Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Management of Causative / Contributing Factor

Practice Recommendations:

Part B: Management

i. Management

ii. Pharmacological Management of Pain Recommendations

iii. Non–Pharmacological Management of Pain Recommendations


i. Management

Establishing a Plan for Pain Management

Recommendation 19
Establish a plan for management in collaboration with interdisciplinary team members that is consistent with individual and family goals for pain relief, taking into consideration the following factors:

  • assessment findings;
  • baseline characteristics of pain
  • physical, psychological, and sociocultural factors shaping the experience of pain;
  • etiology;
  • most effective pharmacological and non-pharmacological strategies;
  • management interventions; and
  • current and future primary treatment plans.

Grade of Recommendation = C

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Recommendation 20
Provide individuals and families/care providers with a written copy of the treatment plan to promote their decision-making and active involvement in the management of pain. The plan will be adjusted according to the results of assessment and reassessment.

Changes to the treatment plan will be documented and communicated to everyone involved in the implementation of the plan.

Grade of Recommendation = A

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ii. Pharmacological Management of Pain Recommendations

Selecting Appropriate Analgesics

Recommendation 21
Ensure that the selection of analgesics is individualized to the person, taking into account:

  • the type of pain (acute or chronic, nociceptive and/or neuropathic);
  • intensity of pain;
  • potential for analgesic toxicity (age, renal impairment, peptic ulcer disease, thrombocytopenia);
  • general condition of the person;
  • concurrent medical conditions;
  • response to prior or present medications;
  • cost to the person and family; and
  • the setting of care.

Grade of Recommendation = A

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Recommendation 22
Advocate for use of the simplest analgesic dosage schedules and least invasive pain management modalities:

  • The oral route is the preferred route for chronic pain and for acute pain as healing occurs.
  • Tailor the route to the individual pain situation and the care setting.
  • Intravenous administration is the parenteral route of choice after major surgery, usually via bolus and continuous infusion.

Grade of Recommendation = C

  • The intramuscular route is not recommended for adults or infants⁄children because it is painful and not reliable.

Grade of Recommendation = B

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Recommendation 23
Use a step-wise approach in making recommendations for the selection of analgesics which are appropriate to match the intensity of pain:

  • The use of the WHO Analgesic Ladder is recommended for the treatment of chronic cancer pain.
  • Pharmacological management of mild to moderate postoperative pain begins with acetaminophen or NSAIDS. However, moderate to severe pain should be treated initially with an opioid analgesic.

Grade of Recommendation = B

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Recommendation 24
Advocate for consultation with a pain management expert for complex pain situations which include, but are not limited to:

  • pain unresponsive to standard treatment;
  • multiple sources of pain;
  • mix of neuropathic and nociceptive pain; and
  • history of substance abuse.

Grade of Recommendation = C

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Recommendation 25
Recognize that acetaminophen or nonsteroidal, anti-inflammatory drugs (NSAIDS) are used for the treatment of mild pain and for specific types of pain as adjuvant analgesics unless contraindicated.

Grade of Recommendation = A

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Recommendation 26
Recognize that adjuvant drugs are important adjuncts in the treatment of specific types of pain.

  • Adjuvant drugs such as anticonvulsants and antidepressants provide independent analgesia for specific types of pain.
  • Extra caution is needed in administering antidepressant and anticonvulsant drugs to the elderly who may experience significant anticholinergic and sedative side effects.

Grade of Recommendation = B

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Recommendation 27
Recognize that opioids are used for the treatment of moderate to severe pain, unless contraindicated, taking into consideration:

  • previous dose of analgesics;
  • prior opioid history;
  • frequency of administration;
  • route of administration;
  • incidence and severity of side effects;
  • potential for age related adverse effects; and
  • renal function.

Grade of Recommendation = A

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Recommendation 28
Consider the following pharmacological principles in the use of opioids for the treatment of severe pain:

  • Mixed agonist-antagonists (eg. pentazocine) are not administered with opioids because the combination may precipitate a withdrawal syndrome and increase pain.
  • The elderly generally receive greater peak and longer duration of action from analgesics than younger individuals, thus dosing should be initiated at lower doses and increased more slowly ("careful titration(").
  • Special precautions are needed in the use of opioids with neonates and infants under the age of six months. Drug doses, including those for local anaesthetics, should be calculated carefully based on the current or most appropriate weight of the neonate. Initial doses should not exceed maximum recommended amounts.

