Pain Uncontrolled on Current Analgesia
at the bedside
- airway, breathing, circulation; full vitals with respiratory rate and a sedation score before any opioid
- look at the chart → was it given, which dose, which route, when; PRN-only paracetamol is not a base
- already on a regular opioid → total opioid in the last 24 h, rescue doses used, time of the last dose, modified-release or patch on board
- look at the site → new pain, new site or pain out of proportion is a new diagnosis, not a dose problem
- can they swallow → vomiting, NPO or ileus means the oral route is not working
- score the pain at rest and on movement; score again after every change
escalate now if
- pain out of proportion to the findings → ischemia, compartment syndrome, necrotizing infection → leg pain, abdominal pain
- new severe pain in a different site → new diagnosis, image it, do not just add a dose
- fever with pain after surgery → abscess, leak or dehiscence; surgery tonight
- RR < 8, falling sedation score, hard to rouse → opioid toxicity: ventilate first, then naloxone
- chest or upper abdominal pain → ECG now → chest pain
differentials
why is the pain uncontrolled: three groups
- a new problem → wound infection or hematoma, compartment syndrome, ischemia, perforation, fracture, urinary retention, constipation; treat the finding, not the score
- the regimen is not reaching them → doses not given, PRN only, interval too long, oral route failing, dose too small for weight or for established tolerance
- the wrong drug for this pain → neuropathic pain (burning, shooting, numb) answers poorly to opioids alone; spasm needs a relaxant; inflammatory or bone pain answers to an NSAID
- distress, delirium, poor sleep → lower the threshold; treat these too → delirium
focused check
- pain → site, radiation, character (sharp, dull, burning, cramping), onset, new vs worse, what helps
- context → post-op day, trauma, cancer, chronic pain, sickle cell, known opioid use or dependence
- drug chart → every analgesic with dose, route, interval, last dose and its effect; the 24-h opioid total and rescue count; laxative prescribed or not; sedatives on board
- history → kidney and liver function, age and frailty, previous reactions, bleeding risk, asthma (NSAIDs), sleep apnea or COPD (opioids)
- exam → the site (wound, abdomen, limb pulses and compartments), sedation and pupils, respiratory rate, bladder, bowel sounds
send now
- no test delays analgesia in a patient in distress, and no routine bloods are needed to escalate it
- RFT → if an NSAID is planned, renal function is unknown or unstable, or an opioid may be accumulating
- LFT → liver disease, alcohol, or paracetamol dosing in doubt
- CBC, CRP, cultures → fever with pain
- ECG, troponin → chest or upper abdominal pain
- imaging at the site → ultrasound or CT when a complication is suspected; bladder scan if lower abdominal pain
treat
treat the cause, fix the regimen
- new finding → that page, that team; uncontrolled pain despite adequate analgesia is a diagnostic finding
- fix the obvious first → drug not given, wrong route, PRN only, interval too long, dose too small
multimodal: base, then rescue
- base, regular → paracetamol 1 g PO/IV q6h (max 4 g/day; less if under 50 kg, frail or liver disease)
- add an NSAID when it is safe → ibuprofen 400 mg PO TDS or ketorolac 10–30 mg IV/IM q6h (max 90 mg/day, 60 mg if elderly or under 50 kg, max 5 days); not with active bleeding or ulcer, AKI, eGFR under 30, or NSAID-reactive asthma; weigh it in heart failure, anticoagulation, CKD or age over 65: lowest dose, shortest course
- moderate to severe pain → a titrated strong opioid, no weak-opioid step first. Opioid-naive adult: morphine 2–5 mg IV in 1–2 mg steps every 10–15 min to effect, or oral IR morphine 5–10 mg; frail, over 65 or eGFR under 30: 1–2 mg IV or 2.5–5 mg PO and longer intervals; RR and sedation score before each dose and 30 min after an IV dose; a laxative and an antiemetic with every regular opioid
- tramadol is an option, not a rung → 50–100 mg PO/IV q6h (max 400 mg/day) for moderate pain when a strong opioid is not wanted; caution in the elderly, seizures, serotonergic drugs
- combination tablets contain paracetamol, count them; regional or local techniques where available; full doses and conversions → analgesia
