Pain Management

Assessment and Treatment

For patients with mild pain, non-opioid analgesics, such as acetaminophen or NSAIDs, are recommended as first-line treatment due to their better numbers needed to treat (2.7) and longer time to re-medication with a safer side effect profile, as stated by the American College of Critical Care and the American Academy of Dermatology 1, 2, 3, 4
Opioids, such as immediate release oxycodone, are recommended for moderate to severe pain, with the CDC and American College of Emergency Physicians strongly preferring immediate release formulations over extended-release or long-acting opioids, such as methadone or fentanyl patches, for initial opioid pain management 5, 6, 7
Immediate release opioids allow for easier dose titration to achieve pain control, as stated by the National Comprehensive Cancer Network, and are indicated for acute pain, while long-acting or extended-released schedule II products are indicated for chronic pain 8
Fentanyl patches are only recommended for patients who are already opioid-tolerant, have severe, persistent, and stable pain, and are well-controlled on short-acting opioids, as stated by the National Comprehensive Cancer Network, and should not be used for acute or unstable pain requiring frequent dose changes 8

For opioid-naïve patients with moderate pain, start with hydrocodone/acetaminophen 5mg/325mg, 1 tablet every 4-6 hours as needed, based on guidelines from the American College of Emergency Physicians, while patients with prior opioid exposure may require higher doses, such as hydrocodone/acetaminophen 7.5mg/325mg or oxycodone/acetaminophen 5mg/325mg 6
Initial IV dosing for fentanyl is 25-50 mcg (0.5-1 mcg/kg) IV every 30-60 minutes as needed, while initial IV dosing for hydromorphone is 0.2-0.6 mg IV every 2-3 hours as needed, as stated by the National Comprehensive Cancer Network 8
Acetaminophen should be limited to less than 4000mg daily to prevent hepatotoxicity, as recommended by the National Comprehensive Cancer Network 9

Constipation, nausea/vomiting, respiratory depression, and sedation are common side effects of opioid therapy, and should be managed with prophylactic bowel regimens, metoclopramide or antidopaminergic drugs, close monitoring, and dose reduction or psychostimulants as needed, as stated by the Annals of Oncology, and the American Society of Clinical Oncology recommends assessing pain intensity regularly and monitoring for common opioid side effects 10, 11, 12, 13
Respiratory depression and hypotension should be monitored closely with both morphine and fentanyl, though the risk appears similar, and can be treated with mu receptor antagonists (naloxone) promptly if needed, as stated by the Annals of Oncology and the American Society of Clinical Oncology 9, 11

Patients with renal impairment require dose adjustment or alternative opioids, with hydromorphone and fentanyl being preferred options, and should use morphine with caution due to metabolite accumulation, as supported by the American College of Critical Care and other authorities 10, 9, 11, 14
Elderly patients should start at lower doses (25-50% of standard adult dose) and be titrated more slowly, with closer monitoring for adverse effects, as recommended by the American Society of Clinical Oncology and the National Comprehensive Cancer Network 10, 13, 11
Genetic polymorphisms affecting CYP2D6 can reduce codeine efficacy in 7-10% of Caucasians and up to 30% of Asians, as reported by the American Society of Clinical Oncology 15