Grade of Recommendation = B

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Recommendation 29
Recognize that meperidine is contraindicated for the treatment of chronic pain.

  • Meperidine is not recommended for the treatment of chronic pain due to the build-up of the toxic metabolite normeperidene, which can cause seizures and dysphoria.
  • Meperidine may be used in acute pain situations for very brief courses in otherwise healthy individuals who have not demonstrated an unusual reaction (ie. local histamine release at the infusion site) or allergic response to other opioids such as morphine or hydromorphone.
  • Meperidine is contraindicated in patients with impaired renal function.

Grade of Recommendation = A

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Optimizing Pain Relief with Opioids

Recommendation 30
Ensure that the timing of analgesics is appropriate according to personal characteristics of the individual, pharmacology (ie. duration of action, peak-effect and half-life) and route of the drug.

Grade of Recommendation = A

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Recommendation 31
Recognize that opioids should be administered on a regular time schedule according to the duration of action and depending on the expectation regarding the duration of severe pain.

  • If severe pain is expected for 48 hours post-operatively, routine administration may be needed for that period of time. Late in the post-operative course, analgesics may be effective given on an "as needed" basis.
  • In chronic cancer pain, opioids are administered on an “around-the-clock” basis, according to their duration of action.
  • Long-acting opioids are more appropriate when dose requirements are stable.

Grade of Recommendation = A

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Recommendation 32
Use principles of dose titration specific to the type of pain to reach the analgesic dose that relieves pain with a minimum of side effects, according to:

  • cause of the pain;
  • individual’s response to therapy;
  • clinical condition;
  • concomitant drug use;
  • onset and peak effect;
  • duration of the analgesic effect;
  • age; and
  • known pharmacokinetics and pharmacodynamics of the drugs administered. Doses are usually increased every 24 hours for persons with chronic pain on immediate release preparations, and every 48 hours for persons on controlled release opioids. The exception to this is transdermal fentanyl, which can be adjusted every 3 days.

Grade of Recommendation = B

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Recommendation 33
Promptly treat pain that occurs between regular doses of analgesic (breakthrough pain) using the following principles:

  • Breakthrough doses of analgesic in the post-operative situation are dependent on the routine dose of analgesic, the individual’s respiratory rate, and the type of surgery, and are usually administered as bolus medications through PCA pumps.
  • Breakthrough doses of analgesic should be administered to the person on an “as needed” basis according to the peak effect of the drug (po/pr = q1h; SC/IM = q 30 min; IV = q 10-15 min).
  • It is most effective to use the same opioid for breakthrough pain as that being given for “around-the-clock” dosing.
  • Individuals with chronic pain should have:
  • An immediate release opioid available for pain (breakthrough pain) that occurs between the regular administration times of the “aroundthe- clock” medication.
  • Breakthrough doses of analgesic for continuous cancer pain should be calculated as 10-15 per cent of the total 24-hour dose of the routine “around-the-clock” analgesic.
  • Breakthrough analgesic doses should be adjusted when the regular “around-the-clock” medication is increased.
  • Adjustment to the “around-the-clock” dose is necessary if more than 2-3 doses of breakthrough analgesic are required in a 24-hour period, and pain is not controlled.

Grade of Recommendation = C

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Recommendation 34
Use an equianalgesic table to ensure equivalency between analgesics when switching analgesics. Recognize that the safest method when switching from one analgesic to another is to reduce the dose of the new analgesic by one-half in a stable pain situation.

Grade of Recommendation = C

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Recommendation 35
Ensure that alternate routes of administration are prescribed when medications cannot be taken orally, taking into consideration individual preferences and the most efficacious and least invasive route.

