Pain Management
Pain Management
Pain is what the patient says it is, and total pain includes physical, emotional, social, and spiritual components. Classify nociceptive (somatic or visceral) versus neuropathic pain; neuropathic pain often needs an adjuvant such as a gabapentinoid, TCA, or SNRI plus an opioid. Know around-the-clock dosing for persistent pain, breakthrough dosing, and reassessment. Opioid selection depends on renal and hepatic function, route, prior exposure, and goals. Avoid meperidine; use morphine cautiously in renal impairment because metabolites accumulate. Constipation is expected, and tolerance does not develop to it, so prophylaxis is routine. Nausea and sedation often lessen; myoclonus, hyperalgesia, or worsening sedation can signal opioid-induced neurotoxicity and prompt rotation or dose reduction.
Traps: labeling a patient as addicted when requesting medication, which may be pseudoaddiction from undertreated pain; confusing tolerance, physical dependence, and addiction; using NSAIDs without considering renal or GI risk; ignoring a bowel regimen; and treating neuropathic pain with opioid escalation alone. Do not withhold opioids for fear of respiratory depression in appropriately titrated doses; assess sedation and respiratory rate.
Worked example/rule of thumb: for a patient on 60 mg oral morphine equivalents per day with stable persistent pain and three breakthrough episodes daily, calculate breakthrough as roughly 10 to 20 percent of the total daily dose (6 to 12 mg oral morphine equivalent) and reassess after 24 hours. If pain remains uncontrolled or toxicity appears, reevaluate mechanism and consider rotation. Rule: treat, reassess, and document function, not just the pain score.