Innovations in End-of-Life Care
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Guidelines for Analgesic Drug Orders

Purpose: The following criteria will serve as a guide for evaluating analgesic orders. The purpose is to assure appropriate use of analgesics based upon individual patient assessment. These guidelines are adapted from the AHCPR Standards for Acute and Cancer Pain Management.^1,2

Critical Points:

1. The character of the pain has been documented on assessment, so that the health care provider writing the medical orders can determine the type of pain the patient is experiencing. For example, burning, shooting pain has been characterized as neuropathic.
2. Drugs used for pain management are based upon severity of pain.
3. If an opioid is required for severe pain, morphine is the drug of choice. For acute pain, the route of choice is IV; for chronic pain, the route is po. If a patient is unable to take po medications, IV, subcutaneous, buccal, sublingual, rectal, and transdermal routes are considered before IM.
4. Patients who report constant pain should receive long-acting medication, with a short-acting medication ordered prn for breakthrough pain.
5. Long acting oral analgesic agents are not used for the management of acute post operative pain. (first 48-72 hrs)
6. Patients who report intermittent pain have medications ordered on a prn basis.
7. Only one combination analgesic (opioid and non opioid, e.g., Vicodin, Tylenol #3) is ordered for prn breakthrough pain.
8. Only one opioid is ordered for continuous moderate to severe pain (e.g., continuous opioid infusion or MS Contin or Oramorph SR or Kadian or OxyContin, or Duragesic.)
9. Short acting po opioids are ordered at intervals no longer than 4 hours.
10. Consider using adjuvant analgesics for non-opioid responsive neuropathic pain.
11. An appropriate plan for a bowel regimen is ordered.
12. A plan is in place for a pharmacologic and/or non-pharmacologic intervention for patients prior to activities that are reported to cause or increase pain.
13. A pain management flow sheet is initiated on all patients rating pain as moderate, that is ³ 5/10, ³ 3/5, or ³ 2/3 on admission.
14. Orders for non-pharmacologic interventions are present and are clearly stated as part of the nursing and medical plan of care.
15. Meperidine (Demerol) is used only for short-term procedural pain. Doses of greater than 600mg per 24 hours should be avoided.
16. Propoxyphene (Darvocet N, Darvon) is avoided due to weak analgesic effect and potential toxicity.³

Sources:

1. Acute Pain Management Guideline Panel. Acute Pain Management: Operative or medical procedures and trauma. Clinical Practice Guideline. AHCPR Pub. No. 92-0032. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, Feb. 1992. [Return to Tool]

2. Jacox A, Carr DB, Payne R, et al. Management of Cancer Pain Clinical Practice Guideline No. 9. AHCPR Publication No. 94-0592. Rockville, MD. Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Public Health Service, March 1994. 2/26/97.[Return to Tool]

3. Inturrisi, C, Colburn, W, Verebey, K, Dayton, H., Woods, G., O’Brien, C. Propoxyphene and norpropoxyphene kinetics after single and repeated doses of propoxyphene. Clinical Pharmacology and Therapeutics. February 1982:(157-167). [Return to Tool]