What is the best alternative for managing severe burn pain in a patient with a morphine (opioid) allergy?

Management of Severe Burn Pain in Patients with Morphine Allergy

For patients with severe burn pain who have a morphine allergy, hydromorphone or oxycodone are the recommended first-line alternatives, with fentanyl being another effective option when parenteral administration is required. 1

Alternative Opioid Options

First-Line Alternatives:

• Hydromorphone: Indicated for patients with severe pain when there is resistance or intolerance to morphine 1

  • Approximately 7.5 times more potent than oral morphine
  • Starting dose without pretreatment: 8 mg oral 1
  • No upper limit for dosing as long as side effects can be controlled

• Oxycodone: Another effective alternative for severe pain when morphine cannot be used 1

  • 1.5-2 times more potent than oral morphine
  • Starting dose without pretreatment: 20 mg oral 1
  • Available in both immediate-release and modified-release formulations

Second-Line Options:

• Fentanyl:

  • Transdermal patches best for stable pain requirements 1
  • Particularly useful for patients unable to swallow or with poor compliance 1
  • Intranasal fentanyl has shown similar efficacy to oral morphine for procedural burn pain 2
  • Starting dose: 12 μg/h transdermal 1
  • Approximately 4 times more potent than oral morphine

• Alfentanil:

  • Useful for procedural pain during dressing changes 3
  • Quick onset and short duration of action
  • Administered as IV boluses of 500 (±250) mcg

Non-Opioid Adjuncts

Always incorporate non-opioid analgesics as part of multimodal pain management:

• Acetaminophen/Paracetamol:

  • 1000 mg every 4-6 hours (maximum 4-6 g daily) 1, 4
  • First-line for mild pain, adjunct for moderate to severe pain

• NSAIDs (if no contraindications):

  • Options include ibuprofen (600 mg QID), diclofenac (50 mg QID), or naproxen (500 mg BID) 1
  • Use gastroprotection when used long-term

Pain Management Protocol

1. Initial Assessment:

   • Cool burns with clean running water for 10-20 minutes 4
   • Remove contaminated clothing or jewelry 4
   • Assess burn severity (depth, TBSA, location)

2. For Severe Pain:

   • Start with IV hydromorphone or IV oxycodone if parenteral route needed
   • For stable patients, oral hydromorphone or oxycodone can be used
   • Titrate to effect as rapidly as possible 1

3. Dosing Strategy:

   • Provide around-the-clock dosing with breakthrough doses 1
   • Breakthrough dose = approximately 10% of total daily dose 1
   • If more than 4 breakthrough doses needed per day, increase baseline dose 1

4. For Procedural Pain (dressing changes):

   • Consider IV alfentanil for short procedures 3
   • Patient-controlled intranasal fentanyl is effective for wound care procedures 2

Important Considerations

• Cross-Sensitivity: Patients with true morphine allergy may have cross-sensitivity to other opioids, particularly those in the same structural class

• Monitoring: Closely monitor for adverse effects including respiratory depression, hypotension, and sedation

• Opioid-Induced Hyperalgesia: Long-term opioid use may lead to increased pain sensitivity 5, requiring rotation to different agents

• Wound Care: Apply silver sulfadiazine cream to second and third-degree burns and cover with sterile, non-adherent dressing 4

Special Situations

• Extensive Burns: Initiate IV fluid resuscitation for burns >20% TBSA in adults 4

• Anxiety Management: Pain management should address anxiety, which is often severe in burn patients 6

• Chronic Pain Prevention: Early and adequate pain control helps prevent chronic pain development

By following this approach, most burn patients can achieve satisfactory pain relief despite having a morphine allergy, using alternative opioids within a multimodal pain management strategy.