  • The indications for transdermal routes of medication include allergy to morphine, refractory nausea and vomiting, and difficulty swallowing.
  • Consider using continuous subcutaneous infusion of opioids in individuals with cancer who are experiencing refractory nausea and vomiting, inability to swallow, or require this route to avoid continuous peaks and valleys in pain control.
  • The cost of medications and the technology necessary for delivery (e.g. pain pumps) should be taken into consideration in selecting certain alternative routes of administration.
  • Consider using a butterfly injection system to administer intermittent subcutaneous analgesics.
  • Epidural access must be managed by clinicians with appropriate

Grade of Recommendation = C

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Recommendation 36
Recognize the difference between drug addiction, tolerance and dependency to prevent these from becoming barriers to optimal pain relief.

Grade of Recommendation = A

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Monitoring for safety and efficacy

Recommendation 37
Monitor persons taking opioids who are at risk for respiratory depression recognizing that opioids used for people not in pain, or in doses larger than necessary to control the pain, can slow or stop breathing.

  • Respiratory depression develops less frequently in individuals who have their opioid doses titrated appropriately. Those who have been taking opioids for a period of time to control chronic or cancer pain are unlikely to develop this symptom.
  • The risk of respiratory depression increases with intravenous or epidural administration of opioids, rapid dose escalation, or renal impairment.

Grade of Recommendation = A

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Recommendation 38
Monitor persons taking opioids who are at risk for respiratory depression recognizing that opioids used for people not in pain, or in doses larger than necessary to control the pain, can slow or stop breathing.

Grade of Recommendation = C

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Recommendation 39
Evaluate the efficacy of pain relief with analgesics at regular intervals and following a change in dose, route or timing of administration. Advocate for changes in analgesics when inadequate pain relief is observed.

Grade of Recommendation = C

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Recommendation 40
Seek referral to a pain specialist for individuals who require increasing doses of opioids that are ineffective in controlling pain. Evaluation should include assessment for residual pathology and other pain causes, such as neuropathic pain.

Grade of Recommendation = C

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Anticipate and Prevent Common Side Effects of Opioids

Recommendation 41
Anticipate and monitor individuals taking opioids for common side effects such as nausea and vomiting, constipation and drowsiness, and institute prophylactic treatment as appropriate.

Grade of Recommendation = B

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Recommendation 42
Counsel patients that side effects to opioids can be controlled to ensure adherence with the medication regime.

Grade of Recommendation = C

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Recommendation 43
Recognize and treat all potential causes of side effects taking into consideration medications that potentiate opioid side effects:

  • Sedation – sedatives, tranquilizers, antiemetics.
  • Postural hypotension – antihypertensives, tricyclics.
  • Confusion – phenothiazines, tricyclics, antihistamines and other anticholinergics.

Grade of Recommendation = A


Anticipate and Prevent Common Side Effects of Opioids –
Nausea and Vomiting

Recommendation 44
Assess all persons taking opioids for the presence of nausea and/or vomiting, paying particular attention to the relationship of the symptom to the timing of analgesic administration.

Grade of Recommendation = C

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Recommendation 45
Ensure that persons taking opioid analgesics are prescribed an antiemetic for use on an “as needed” basis with routine administration if nausea/vomiting persists.

Grade of Recommendation = C

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Recommendation 46
Recognize that antiemetics have different mechanisms of action and selection of the right antiemetic is based on this understanding and etiology of the symptom.

Grade of Recommendation = C

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Recommendation 47
Assess the effect of the antiemetic on a regular basis to determine relief of nausea/ vomiting and advocate for further evaluation if the symptom persists in spite of adequate treatment.

Grade of Recommendation = C

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Recommendation 48
Consult with physician regarding switching to a different antiemetic if nausea/vomiting is determined to be related to the opioid, and does not improve with adequate doses of antiemetic.

Grade of Recommendation = C

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Anticipate and Prevent Common Side Effects of Opioids –
Constipation

Recommendation 49
Institute prophylactic measures for the treatment of constipation unless contraindicated, and monitor constantly for this side-effect.

  • Laxatives should be prescribed and increased as needed to achieve the desired effect as a preventative measure for individuals receiving routine administration of opioids.

Grade of Recommendation = B

  • Osmotic laxatives soften stool and promote peristalsis and may be an effective alternative for individuals who find it difficult to manage an increasing volume of pills.

Grade of Recommendation = B

  • Stimulant laxatives may be contraindicated if there is impaction of stool. Enemas and suppositories may be needed to clear the impaction before resuming oral stimulants.

