What is the best pain management option for a patient with a history of allergy to morphine, experiencing increasing stabbing pain in the front and side of the left ribs, shortness of breath (SOB), and impaired respiratory function, who prefers Toradol (ketorolac) and wishes to avoid narcotics?

Pain Management for Severe Rib Pain with Morphine Allergy

Ketorolac (Toradol) is appropriate for your acute rib pain, but it must be limited to 5 days maximum and requires careful monitoring given the severity of your pain and respiratory symptoms. 1

Immediate Ketorolac Prescribing Strategy

• Start with ketorolac 30 mg IM as a loading dose, followed by 15-30 mg IM or oral every 6 hours for pain control, with a maximum of 120 mg/day after the first day 1, 2
• The FDA explicitly limits ketorolac use to ≤5 days total duration due to increased risk of gastrointestinal bleeding, renal impairment, and operative site bleeding with longer use 1
• Ketorolac provides analgesia equivalent to standard doses of morphine and meperidine for moderate-to-severe pain, though onset may be delayed 30-60 minutes 3, 4

Critical Limitation You Must Understand

• Ketorolac has a significant failure rate—more than 25% of patients obtain little or no response in acute severe pain 4
• If your pain remains at level 8 after 60 minutes of ketorolac administration, you will need alternative or supplemental analgesia 4

Alternative Opioid Options (Given Morphine Allergy)

Since you are allergic to morphine but wish to avoid narcotics, you need to understand that "avoiding narcotics" may not be realistic for pain level 8 with increasing severity:

• Hydromorphone or oxycodone are alternative opioids that can be used when morphine causes allergy or intolerance 5
• These are structurally different from morphine and may not trigger the same allergic response, depending on the nature of your morphine allergy 5
• Fentanyl patches are another option for severe pain, though they require 12-24 hours to reach therapeutic levels and are not ideal for acute escalating pain 5

Multimodal Analgesia to Maximize Ketorolac Effectiveness

• Combine ketorolac with scheduled acetaminophen (1000 mg every 6-8 hours) to enhance analgesia through different mechanisms 5
• This combination approach can reduce opioid requirements by 25-50% if opioids become necessary 3
• Avoid exceeding 4000 mg acetaminophen daily to prevent hepatotoxicity 6

Monitoring Requirements Given Your Symptoms

• Your shortness of breath and stabbing rib pain require evaluation for serious causes (pneumothorax, pulmonary embolism, rib fracture) before relying solely on analgesia
• Ketorolac can mask symptoms of serious underlying conditions 1
• If you experience worsening SOB, hemoptysis, or syncope, seek emergency evaluation immediately rather than escalating pain medication

Safety Precautions Specific to Ketorolac

• Risk of gastrointestinal bleeding increases significantly with doses >60 mg/day and use beyond 5 days, particularly if you are over 65 years old 1, 7
• Ketorolac causes reversible platelet inhibition and may increase bleeding time, though this rarely causes clinical problems outside of surgical settings 8, 7
• Acute renal failure can occur but is usually reversible with drug discontinuation 1, 7
• Contraindications include active GI bleeding, renal impairment, coagulation disorders, and aspirin/NSAID allergy 7

What Happens After 5 Days

• You must transition to alternative analgesia before completing 5 days of ketorolac 1
• Options include:
  • Oral NSAIDs (ibuprofen 600-800 mg every 6-8 hours) combined with acetaminophen 5
  • Alternative opioids if pain remains severe (hydromorphone, oxycodone) 5
  • Adjuvant analgesics such as gabapentin if neuropathic component develops 5

Common Pitfall to Avoid

• Do not assume ketorolac will provide the same rapid relief as opioids—it requires 30-60 minutes for onset and may not adequately control level 8 pain in all patients 4, 2
• Do not continue ketorolac beyond 5 days even if pain persists, as serious adverse events increase dramatically 1
• Do not use ketorolac as monotherapy if pain is escalating daily—this suggests a progressive process requiring diagnostic evaluation, not just stronger analgesia 1