Advocacy
The Use of 'As Needed' Range Orders for Opioid Analgesics in the Management of Acute Pain
A Consensus Statement of the American Society for Pain Management Nursing and the American Pain Society
Position
Effective pain management requires careful individual titration of analgesics that is based on a valid and reliable assessment of pain and pain relief. A registered nurse who is competent in pain assessment and analgesic administration can safely interpret and implement properly written “as needed” or PRN range orders for analgesic medications. The American Society for Pain Management Nursing (ASPMN) and the American Pain Society (APS) support safe medication practices and the appropriate use of PRN range orders for opioid analgesics in the management of acute pain.
Background
PRN range orders for opioids (e.g., “morphine, 2 to 6 mg IV every 2h PRN for pain”) are commonly used to provide flexibility in dosing to meet individual patient needs because wide variability exists in patients’ responses to analgesics. Evidence-based clinical practice guidelines support the need for individual titration of the dose of opioid analgesics. Range orders enable necessary and safe adjustments in doses based on individual responses to treatment. To promote patient safety and reduce medication errors, it is critical that physicians, nurses, and pharmacists share a common understanding of how to properly write, interpret, and carry out PRN range orders.
Recommendations
Prescribers
- Construct orders that contain a dosage range with a fixed time interval.
- Consider patient and drug characteristics including, but not limited to pain type and intensity, pain duration, patient age, past exposure and prior response to analgesics (both pain relief and side effects), comorbidities, end organ function, concomitant administration of other drugs, and pharmacokinetics of the analgesic to be ordered.
- Provide a dosage range large enough to permit appropriate and safe dose titration. The maximum dose within the range should not be greater than four times the minimum dose. The dosing interval should be appropriate for the drug and route of administration, taking into account usual absorption and distribution characteristics, time to onset, time to peak effect, and duration of action. Open-ended orders such as “titrate to comfort” are not acceptable.
Nurses
- Base decisions about the implementation of range orders on a thorough pain assessment and knowledge of the drug to be administered. Assessment should include at minimum pain intensity, temporal characteristics of the pain, and the patient’s previous response to this or other analgesics (e.g., pain relief, side effects, and impact on function). The nurse should be familiar with the anticipated time of onset, time to peak effect, duration of action, and side effects of the analgesic to be administered.
- Verify the appropriateness of the dose and the dosing interval for the current situation.
- Verify patient’s drug allergy status.
- Tell the patient the name of the drug and the dose to be administered.
- Evaluate the patient’s response to the analgesic dose and dosing interval.
- Ensure complete documentation and communication of patient’s response to dose and dosing interval.
- Assist with the development of policies and processes that enhance patient comfort and assure medication safety.
Institutions
- Ensure that prescribers are writing appropriate range orders for analgesics.
- Assess competency of nursing staff to interpret and implement range orders for analgesics.
- Provide ongoing education for safe medication practices.
- Ensure the implementation of policies and processes that provide safe, effective analgesic dosing of analgesics.
Summary
- The treatment of pain requires individual titration of analgesics by a practitioner competent in pain assessment, analgesic administration, and evaluation of response to treatment.
- PRN range orders for analgesics must be written in accordance with evidence-based clinical practice guidelines.
- Institutions should allow PRN range orders for opioid analgesics in order to meet the mandate for safe and effective pain management. Processes are required to ensure staff competency in the writing, interpretation, and implementation of these orders. The safety and quality of pain management practices should be monitored.
References
American Geriatric Society. (2002). The management of persistent pain in older persons. The Journal of the American Geriatrics Society, 50(6), 1–20.
American Pain Society. (n.d.). The assessment and management of acute pain in infants, children, and adolescents. Retrieved from http://www.ampainsoc.org/advocacy/pediatric2.htm
American Pain Society. (2003). Principles of analgesic use in the treatment of acute pain and cancer pain (5th Ed.). Glenview, IL: Author.
American Pain Society. (2004). Guideline for the management of cancer pain. Glenview, IL: Author.
Joint Commission on Accreditation of Healthcare Organizations. (n.d.). Pain assessment and management standards. Retrieved from http://www.jcaho.org
McCaffery, M. & Pasero, C. (1999). Pain: Clinical manual (2nd Ed.). St Louis, MO: Mosby.
Copyright © 2004 American Society for Pain Management Nursing and American Pain Society.
American Society for Pain Management Nursing
7794 Grow Drive
Pensacola, FL 32514
888/342-7766
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E-mail aspmn@puetzamc.com
www.aspmn.org
American Pain Society
4700 W. Lake Avenue
Glenview, IL 60025-1485
847/375-4715
Fax 866/574-2654, 847/375-6480
E-mail info@ampainsoc.org
www.ampainsoc.org