1. Inadequately treated acute pain can lead to prolonged hospital stay, delayed recovery, psychological consequences, increased costs and the development of chronic pain. Pain in terminally ill should always be relieved. Acute Pain: Time limited (0-6wks after pain episode, injury or surgery) Reserve opioids for treating severe conditions due to trauma, acute medical/ orthopedic problem, post-op pain or acute exacerbation of chronic problem Opioid rx not appropriate for non-severe conditions (i.e back sprain). 1wk supply or ≥2 opioid rxs for back sprain assoc w/ 2x risk of long-term disability Negative attitudes of providers toward opioids and pts w/ chronic pain can lead to inadequately treated acute pain, esp in the hospital setting. Do not withhold or overly limit rx if pt in pain w severe acute condition (i.e. ulna fx, pancreatitis, POD1, bony mets, etc)! Pain Assessment: Multifactorial: physical exam, validated scales (PEG/ Functional Capacity Evaluation), consider sociocultural characteristics of pain Confident diagnosis? Important not to mask acute pain if unknown source Acute pain treatment: If opioids rx’ed, should be lowest effective dose for shortest duration (<2 wk) SMART tx goals: Specific, Measurable, Achievable, Realistic, Time based Set clear expectations w/ pt. Taper by 6wks or assess for chronic pain mgmt Consider scheduled non-opioid rx + PRN opioid (i.e. scheduled Toradol/ PO NSAIDS + PRN Norco) to decrease need for opioids if mild-mod pain. Schedule opioids if mod-severe pain (+/- with scheduled NSAIDS). Consider PCA if repeated doses of IV opioids anticipated/ required Use short acting PO opioids (rather than IV) once tolerating POs For pts on chronic opioids w/ acute post-op pain, develop plan w pt, surgeon and PCP for time-limited increased short-acting opioids only Acute Pain/ Palliative Care(1) C.L.I.P.S. Updated 2/2016 E. Wiener

2. Palliative care pain management principles: Primary goal is relief of suffering; less concern about addiction or tolerance in this setting Address emotional, spiritual, mental suffering and fears that may affect pain. Discuss goals of care. Involve family, SW, chaplain, and/or hospice/ AIM in developing tx plan. Consider limiting labs/meds or full comfort care. Treating severe acute or acute on chronic pain (not just at end of life): Address and understand the cause of pain and if any interventions needed/ desired based on GOC Starting doses for opioid naïve in mod/sev pain: Morphine 15-30mg POq4h, oxycodone 10-20mg PO q4h, hydromorphone 4-8mg POq4h. Strongly consider IV: morphine 5-10mg or hydromorphone 0.8- 1.5mg q15-30min until pain controlled. Consider acetaminophen/NSAIDs for co-analgesia. Assess pain frequently, titrate up as needed. IV opioids peak in 10-30 min, PO opioids peak in 1hr. Reassess at peak times and re-dose if needed. If pain uncontrolled after successive doses, increase dose by 25-50% (moderate pain) or 50-100% (severe pain). Consider PCA. When pain not expected to resolve shortly, Rx standing + PRN meds. Schedule standing based on ½ life (q3-4h for PO short-acting opioids) + PRN based on time-to-onset (q1h PO or q15-30 min IV). Write holding orders for scheduled meds (sedation, respiratory depression). If expect long-term use, convert to long-acting opioids once pain controlled. Calculate Total Daily (24h) Dose (TDD), convert 50-75% of TDD into long-acting opioid (methadone vs. MS contin). Rx ~10% TDD as short-acting opioid q1-2hPRN (i.e. MS Contin 60mg q12h + morphine 15mg POq1h PRN). Always rx scheduled bowel regimen w/ opioids (Start Docusate 100TID + 2 senna @ bedtime, add lactulose 30ml q24 if needed, if no BM in 3 days add bisacodyl suppository or fleet enema). Consider common hospice meds (in hospice order set): Roxanol (short-acting liquid morphine) for pain or SOB; Lorazepam for anxiety, SOB, insomnia; Atropine drops/ Scopolamine for oral secretions Resources: AAFP 2014, CA Medical Board 2014, WA AMDG 2015, Mt. Sinai Hospital Palliative Care guidelines Acute Pain/ Palliative Care (2) C.L.I.P.S.