Pain Management with As Needed Medications (PRNs)

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Patients, whose painful conditions are managed through pharmacological and non-pharmacological interventions, may still experience instances of increased pain. The natural phenomenon of breakthrough pain often requires an “as needed” dose of pain medication to continue to provide effective pain management. When coupled with our clinical judgement, PRN medications remain a safe and effective treatment option to manage our patient’s breakthrough pain. (1, 2, 4)

PRN Pain Medication

PRN stands for “as needed”.  Breakthrough doses (BTD) are PRN doses of immediate-release pain medication given to manage a patient’s breakthrough pain. (1, 4)

A starting BTD is typically 10% of the 24-hour total of their opioid medications and can be given as frequently as q1 hour PRN. (1, 2, 4)

It is acceptable to have up to 3 BTDs per day in addition to scheduled pain medications for effective pain management. (1, 2, 4)

If a patient starts to require 3 or more BTDs per day for three or four days in a row, re-evaluate the 24-hour dosage total and consider options such as titration. (1, 2, 4)

Role in Managing Breakthrough Pain

Every member of a patient’s inter-professional team is responsible for being aware of common indicators of pain and advocating for effective breakthrough pain management.

Signs and symptoms of pain may include: patient self-reporting pain, facial grimacing, crying, groaning, irritability, guarding body parts, social withdrawal, and responsive behaviours. (4)

Allied Health: (PSWs, SW, PT, OT, SCPs etc.)

  • Share all observations you witness during your caregiving or reported to you by family members that indicate the patient may be experiencing pain with the primary nurse(s) caring for them.
  • Provide non-pharmacological interventions for pain based on your scope of practice i.e. a PT providing heat therapy to a patient.

Nursing:

  • Screen patients living with painful conditions for pain. The ESAS-r tool is useful for screening symptoms, including pain.
  • Conduct a comprehensive pain assessment to understand the BT pain fully. The OPQRSTUV Symptom Assessment Acronym is a recommended symptom assessment tool. If your assessment findings indicate the need for a BTD, the next step is to review what PRN orders are available / contact a Physician/Nurse Practitioner (MD/NP) for new orders.
  • Using your clinical judgement, review the medication order to determine if the order is “clear, complete and appropriate” pg.4 (3) for your patient when deciding to administer the BTD.
  • A proper PRN order will indicate the reason to administer the PRN (pain etc.) and how often the medication can be administered (q2 hours etc.) in addition to medication name and route. An acceptable PRN order might look like: morphine 5mg q1h by mouth PRN for pain.
  • Evaluate the effectiveness of the BTD by reassessing the patient for pain and side effects. Document findings and update the patient’s care plan, and communicate this with the team. (1, 2, 4)
  • Provide ongoing health teaching on safe & effective PRN medication usage for patients & families. (4)

MD/NP:

  • Provide clear and patient centered orders that reflect their goals of care.
  • Be available to the inter-professional team to provide order clarification or changes to meet the evolving needs of the patient.
  • Provide ongoing health teaching on safe & effective PRN medication usage for patients & families. (4)

Common Language

Background pain is pain that is typically present for greater than 12 hours and present when not taking medications around the clock to manage it.(1, 4)

Breakthrough pain (BT) is an increase of pain that arises unexpectedly or because of predictable causes in addition to their managed background pain.(1, 4)

Types of Breakthrough Pain

  • Incident pain is predictable, for instance occurs when someone is moving an affected area of the body or involuntary during personal care and can be prevented with proactive interventions. (1, 4)
  • Spontaneous pain occurs unexpectedly and has no identifiable cause, and it is hard to prevent. (1, 4)
  • End-of-Dose Failure is very rare.  It occurs when a dose of medication stops effectively managing background pain earlier than its designed to last for i.e. a 12-hour medication stops effectively managing background pain after 8 hours. ( 1, 4)

Resources:

  1. BC Centre for Palliative Care. (2017). BC Inter-professional palliative symptom management guidelines
  2. Pallium Canada. (2016). The pallium palliative pocketbook: A peer-reviewed referenced resource (2nd ed.)
  3. CNO (2019). Practice Standard: Medication
  4. Pasero, C., McCaffery, M. (2011). Pain Assessment and Pharmacologic Management. St. Louis, MO: Mosby

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