When should I administer another pain reliever to a patient with inadequate pain control?

When to Administer Another Pain Reliever for Inadequate Pain Control

For patients with inadequate pain control, reassess pain intensity and administer additional pain medication at specific time intervals based on the route of administration: every 60 minutes for oral opioids and every 15 minutes for intravenous opioids. 1

Timing of Reassessment and Redosing

For Oral Pain Medications

• Reassess pain and side effects every 60 minutes after oral opioid administration to determine if another dose is needed 1
• If pain score remains ≥4 or unchanged after 60 minutes, administer 50-100% of the previous rescue dose 1
• If pain score decreases to 4-6, repeat the same dose and reassess again in 60 minutes 1

For Intravenous Pain Medications

• Reassess pain and side effects every 15 minutes after IV opioid administration 1
• If pain score is unchanged or increased after 15 minutes, give 50-100% of the previous rescue dose 1
• If pain score decreases to 4-6, repeat the same dose and reassess in 15 minutes 1

Dosing Strategy Based on Opioid Tolerance Status

Opioid-Naïve Patients

• Start with 5-15 mg oral morphine or 1-5 mg IV morphine (or equivalent) for pain intensity ≥4 1
• Follow the 60-minute (oral) or 15-minute (IV) reassessment intervals described above 1

Opioid-Tolerant Patients

• Calculate the previous 24-hour total opioid requirement 1
• Increase rescue doses by 10-20% of the 24-hour total dose for breakthrough pain 1
• Use the same reassessment intervals: 60 minutes for oral, 15 minutes for IV 1
• If pain remains unchanged after 2-3 cycles of dosing, consider changing the route from oral to IV or implementing alternate strategies 1

Critical Principle: Scheduled vs. As-Needed Dosing

Analgesic dosing should be continuous or scheduled rather than as-needed, because allowing pain to reemerge before administering the next dose causes unnecessary suffering and anxiety. 1

• For continuous pain, administer pain medication on a regular schedule with supplemental doses for breakthrough pain 1
• Provide rescue doses of short-acting opioids at 10-20% of the 24-hour oral dose for breakthrough pain 1

Common Pitfalls to Avoid

• Never wait for pain to return to severe levels before redosing - this increases suffering and makes subsequent pain control more difficult 1
• Do not use mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) in patients on opioid maintenance therapy, as these will precipitate withdrawal 1
• Avoid extending reassessment intervals beyond the recommended timeframes, as undertreating acute pain leads to decreased opioid responsiveness 1

Non-Opioid Considerations

For non-opioid analgesics:

• Ketorolac oral: administer every 4-6 hours as needed, not to exceed 40 mg/day, with total treatment duration not exceeding 5 days 2
• Acetaminophen: administer every 8 hours, not exceeding 6 caplets (typically 3900 mg) in 24 hours 3
• Consider multimodal analgesia with NSAIDs and acetaminophen to reduce total opioid requirements 1