Pain Control: Opiods

I will go over some general information regarding opioid use for analgesia. In subsequent entries I will go over different opioid use for 1) mild to moderate pain, 2) moderate to severe pain, and 3) severe pain. I would say for my practice most patients fall into the moderate to severe pain, but for a short period of time.

Opioids

Key Points:

• No ceiling effect (as a general statement this means the larger the dose, the larger the effect)
• Tolerance can develop with chronic use
• Overuse can lead to respiratory depression or seizures

Examples: 

Mild to moderate pain: codeine or tramadol

Moderate to severe pain: hydrocodone, oxycodone, hydromorphone

Severe pain: morphine, codeine, methadone

**Some of these can crossover between categories based on dosage.

Source: Handbook of Neurosurgery, Greenberg 6th ed

Pain Control: Toradol

Working in a surgical specialty, I have had to learn how to manage pain successfully.... and I must admit with some patients, I'm still learning. Pain is subjective so there is no magic recipe that works for every patient... you will have patients that 1) have intolerable side effects or allergies to your normal post op prescriptions, 2) have a history of narcotics abuse, 3) are drug seekers, 4) are people in true pain, and 5) are everything in between. It is good to have an idea of different pharmacological options to treat pain. Over the next few entries I will go over some of the main pain medications we use and some random ones as well.

TORADOL (ketoraolac tromethamine)

Key points:

• only parenteral NSAID approved for use in pain control in US
• Analgesic effect is more potent than anti-inflammatory
• Single dose administration = 30mg IV or 60mg IM (in healthy adult)
• Multiple doses = 30mg IV/IM q6hrs (max 120mg/day)
• PO is available, but used only as a continuation of IV/IM therapy - comes in 10mg tabs

Why might you use toradol?

• if constipation is an issue with your patient
• if you are worried about sedation/respiratory depression 
• patients with narcotic dependency
• if your patient gets nausea with narcotics

Cautions:

• do not use for > 72 hrs of pain control - some say 5 days is the max
• can prolong bleeding time (secondary to platelet inhibition) in post op patients - use caution 
• although injections bypass the GI system, patients can still get GI irritation
• monitor for renal side effects

Source: Handbook of Neurosurgery Greenberg, 6th Ed