What is the recommended approach to pain management for hospitalized patients?

Pain Management for Hospitalized Patients

Hospitalized patients should receive routine pain assessment using validated tools, with treatment prioritizing an analgesia-first multimodal approach that combines scheduled opioids (when indicated) with non-opioid adjuncts and non-pharmacological interventions, while avoiding as-needed dosing and benzodiazepines. 1

Core Assessment Strategy

• Implement routine pain monitoring using validated scales in all hospitalized patients, with reassessment frequency based on clinical status 1
• For patients unable to self-report pain (ICU, intubated, cognitively impaired), use the Behavioral Pain Scale (BPS) or Critical-Care Pain Observation Tool (CPOT) rather than vital signs alone 1
• Vital signs may serve as a cue to initiate further pain assessment but should not be the sole assessment method 1
• Document pain scores systematically to ensure treatment goals are achieved 1

Pharmacological Management Framework

First-Line Opioid Therapy

• Administer IV opioids as the first-line drug class for treating non-neuropathic moderate-to-severe pain in hospitalized patients 1
• All IV opioids (morphine, fentanyl, hydromorphone) are equally effective when titrated to similar pain endpoints 1
• Use scheduled continuous dosing rather than as-needed orders to maintain consistent analgesia and avoid breakthrough pain 1
• For procedural pain, administer opioids at the lowest effective dose preemptively before procedures 1

Critical caveat: Avoid mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) as they can precipitate withdrawal in opioid-tolerant patients 1

Multimodal Non-Opioid Adjuncts

The evidence strongly supports combining multiple non-opioid agents to reduce opioid consumption and improve outcomes 1:

• Acetaminophen: Front-line agent for all patients unless contraindicated by hepatic dysfunction; provides moderate efficacy with antipyretic benefits 1
• NSAIDs (ibuprofen, ketorolac): Effective opioid-sparing agents but use cautiously in elderly patients, those with renal insufficiency, bleeding risk, or receiving nephrotoxic medications 1
• Gabapentin or carbamazepine: Add enterally for neuropathic pain components in combination with IV opioids 1
• Ketamine: Consider for opioid-sparing effects, particularly in surgical patients at high risk of opioid side effects, though monitor for delirium and agitation 1
• Lidocaine infusions: Generally well-tolerated with high safety profile, though robust efficacy data are limited 1

Special Population Considerations

For patients on methadone maintenance therapy 1:

• Continue the usual methadone maintenance dose (verify with treatment program)
• Add short-acting opioid analgesics separately for acute pain
• Higher doses at shorter intervals may be needed due to cross-tolerance
• If NPO, give methadone parenterally at half to two-thirds the oral dose divided into 2-4 doses

For patients on buprenorphine maintenance therapy 1:

• Continue buprenorphine and titrate short-acting opioids (for brief pain duration only)
• Alternative: Divide buprenorphine to every 6-8 hours for better analgesia
• For severe pain: Discontinue buprenorphine, use full agonist opioids, then reconvert when acute pain resolves
• Keep naloxone at bedside and monitor respiratory status closely

Non-Pharmacological Interventions

Integrate these evidence-based interventions as they reduce opioid consumption and improve pain scores 1, 2:

• Music therapy: Patient-selected music reduces procedural and resting pain 1, 2
• Massage therapy: Simple massage techniques decrease pain intensity and anxiety 1, 2
• Relaxation techniques: Breathing exercises and guided imagery provide measurable pain relief 1, 2
• Family presence: Facilitates emotional support and patient reorientation 1, 2
• Environmental optimization: Control noise, ensure natural light exposure, optimize room temperature 1, 2

Protocol-Based Implementation

Implement assessment-driven, protocol-based stepwise approaches that mandate 1:

• Regular pain assessment with validated tools
• Clear guidance on medication choice and dosing
• Treating pain as priority before administering sedatives (analgesia-first approach)
• Daily review of sedation needs paired with spontaneous awakening trials when applicable 1

ICU-Specific Considerations

• Target light sedation when possible (RASS ≥ -2) rather than deep sedation to reduce delirium, ventilator days, and mortality 1
• Avoid benzodiazepines as they increase delirium risk and worsen outcomes 1
• Use short-acting sedatives (dexmedetomidine, propofol) when sedation is required 1
• Implement bundled care approaches (ABCDEF bundle) that combine pain management, light sedation, delirium monitoring, and early mobilization 1

Common Pitfalls to Avoid

• Never use vital signs alone for pain assessment—they lack specificity and sensitivity 1
• Avoid as-needed dosing for continuous pain—scheduled dosing provides superior control 1
• Do not withhold opioids in patients with substance use history due to unfounded addiction concerns—undertreated pain causes worse outcomes 1
• Never combine acetaminophen-opioid products at high doses—prescribe separately to avoid hepatotoxicity 1
• Avoid abrupt opioid discontinuation—taper by 10-25% every 2-4 weeks to prevent withdrawal 3

Monitoring and Reassessment

• Reassess pain scores after each intervention to ensure efficacy 1
• Monitor for opioid-related adverse effects: respiratory depression, sedation, delirium, ileus, nausea 1
• Screen for opioid-induced hyperalgesia in patients requiring escalating doses despite treatment 1
• Evaluate for tolerance and withdrawal symptoms, particularly after prolonged use 1, 3