Firstly, a of disclaimer. I am by no means an expert in pharmacology, pain management or pain physiology – these are enormous fields which take many decades to properly get your head around! Broad brush strokes are one thing, but everywhere has its own local guidelines for specific management so be sure to check those out before going wild with shuffling someone’s analgesics. These are not clinical guidelines! More musings by an enthusiast.

When I prescribe opioids, I tend to run through a few steps in my head – here is my little cheat-sheet to guide your own practice.

Step 1: Do I Need an Opioid?

It’s the return of the beloved WHO Analgesic Ladder! Though I have a fairly liberal attitude to how to climb ladders, the ladder should always remain intact rather than just a big pile of individual rungs.

If you have a patient who is in severe pain, they’re not going to thank you for giving them two paracetamol and disappearing for an hour whilst you wait for them to work. In these circumstances I tend to take a running jump at the ladder and try and land somewhere nearer the top – get the pain safely under control with careful titration of strong opioids. However, having arrived on the ladder I then acknowledge it by prescribing regular non-opioid analgesia to ensure we build up some background for once my rescue opioid dose wears off. 

Thankfully, most of your patients will be up for you climbing the ladder one rung at a time. As you ascend, keep going with the steps below and shuffle your PRN’s across to regular. Whilst each non-opioid step may not get rid of the pain by itself, the combined effect just might and you could even spare your patient the opioid related side-effects!

Step 2: Which Opioid Should I Prescribe?

Whether at the weak opioid or strong opioid stage of your ladder, there are a few choices to make – each will have its own advantages and disadvantages. I’ve listed some of the agents along with some of the advantages and pitfalls:

• Codeine – Weak Opioid. Very common! Patients have often experienced taking it before and will be able to tell you how it makes them feel. Experiences range from uneventful analgesia to dizziness, instantaneous vomiting, constipation and respiratory depression. These experiences are as a result of unpredictable metabolism. A lot of organisations don’t allow it to be prescribed to children for this reason!
• Tramadol – Weak Opioid. Can be given intravenously which is often handy. Experiences vary a lot as well though I’ve had more reports from people who say Tramadol makes them feel really unsteady and confused.
• Dihydrocodeine – used from time-to-time in place of Codeine. It’s metabolism is much more predictable and so you might have more luck with this if your patient finds Codeine intolerable.
• Morphine – an all-rounder! The archetypal strong opiate. Can be given orally or intravenously and comes in quick-release and slow-release preparations. This is usually where you end up at the top of your ladder.
• Oxycodone – an alternative strong opioid. It could be an alternative to morphine if that isn’t tolerated and is available in oral quick-release and slow-release preparations.

Small Print

A handful of other more niche drugs exist and you might well come across them from time to time, used particularly in palliative care or chronic pain. As a rule, non-specialists should not be initiating these drugs!

• Fentanyl – Strong opioid. Comes in lozenges, patches and even lollipops! Used for short but painful procedures or for breakthrough pain.
• Alfentanil – Strong opioid. Again used for breakthrough pain but doesn’t come in such exciting flavours.
• Buprenorphine – Strong opioid. Also comes in patches!

Step 3: Where Am I Going with This?

This is often a big pile of questions that I ask myself to make sure I have a plan beyond the next few doses of pain-killers.

Patients will have pain which generally falls into one of three categories – acute pain, chronic pain and acute-on-chronic pain. Is my plan to get them through the next few days and then return them to a fully pain-free state? Will I need to establish them back on their standard chronic pain regimen? Do they have chronic pain which is getting worse?

If their pain is getting worse, why might that be? Is there anything I could do to improve things (often catheters, drains etc can be a big source of pain)? Do I need help or support in making this decision?

I think twice, three times and then four times about starting someone on long-term opioid medications – even if your intentions are honourable, patients who are discharged home on long-acting opioids might end up on them for a long time! Equally, I would never soldier on trying to manage a patient with chronic pain without calling in some experts – these are patients with complex needs who often need other interventions to go alongside the pharmacology.

Step 4: Can I Foresee Any Problems?

These fall into a handful of categories, which I’ve handily partitioned up:

1. Side-effects – our patient might well become nauseated or constipated as a result of our prescription, so be ready to review and potentially treat side-effects. If their bowel isn’t working wonderfully already are we sure we want to throw more fuel on the fire? Or cause decompensation of their type 2 respiratory failure? Equally disorientation and confusion are common – is this already an issue? If so we might make it worse and cause other management problems. This leads handily onto…

2. Physical safety – will there be someone around to help keep an eye on our patient if they’re on potentially sedating medications? Will serious side-effects be picked up in time with the current observations frequency? Are there enough staff on the ward to manage if our patient becomes more confused? This will often form part of your mini-MDT with the ward staff about what is best for the patient.

3. Administration – some of the drugs above will need two members of staff to administer, some will only need one. This can significantly affect how promptly your patient can receive their pain relief!

If you’re struggling, most hospitals have access to a ‘pain team’ during normal hours and out-of-hours a good source of information will be the on-call anaesthetist. My advice would be to call them sooner rather than later, as it can be easy to get in a pickle!

Take Home Messages

So, in summary and true medical education style there are some key messages:

• Opioids aren’t always the answer to pain.
• Avoid drug-specific pitfalls by taking your time with selecting an opioid of choice.
• Think about your short-, medium- and longer-term analgesic plan.
• Keep your patients safe by considering side-effects and nursing care when prescribing opioids.

Overall: At all times ask yourself ‘do I need help with this?’.