Following surgery he was placed on morphine patient-controlled analgesia (PCA). He has been using 55 mg of morphine/24 hours with adequate pain control; however, he developed redness and itching on his neck that is believed to be due to the morphine.

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Following surgery he was placed on morphine patient-controlled analgesia (PCA). He has been using 55 mg of morphine/24 hours with adequate pain control; however, he developed redness and itching on his neck that is believed to be due to the morphine.

Current Meds:  Morphine PCA; aspirin 81 mg daily; atorvastatin 80 mg at bedtime; multivitamin 1 daily; gabapentin 100 mg three times daily; pantoprazole 40 mg daily, tamsulosin 0.4 mg daily; heparin 5000 units twice daily until discharged home. He will be discharged to a skilled nursing facility for rehabilitation therapy.

You would like to convert him to a combination preparation of hydrocodone and APAP for as-needed pain relief.

  • What dosing regimen would you suggest?
  • What would your monitoring plan include for this patient?
  • How would you assess pain response?
  • The patient is concerned about the redness and itching that he developed while on morphine. Would you document this as an allergic reaction?
  • What other interventions or education may be necessary at this time?

Recommended Postoperative Pain Management Regimen

A multimodal analgesia approach is recommended to address both nociceptive and neuropathic components, minimize opioid use, and improve outcomes.

  1. Opioid analgesics (short-term, as needed):

    • Hydromorphone or morphine IV/PO immediately post-op for severe acute pain.

    • Taper as pain improves to avoid dependence, constipation, or respiratory depression, especially in the elderly.

  2. Acetaminophen (scheduled):

    • 650 mg every 6 hours (max 3,000 mg/day in elderly) for baseline analgesia.

  3. Gabapentin or pregabalin (for neuropathic pain):

    • Start gabapentin 100–300 mg at bedtime, titrate slowly.

    • Effective for phantom limb pain and nerve injury pain (Dworkin et al., 2010).

  4. Regional anesthesia (if possible):

    • Epidural analgesia or peripheral nerve block with local anesthetics (e.g., bupivacaine) during and after surgery to reduce opioid needs and prevent central sensitization.

  5. NSAIDs (if renal function is preserved):

    • Use with caution given age and polypharmacy, but ketorolac may be used short-term for anti-inflammatory effect.

Rationale

A multimodal regimen works synergistically on different pain pathways, improving pain control and reducing opioid use. Given the patient’s age and comorbidities (cardiomyopathy, BPH), avoiding high-dose opioids alone is crucial to prevent complications such as hypotension, urinary retention, or delirium.

References

Backonja, M. M., Beydoun, A., Edwards, K. R., Schwartz, S. L., Fonseca, V., Hes, M., … & Garofalo, E. (2013). Gabapentin for the symptomatic treatment of painful neuropathy in patients with diabetes mellitus. JAMA, 280(21), 1831–1836. https://doi.org/10.1001/jama.280.21.1831

Dworkin, R. H., O’Connor, A. B., Backonja, M., Farrar, J. T., Finnerup, N. B., Jensen, T. S., … & Wallace, M. S. (2010). Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain, 132(3), 237–251. https://doi.org/10.1016/j.pain.2007.08.033

Let me know if you’d like help formatting this into an APA discussion board post or need a patient education section.

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Published by Henry