6/28/17 at HUP: pain management pearls!

We were very excited to welcome new palliative care attending Dr. Jay Vanston to HUP. He gave us an excellent talk on basics of pain management and PCA titration. While I couldn’t possibly capture the scope of the wisdom he imparted in that hour, here are some pearls:

PAIN MANAGEMENT PEARLS

1) If you don’t have IV access, you can give the same dose SQ. Both IV and SQ administration will cause peak effect in ~10-15 min (SQ a little slower)
2) PO doses of most oral opiates peak in ~1h; IV doses peak in 10-15 min
3) Quick tip for fentanyl patch conversion: a 50 mcg fentanyl patch = 50mg PO morphine q12 hours
4) Fentanyl patches have a peak around 12-17 hours after application, so don’t shut off their IV opiates until ~6h after patch placement
5) Methadone potency depends on baseline opiate use. The higher the patient’s baseline opiate use, the more potent methadone will be for that person.

PCA titration

  • Basal dose: start with ~1/6 of the IV dose given over the 1st hour of attempted pain control
  • Bolus dose: generally 1/2 of hourly basal rate, can give q10-15 min
  • Conversion to PO: calculate 24h dose, convert to PO opiate of choice, and divide in half to get long acting (MS Contin/Oxycontin) dosage BID.
  • You can give 10% of the 24h dose as PO breakthrough (generally q2-4h)