Grade of Recommendation = C

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Recommendation 50
Counsel individuals on dietary adjustments that enhance bowel peristalsis recognizing personal circumstances (seriously ill individuals may not tolerate) and preferences.

Grade of Recommendation = C

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Recommendation 51
Urgently refer persons with refractory constipation accompanied by abdominal pain and/or vomiting to the physician.

Grade of Recommendation = C

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Anticipate and Prevent Common Side Effects of Opioids –
Drowsiness/Sedation

Recommendation 52
Recognize that transitory sedation is common and counsel the person and family/care provider that drowsiness is common upon initiation of opioid analgesics and with subsequent dosage increases.

Grade of Recommendation = C

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Recommendation 53
Evaluate drowsiness which continues beyond 72 hours to determine the underlying cause and notify the physician of confusion or hallucinations that accompany drowsiness.

Grade of Recommendation = C

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Anticipate and Prevent Procedural Pain

Recommendation 54
Anticipate pain that may occur during procedures such as medical tests and dressing changes, and combine pharmacologic and non-pharmacologic options for prevention.

Grade of Recommendation = C

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Recommendation 55
Recognize that analgesics and/or local anaesthetics are the foundation for pharmacological management of painful procedures. Anxiolytics and sedatives are specifically for the reduction of associated anxiety. If used alone, anxiolytics and sedatives blunt behavioural responses without relieving pain.

Grade of Recommendation = C

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Recommendation 56
Ensure that skilled supervision and appropriate monitoring procedures are instituted when conscious sedation is used.

Grade of Recommendation = C

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Patient and family education

Recommendation 57
Provide the person and their family/care providers with information about their pain and the measures used to treat it, with particular attention focused on correction of myths and strategies for the prevention and treatment of side effects.

Grade of Recommendation = A

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Recommendation 58
Ensure that individuals understand the importance of promptly reporting unrelieved pain, changes in their pain, new sources or types of pain and side effects from analgesics.

Grade of Recommendation = C

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Recommendation 59
Clarify the differences between addiction, tolerance, and physical dependence to alleviate misbeliefs that can prevent optimal use of pharmacological methods for pain management.

  • Addiction (psychological dependence) is not physical dependence or tolerance and is rare with persons taking opioids for chronic pain.
  • Persons using opioids on a chronic basis for pain control can exhibit signs of tolerance requiring upward adjustments of dosage. However, tolerance is usually not a problem and people can be on the same dose for years.
  • Persons who no longer need an opioid after long-term use need to reduce their dose slowly over several weeks to prevent withdrawal symptoms because of physical dependence.

Grade of Recommendation = A

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Effective Documentation

Recommendation 60
Document all pharmacological interventions on a systematic pain record that clearly identifies the effect of analgesic on pain relief. Utilize this record to communicate with interdisciplinary colleagues in the titration of analgesic. The date, time, severity, location and type of pain should all be documented.

Grade of Recommendation = C

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Recommendation 61
Provide the individual and family in the home setting with a simple strategy for documenting the effect of analgesics.

Grade of Recommendation = C

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iii. Effective Non–Pharmacological Management of Pain

Recommendation 62
Combine pharmacological methods with non-pharmacological methods to achieve effective pain management.

  • Non-pharmacological methods of treatment should not be used to substitute for adequate pharmacological management.
  • The selection of non-pharmacological methods of treatment should be based on individual preference and the goal of treatment.
  • Any potential contraindications to non-pharmacological methods should be considered prior to application.

Grade of Recommendation = C

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Recommendation 63
Institute specific strategies known to be effective for specific types of pain, such as superficial heat and cold, massage, relaxation, imagery and pressure or vibration, unless contraindicated.

Grade of Recommendation = C

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Recommendation 64
Implement psychosocial interventions that facilitate coping of the individual and family early in the course of treatment.

Grade of Recommendation = B

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Recommendation 65
Institute psycho-educational interventions as part of the overall plan of treatment for pain management.

Grade of Recommendation = A

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Recommendation 66
Recognize that cognitive-behavioural strategies combined with a multidisciplinary rehabilitative approach are important strategies for treatment of chronic non-malignant pain.

Grade of Recommendation = A

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