Considerable variation exists in the amount of opioid individuals require for comfort (APS, 2008). For example, research has established that as much as a tenfold difference exists among patients in opioid requirements during the postoperative period (Myles, 2004). At all times, nurses must strive to achieve a balance between pain relief and adverse effects (Pasero, 2010a). The goal of titration is to use the smallest dose that provides satisfactory analgesia with the fewest adverse effects (Pasero, 2010a; Pasero, Quinn, Portenoy, McCaffery, & Rizos, 2011).
In opioid-naïve patients with moderate to severe pain, recommended starting IV doses are given (e.g., 2-3 mg of morphine, 0.4 mg of hydromorphone, or 25-50 mcg of fentanyl) (APS, 2008). When an increase in the opioid dose is necessary and safe, many clinicians increase by percentages. When a slight improvement in analgesia is needed, a 25% increase in the opioid dose may be sufficient; for a moderate effect, a 50% increase; and for a strong effect, such as for the treatment of continued severe pain, a 100% increase may be indicated (Pasero, Quinn, Portenoy, McCaffery, & Rizos, 2011). The time that the dose should be increased is determined by considering the peak effect of the opioid. The frequency of IV opioid doses during initial titration may be as often as every 5 to 15 minutes (see Table 5-2). The patient must be observed closely for adverse effects (Aubrun, Monsel, Langeron, Coriat, & Riou, 2002; Lvovschi et al., 2008). Conservative initial opioid doses along with careful monitoring during titration are recommended in the older adult population (APS, 2008; Keïta, Tubach, Maalouli, Desmonts, & Mantz, 2008; Pasero, 2010a; Pasero, Quinn, Portenoy, McCaffery, & Rizos, 2011); however, doses should be increased based on patient response rather than a specific age.
Doses should not be increased in patients who are excessively sedated (e.g., unable to keep eyes open and falling asleep mid-sentence) (Pasero, 2009b). In such cases, nonopioid analgesics should be added or increased (e.g., full doses of an NSAID and acetaminophen). As noted, it may not be possible to achieve optimal pain control in the PACU for all patients; the process is viewed as occurring on a continuum (Pasero, 2009a; Pasero, Quinn, Portenoy, McCaffery, & Rizos, 2011). Ensuring safe pain management is a primary objective.