The Use of As-Needed Range Orders in the Management of Acute Pain: A Consensus Statement of the American Society of Pain Management Nursing and the Am

Table 1. Considerations for Writing and Interpreting PRN Range Orders for Opioid Analgesics

Reasonable range. The maximum dose in a range order for an opioid should be at least 2 times, but generally no larger than 4 times, the smallest dose. This range is large enough to provide appropriate options for effective dose titration and small enough to establish a safe dose in an individual. Patient's prior drug exposure. If the patient is opioid-nave, the first dose administered should be the lowest dose in the range; if the patient is opioid tolerant, or has received a recent dose with inadequate pain relief and tolerable side effects, a dose on the higher end of the range should be administered. Prior response. Inquire about the patient's response to previous doses. How much relief did prior doses provide, and how long did it last? Did the patient experience side effects? Age. For very young or elderly patients, "start low and go slow"—begin with a low dose and titrate up slowly and carefully. More frequent reassessments are indicated for more fragile or less resilient patients. Liver and renal function. If the patient has hepatic or renal insufficiency, anticipate a more pronounced peak effect and a longer duration of action. Pain severity. As a general rule, for moderate to severe pain, increase the dose by 50% to 100%; do not increase by >100% at one time; to "fine-tune" the dose once pain is at a mild level, increase or decrease by 25%. Anticipated pain duration. Is the pain acute, chronic, or progressive (likely to worsen)? In other words, is the patient likely to require more or less analgesic over time? Kinetics. Know the onset, peak, and duration of action for the specific drug ordered. Doses of short-acting opioids can be increased at each specified dosing interval, unlike scheduled long-acting opioid formulations. Comorbidities that may affect patient response. Example: Debilitated patients, or those with respiratory insufficiency, may be at more risk for hypoxia if oversedated. Concomitant administration of other sedating drugs. When other CNS depressants are administered in combination with opioids, the dose of each medication required to achieve the desired effect may be 30% to 50% less than if either drug was administered alone. Combination drugs. Limit doses of combination drugs (e.g., opioids with acetaminophen or an NSAID). Average adults should not receive more than 4,000 mg of acetaminophen in 24 hours. Combination drugs may contain as much as 750 mg of acetaminophen per tablet. If substantial upward dose titration is required or anticipated, use opioid-only preparations. EXAMPLE: Opioid-nave patient arrives on unit with order: Morphine sulfate 2 mg to 6 mg IV every 2h PRN pain. Give 2 mg for first dose. Assess effects after 5 to 15 minutes. If adequate relief, reassess in 1 to 2 hours. If no side effects but inadequate relief, may give additional 4 mg at time of peak effect from first dose. Total dose is 6 mg in a 2-hour period.