What are the guidelines for pain management in a hospital setting?

Hospital Pain Management Guidelines

All hospitalized patients should undergo systematic pain assessment using validated tools at admission and every 4 hours thereafter, with analgesic treatment initiated immediately without waiting for definitive diagnosis, prioritizing multimodal therapy combining scheduled acetaminophen with opioids titrated to effect. 1

Core Assessment Principles

Patient self-report is the gold standard for pain assessment and must include pain intensity using validated scales (0-10 Numeric Rating Scale, Visual Analog Scale, or Verbal Rating Scale), pain quality (aching/throbbing for somatic, cramping/gnawing for visceral, shooting/stabbing for neuropathic), temporal patterns, functional impact, and response to prior analgesics. 1

High-Risk Populations Requiring Special Attention

• Pediatric patients, elderly, and cognitively impaired are at highest risk for inadequate pain management and require behavioral pain assessment tools (Behavioral Pain Scale or Critical-Care Pain Observation Tool) when unable to self-report. 1

• Cultural differences in pain expression must be acknowledged, as optimal treatment is enhanced by recognizing these variations. 1

Comprehensive Assessment Components

Pain assessment must document: 1

• Pain characteristics: onset, location, radiation, duration, intensity at rest and with movement, breakthrough pain frequency
• Associated factors: trigger factors, relieving factors, impact on sleep/appetite/mood/function
• Patient factors: comorbidities (hepatic/renal impairment), concurrent medications, substance use history, psychological distress
• Psychosocial distress amplifies pain perception and must be evaluated alongside physical pain 1

Treatment Initiation

Analgesic management must begin as soon as possible when indicated—diagnosis of pain etiology should NOT delay administration of analgesics. 1 This principle applies even to abdominal pain, where pain medication has been demonstrated to preserve diagnostic ability. 1

Pain Categorization Guides Treatment Selection

Classify pain as: 1

• Acute pain (trauma, post-operative)
• Acute exacerbation of recurring condition
• Chronic/persistent pain
• Cancer pain

Each category requires different intervention pathways, including consideration for long-term pain management referrals or social service interventions. 1

Pharmacologic Management Algorithm

First-Line Multimodal Approach

Start with scheduled acetaminophen 1000 mg IV every 6 hours (maximum 4g/day) as the foundation, then add opioids based on pain severity. 2, 3 This multimodal approach reduces opioid requirements and improves outcomes. 3

Opioid Selection and Dosing

For moderate to severe pain, initiate IV fentanyl 0.35-0.5 μg/kg bolus, followed by continuous infusion 0.7-10 μg/kg/hr if pain persists. 2, 3, 4 Fentanyl is preferred due to minimal hemodynamic effects and rapid onset. 2

Alternative: Hydromorphone 0.2-0.6 mg IV bolus, followed by infusion 0.5-3 mg/hr, particularly for patients tolerant to morphine/fentanyl, though it may accumulate with hepatic/renal impairment. 2

Morphine 0.1-0.2 mg/kg IV every 4 hours can be used but requires slow administration to avoid chest wall rigidity and has greater hemodynamic effects than fentanyl. 4

Adjunctive Therapies for Refractory Pain

Low-dose ketamine (0.5 mg/kg IV push, then 1-2 μg/kg/hr infusion) should be added when seeking to reduce opioid consumption, particularly for procedural pain. 2, 3

Special Dosing Considerations

Patients with hepatic cirrhosis or renal failure require lower starting doses with slow titration and careful monitoring, as morphine pharmacokinetics are significantly altered. 4

Non-Pharmacologic Interventions

Healthcare settings must have both pharmacologic agents AND non-pharmacologic interventions readily available. 1 Evidence supports: 5

• Hypnosis, acupuncture, and natural sounds for pain intensity reduction
• Heat application for muscle relaxation in pediatric patients 6
• Distraction techniques particularly effective in children 6
• Family presence during procedures is viable and useful in acute care 1

Protocol Development and Quality Improvement

Hospitals must develop physician/nurse-developed, nurse-initiated analgesic protocols with measurement of patient response as required by accrediting agencies. 1

Essential Protocol Components

• Pain assessment begins at EMS/admission and continues until discharge 1
• Reassess pain scores every 4 hours minimum and before/after each intervention 3
• Document both patient self-report and nursing assessment to identify discrepancies 7, 8
• Quality improvement programs must review pain management practices at regular intervals 1

Critical Pitfalls to Avoid

Addiction vs. Pseudo-addiction

Aberrant behaviors do NOT equate with addictive disease and may indicate under-treatment of pain. 1 Pseudo-addiction (drug-seeking behavior that resolves with adequate analgesia) is caused by inadequate pain management, not true addiction. 1

All patients should be treated appropriately for pain reports, including those with known addictive disease, with consideration for brief intervention and substance abuse treatment referrals. 1

Medication Safety

Avoid COX-1 selective NSAIDs in GI bleeding patients as they may worsen bleeding. 2 IV lidocaine is NOT recommended as an adjunct due to safety concerns outweighing benefits. 2

Take extreme care with morphine dosing to avoid confusion between concentrations and between mg and mL—prescriptions must include both total dose in mg AND total volume. 4

Undertreatment Risks

Neonates and young infants require adequate pain prophylaxis—do not withhold based on age. 1 Pain medication administration should be as painless as possible, using appropriate techniques. 1

Discharge Planning

At discharge, patients must receive written instructions with an individualized pain treatment plan, including medication-specific safety considerations and follow-up arrangements. 1