Timely article in Medscape that patients with intractible, uncontolled pain should be treated quickly as a "PAIN CODE" situation with narcotic dose doubled every 8 min for IV meds, q 30 min for SC route, Q1hr for PO med.. Karen
From The Institute for Palliative Medicine
Pain Code: Get Pain Under Control Quickly
Charles F. von Gunten, MD, PhD
Posted: 09/08/2011 Free Medscape registration required
....Imagine a patient who has advanced cancer who has been admitted to the hospital complaining of 10 out of 10 pain. Your goal is to get the pain under control quickly. The most important fact to remember is this -- the time to pain control is the same as the time to the maximum concentration of the opioid in the blood.
So for a drug such as morphine given intravenously, the time to maximum concentration is 8 minutes. Therefore, successive doses of morphine can be given every 8 minutes. For someone whose pain is completely out of control, 10 out of 10, you want to double the dose to get that pain under control.
So for example, with the patient I described, with 10 out of 10 pain, he might have been on a patient-controlled analgesia dose of 1 mg of morphine. You want to double it to 2 mg. If after 8 minutes that pain is not controlled, you double it again. That would be a 4-mg dose. Wait 8 minutes. If the patient is not experiencing any relief, then you want to double it again to 8 mg. If the patient is still not getting any relief after another 8 minutes, double it again to 16 mg.
The point here is you're doubling the dose of the opioid at the level of the receptor. When the patient begins to describe relief, you found the dose that is controlling that person's pain.
The most frequent mistake that people make is they dose every half-life. When someone is in a pain crisis, you want to get on top of that pain quickly. You want to avoid the demoralization that comes from not being able to deal with the pain right away...