Handbook for Mortals : Controlling Pain : A few rules about pain management

There are some general rules about pain management that are helpful to know.

If you have more pain after having had no pain on a stable dose of an opioid, your regular dose will generally need to be increased by at least one-half (50%). For example, if you are taking 10 milligrams (mg) of morphine every four hours, your doctor will usually need to increase your dose to 15 mg every four hours to get pain relief again. This is just as true if you were taking 100 mg every four hours; the new dose is likely to be about 150 mg.

The dose of medication needed to treat breakthrough pain [see definition] is determined by the dose of pain medicine that you take regularly. The breakthrough dose is usually equivalent to one to two hours' worth of your regular dose. So, your breakthrough dose should increase as your regularly scheduled dose increases. This is not because you are taking too much medicine. It is because the breakthrough dose has to be calculated as a percentage of the regular dose. Again, the person taking 10 mg every four hours will need 3 to 5 mg for breakthrough pain, and the person taking 100 mg will need 30 to 50 mg. These larger doses often cause some anxiety for professionals who are not used to using them. Talk to your doctor about the dose of medicine you should take for breakthrough pain, and have your doctor talk with people in your family or care team who need to understand how the dosing works.

Because incident pain [see definition] is predictable, the best treatment is to take a dose of medication before starting the activity that produces pain. The dose may or may not be the same as your breakthrough pain dose. Work with your doctor and use your own experience to determine what dose best prevents pain before specific activities.

You can treat end of dose [see definition] failure in one of two ways, depending on your medicine and your medication schedule. You can increase the dose of medicine, or you can decrease the amount of time between doses. Also, if you are using pills that are not long-acting, you might switch to long-acting versions that "smooth out" the transition time between doses. Talk with your doctor about the best choice for you.

The amount of medicine that you take will be very different depending on the route used. If you switch from morphine tablets to injections, [see ways to take] for example, the dosage usually needs to be cut to about one-third.

It is usually better to take one kind of opioid at a time, although you will need to take two if one is a transdermal patch. Taking only one opioid limits the side effects and makes it easier to calculate dose changes. However, there may be times when you need to change opioids. When this happens, your doctor may prescribe a slightly lower dose than the "equivalent dose" to your previous opioid. This is because equivalent doses are not exact and because your body may need less of an opioid that it is not used to having. Use your breakthrough medication for pain while you and your doctor adjust your new medicine.

Opioids are really very safe drugs; used as described, they are very unlikely to speed up dying even if you end up taking very large doses. Some people feel that opioids must kill - they are so often in use at the end of life. But this is not the case. They provide a great deal of comfort and are quite safe when used appropriately.

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Keywords: rules for pain management, dose titration, opioid rotation
Handbook for Mortals book cover Copyright © 1999, 2006 by Joanne Lynn. This extract from the Handbook for Mortals by Joanne Lynn, M.D. and Joan Harrold, M.D. is used with permission. To learn more about improving care at the end of life visit the main web site for Americans for Better Care of the Dying.
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