia
Consider early double volume exchange transfusion
Consider treating neuropathic component
Maintain with a continuous infusion + PCA or bolus dosing. Patients with escalating doses of opioids should be monitored for respiratory depression.
Wean off continuous infusion to sustained release opioids, with PCA or bolus IV dose rescue. Then substitute sustained release potent opioids for rescue.

Options for Analgesic Administration

Non narcotic agents:

Acetaminophen:

Excellent adjunct to opioids, although almost never adequate for analgesia alone. No effect on platelet functiondose is 10 mg/kg for children to a maximum of 6gm/day for adults. Some opioids contain acetaminophen in addition to the opioid such as percocet, tylox, vicodin, and obviously tylenol with codeine. Rectal administration (used mostly in younger children) requires a loading dose of 30 mg /kg as an initial dose to achieve therapeutic drug levels.

Nsaids:Cox2 inhibitors, (VIOX, Celebrex),Ibuprofen,Ketorelac

May be helpful adjuncts in certain patients. Side effects include gastric irritation, antiplatelet effects and decreased renal perfusion. Ketorelac is the most potent because of its formulation as an intravenous agent. It is recommended to limit. Ketorelac to 72hrs because of its side effect profile. The newer COX2 inhibitors have less of an effect on gastric mucosa and renal function, although there still is the potential for the above side effects. Viox is available in liquid form.

Sedatives (Benzodiazepines,Antihistamines)

Sedatives may be helpful for patients who are extremely anxious. They should not substitute for opioids as they are not analgesic. Also there is a multiplicitive effect on respiratory depression when combined with opioids, so continuous monitoring may be necessary. They may also be helpful for pruritis.

Opioids

Weak Opioids

Codeine: Comes mixed with acetaminophen, or alone. The dose is1mg/kg PO and may be given q4-hrs. It is very nauseating and many patients report this as an allergic reaction ( which it isn’t). Has many active metabolites and is much less potent/pure than oxycodone.

Oxycodone (Percocet, tylox, oxycotin): The dose is 0.1 mg/kg, and comes mixed with acetaminophen. It has a lower incidence of nausea and vomiting compared to codeine or vicodin.

Codeine : It is available in a liquid form for smaller children.

Hydrocodone: (Vicodin, Lortab) This drug is popular because unlike oxycodone, it does not require triplicates to prescribe it. It is similar in side effect profile to codeine.

Potent Opioids

Morphine : The gold standard for opioids. Usual starting doses are 0.1 mg/kg. Available in IV, PO, and sustained release forms.

Hydromorphone: Similar to morphine, but has less active metabolites and less side effects. It is 5 times more potent!, than Morphine. Dose varies but starting doses of 0.02 mg /kg are common.

Fentanyl: Potent synthetic opioid, with rapid onset and relatively short duration. This is an excellent drug for rapidly stabilizing a patient in severe pain. Rapid infusion of large doses may cause chest wall rigidity. At present fentanyl no PO form is available.

Methadone: Available in both IV and PO forms. Used mainly to convert IV therapy to PO. Difficult to dose.

Patient Controlled Analgesia (PCA) (click here to see UCSD pediatric PCA pain form)

Any intravenous opioid can be given via PCA. The most common are morphine, hydromorphone, and fentanyl. See the protocol for recommended drug doses, and lock out times. Patient preferences are very variable to drug, dose and other parameters of PCA administration. Good results are obtained by taking the patients feedback about the amount of analgesia and adjusting the PCA accordingly. Please note that the recommended starting doses on the pediatric PCA form were designed t=to meet the needs of all pain patients and may be extremely ineffective in opioid tolerant patients. Sickle cell pateints often exceed these doses by 10 times! The doses may need to be increased rapidly to provide adequate analgesia, and frequent reassessment is the key to providing adequate analgesia.