Opioids and Adjuvants

In the acute setting, frequent small doses of intravenous opioids may be used. Hydromorphone, morphine, and fentanyl are all acceptable choices, while meperidine should be avoided because of the potential accumulation of active metabolites and reduction in seizure threshold. Individual patients will have different opioid requirements so doses must be carefully titrated to effect in order to achieve analgesia. Trauma is more likely to occur in young males, individuals with psychiatric disorders, and those with substance abuse problems. Although these patients often require high doses of opioids, and are at increased risk for addiction and aberrant behaviors, there is a clear consensus that these concerns should not affect the short-term goal of adequate pain control (Bourne et al. 2008). In patients who receive parenteral opioids, there is strong evidence that the use of PCA is associated with better pain relief and less side effects than PRN administration. Specific issues that may need to be addressed depending on the circumstances include opioid-hyperalgesia, pain intolerance, poor coping skills, and withdrawal in those with opioid or other drug dependencies. In these cases, the use of multimodal analgesic regimens that include adjuvants, non-steroid anti-inflammatory drugs, ketamine, and regional anesthesia should be implemented whenever possible (Table 19.5).

Table 19.5 Sample pain regiments for the trauma patient.

Initial presentation

Morphine 1-4 mg q1 h Hydromorphone 0.5-1 mg q1 h Fentanyl 25-50 mcg q20-30 min

Intensive care unit (intubated or sedated)

Hospital floor

NPO

Tolerating PO

Background pain Breakthrough pain

Fentanyl 1-2 mcg/kg/h infusion

Morphine 2-10 mg q2 h prn Fentanyl 25-100 mcg q1 h prn Hydromorphone 0.5-2 mg q2 h prn

Opioids via PCA Methadone

Continous ketamine infusion

Hydromorphone PCA 0/0.2/6 Morphine PCA 0/1/6

Scheduled long-acting oral opioids (MsContin, OxyContin), Methadone NSAIDs

PRN oral opioids

NPO = nil per os; PCA = patient-controlled analgesia; NSAIDs = non-steroidal anti-inflammatory drugs.

NPO = nil per os; PCA = patient-controlled analgesia; NSAIDs = non-steroidal anti-inflammatory drugs.

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