- the WHO ladder was built for cancer pain; acute inpatient pain is a scheduled non-opioid base, adjuvants matched to the pain type, and opioids titrated as rescue
already on a regular opioid
- breakthrough dose → one sixth of the total 24-h opioid dose, by the same route family; not a fixed 5 mg
- three or more rescue doses in 24 h → the regular dose is too low: add the rescue total into the next day’s regular dose with the treating team or the pain team; never add a modified-release dose or a patch at night
- tolerance or dependence → usual rescue doses do little; titrate from the patient’s own dose, not from a naive dose; withdrawal adds agitation and sweating
- do not escalate → if the sedation score is rising or the RR is falling: hold, reassess, look for accumulation (renal function, interactions, gabapentinoids, benzodiazepines)
- oral morphine to SC morphine divide by 2; tramadol to oral morphine divide by 10; other conversions with the pain or palliative team → analgesia
adjuncts for neuropathic or spasm pain
- neuropathic agents are not rescue drugs at 2 AM: they start or change by day, work over days, and the night plan is the base plus a titrated opioid
- gabapentin 100–300 mg PO at night to start, built up over days (or pregabalin 25–50 mg PO BD) → neuropathic pain; halve in renal impairment; with opioids they cause respiratory depression (FDA 2019), worst over 65, in lung disease, renal impairment or with benzodiazepines: never start TDS dosing on top of a new opioid
- baclofen 5 mg PO TDS → spasm; renal warning → accumulates in renal impairment and causes confusion, seizures and coma; avoid if eGFR under 30, reduce and watch above it; sedating in the elderly
- hyoscine butylbromide 20 mg PO/IV → colicky visceral pain
opioids when the kidneys are poor
- morphine and codeine accumulate below a creatinine clearance of about 30 mL/min: sedation and respiratory depression build while the parent level looks fine
- prefer fentanyl or alfentanil, or oxycodone at a reduced dose with monitoring; no modified-release or background infusions while renal function is unstable; conversions with the pain or palliative team → analgesia
opioid toxicity
- respiratory depression, still breathing → RR < 8 or rising sedation: stop the opioid, oxygen, bag-mask if breathing is inadequate, call for help; naloxone 0.1 mg IV, repeat every 2–3 min to a respiratory rate above 12, not to full alertness (over-reversal brings severe pain, withdrawal and pulmonary edema)
- peri-arrest or apneic → ventilate first; naloxone 0.4 mg IV/IM, repeat every 2–3 min (0.4–2 mg range), ICU; cardiac arrest is ALS first → respiratory rate
- naloxone wears off before the opioid: observe well beyond the dose, longer after modified-release opioids, methadone or a fentanyl patch; repeated doses needed → infusion and ICU
reassess
- when → 30 min after an IV dose, 60 min after oral or SC, then at each round
- what → pain at rest and on movement, can they cough, turn and mobilise; respiratory rate and sedation score; nausea, itch, constipation, urinary retention
- not working → back to the three groups: new problem, regimen, wrong drug; sedated but still in pain is a wrong-drug or wrong-route problem, not a dose problem
- pain or palliative team → opioid tolerance, renal impairment, complex or neuropathic pain, ongoing IV or SC opioid need
- hand over → pain score and regimen, 24-h opioid total and last dose, sedation and RR, what was changed and when the next review is due
evidence
| source | type |
|---|---|
| APS/ASA 2016 postoperative pain management guideline | specialty-society guidance |
| CDC 2022 clinical practice guideline for prescribing opioids for pain | national guideline |
| FDA 2019 gabapentinoid respiratory depression warning | regulatory / safety update |
| 2025 AHA ECC guidelines, opioid-associated emergencies | international guideline |
| NICE NG180 perioperative care in adults (multimodal analgesia) | international guideline |
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
go deeper the full MOC+ Acute Medicine set covers the on-call essentials.
free the on-call checklist covers the whole shift on one printable page.
studying for the IM exam? the IM Rapid Review covers this in the same format. see the sample chapter.
reviewed Jul 2026updated Oct 2026file complaint/pain-uncontrolled-on-current-analgesia