Level 1 Medications—Mild to Moderate Pain

Medications on the first step of the ladder are intended to manage mild to moderate pain and include acetaminophen, NSAIDs (both selective and nonselective), and adjuvant medications or coanalge-sics. Adjuvant medication that can add to pain relief, although they are not primarily classed as pain medications, include antidepres-sants, anticonvulsants, muscle relaxants, and topical medications.

Level II Medications—Moderate to Severe Pain

On the middle step of the ladder are medications intended to manage moderate to severe pain, and include combination medications with an opioid, such as hydrocodone or oxycodone, and acetaminophen. In addition, tramadol, a mixed mu agonist and selective serotonin reuptake inhibitor, is also included in this group of medications. Adjuvant medications for this level could include the muscle relaxants, antidepressants, and so forth, of the lower level, but the acetaminophen or NSAIDs of the lower level could also be used at this point for additional pain relief.

Level III Medications—Severe Pain

Patients who are reporting severe pain require strong opioid medications for pain relief. Included in this group of medications are the opioids, morphine, fentanyl, hydromorphone, and methadone. As with the other steps, adjuvant medication should be continued to help reduce opioid needs and provide additional pain relief (adapted from D'Arcy, 2007).

Clinical Although the analgesic ladder provides some guidance in the Pearl choice of medications, the overall assessment, history, and physical examination, along with comorbidities and organ functions, need to be considered when selecting a medication for pain.

It is important to remember that the patient's report of pain is more than a number. There are many pieces of the patient puzzle that need to fit together just right to achieve effective pain management. Although the severity ratings of the analgesic ladder are a guide to choosing the correct medication because there is a group of medications in each level, the practitioner can individualize the medication selection. The efficacy of the medication is an individualized response based on the patient's report of decreased pain or increased functionality (D'Arcy, 2007).


Although acetaminophen and NSAIDs are considered to be weaker medications for pain, they can provide a good baseline of relief that can help decrease the amount of opioid required to treat chronic pain. Both of these medications are seriously overlooked and underutilized as coanalgesics when higher intensity pain is reported. Multimodal analgesia, which is recommended for complex pain needs and for postoperative pain relief, may consist of any combination of medications and can include the use of acetaminophen and NSAIDs. However, there are some important considerations when adding these medications into a pain management regimen. These medications are not benign and have risk potential that should be considered when they are used with all patients. They also have maximum dose levels that create a ceiling for dose escalations.

■ Acetaminophen (APAP, Paracetamol)

Acetaminophen is used all over the world to treat pain. It is sold as Tylenol products, paracetamol in Europe, and is widely added to many over-the-counter pain relievers, such as Excedrin, Midol, and Tylenol products. It is available in many forms, such as in tablets, gel caps, elixirs, and as pediatric formulations. Most home medicine chests have some type of acetaminophen compound that the family uses for relief of minor aches and pains. Because it is so popular, there were 24.6 billion doses sold in 2008.

Acetaminophen is classed as a para-acetaminophen derivative (Nursing 2010 Drug Handbook, 2009), and it has a similar use profile to aspirin, without the potential to damage gastric mucosa (American Pain Society [APS], 2008). Pain relief efficacy of acetaminophen is superior to placebo but slightly less effective than NSAIDs (APS, 2008). The action of the medication is thought to be inhibition of prostaglandins and other pain-producing substances (Nursing 2010 Drug Handbook, 2009).

Advantages of acetaminophen over NSAIDs include the following:

■ Fewer GI adverse effects

■ Fewer GI complications

In general, acetaminophen is safe and effective when used according to the directions on over-the-counter preparation labels and any prescription-strength medication information. There are serious concerns today about acetaminophen overdoses, both intentional and uninten tional. The U.S. Food and Drug Administration (FDA) has been holding hearings and is considering reducing the recommendations for daily total dose from 4,000 mg per day to a lower limit. The FDA is considering making the 500-mg strength tablets available only by prescription and limiting the number of doses in each package (Alazraki, 2009).

The concerns underlying these fears are caused by some very serious statistics about the increase in liver disease related to acetaminophen use. There is a clear connection between acetaminophen overuse and liver disease and failure. Total acetaminophen dosage should not exceed 4,000 mg per day and should include any combination medication taken by the patient that may include acetaminophen (Trescot et al., 2008). Even at this dose, there is an associated risk of hepatotox-icity (APS, 2008).

From 1998 to 2003, acetaminophen was the leading cause of acute liver failure in the United States (Alazraki, 2009). During the interim between 1990 and 1998, there were 56,000 emergency room visits, 26,000 hospitalizations, and 458 deaths reportedly connected to acetaminophen overdoses (Alazraki, 2009). Many of these overdoses were unintentional and caused by a knowledge deficit about the "hidden" acetaminophen found in combination medications. Some of the most common prescription strength combinations with acetaminophen include the following:

Other over-the-counter medications that contain hidden acetaminophen include the following:

■ Alka-Seltzer Plus

■ Cough syrups, such as NightQuil/DayQuil cold and flu relief

■ Over-the-counter pain relievers, such as Pamprin and Midol maximum strength menstrual formula

Care should be taken with older patients, patients with impaired liver function, and any patient who uses alcohol regularly (APS, 2008; AGS, 2009). In these cases, acetaminophen doses should not exceed 2,000 mg/day, or preferably it should not be used at all (AGS, 2009). The risk of liver failure is very real. It is imperative for all patients who are taking medications containing acetaminophen to read and understand the medication administration guidelines and recommendations. Exceeding daily recommended doses of acetaminophen can have deadly consequences.

One little known impact is the effect of acetaminophen on the anticoagulant warfarin. Careful monitoring of anticoagulation should take place when a patient is taking both acetaminophen and warfarin, because acetaminophen is an underrecognized cause of over anticoagulation when these medications are used concomitantly (APS, 2008).

Aspirin is one of the oldest pain relievers known to man. It is classed as a salicylate (Nursing 2010 Drug Handbook, 2009). Before the beginning of modern medicine, salicylate-rich willow bark was used as one of the earliest forms of pain relief. Most Americans use aspirin for minor aches and pain, and because of its action on platelet activity, it has been promoted for early in-the-field treatment for patients who are experiencing a heart attack. It is also used for pain relief of osteoarthritis, rheumatoid arthritis, and for other inflammatory conditions but has been replaced by other newer NSAIDs (Nursing 2010 Drug Handbook, 2009; APS, 2008).

Aspirin is available in many different doses, but the most common dose is 500 to 1000 mg every 4 or 6 hours with a maximum dose of 4,000 g per day. It is available in buffered, sustained release, and chew-able formulations.

Despite its easy availability and high usage profile, there are some serious adverse events connected with regular aspirin use. These include the following:

■ Gastrointestinal (GI) distress

■ GI ulceration and bleeding

■ Prolonged bleeding times

■ Reye syndrome

■ Aspirin hypersensitivity

These reactions to aspirin are quite serious and in some cases life threatening. GI ulceration and bleeding can cause death. Aspirin is not recommended for children under the age of 12 because of the potential for Reye syndrome, which can develop when a child has a viral illness and aspirin is given for pain relief (APS, 2008). Aspirin hypersensitivity reactions can be minor or very severe. A minor reaction presents as a respiratory reaction with rhinitis, asthma, or nasal polyps. A smaller group of patients can get more serious reactions that include the following:

■ Angioneurotic edema

■ Hypotension

Although aspirin seems like a very simple analgesic, care should be taken with any aspirin use.

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