Paradigm-Based Treatment Approaches For Burn Pain Control - UpToDate

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Paradigm-based treatment approaches for burn pain

control
Authors: Shelley Wiechman, PhD, Sam R Sharar, MD
Section Editor: Marc G Jeschke, MD, PhD
Deputy Editor: Kathryn A Collins, MD, PhD, FACS
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2021. | This topic last updated: Sep 03, 2020.
INTRODUCTION
Pain management is a central component of the treatment of patients with burns. Despite
advances in burn care, control of burn pain is often inadequate during the acute and chronic
rehabilitation phases of burn care [1]. Pain is among the most common causes of distress
during the first year after recovery and, hence, should be aggressively managed [2,3]. Burn pain
management is typically based upon clinical experience and physician and/or institutional
preference, since available evidence is insufficient to clearly support one approach [4].
The approach to the management of patients with acute, background, procedural, and chronic
pain secondary to burns will be discussed here. An overview of the pharmacologic and
nonpharmacologic treatment options for managing burn pain is reviewed elsewhere. (See
"Management of burn wound pain and itching".)
BURN PAIN PARADIGM
A burn pain paradigm guides the use of analgesics for management of the different phases and
variability of burn pain [5]. This paradigm is based upon five phases of burn pain occurrence
and includes:
● Background pain – Pain that is present while the patient is at rest, results from the thermal
tissue injury itself, and is typically of low-to-moderate intensity and long duration.
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● Procedural pain – Brief but intense pain that is generated by wound debridement and
dressing changes and/or rehabilitation activities (eg, physical therapy and occupational
therapy).
● Breakthrough pain – Unexpected spiking of pain levels that occurs when current analgesic
effects are exceeded, either at rest, during procedures, or with anxiety.
● Postoperative pain – A predictable and temporary increase in pain occurs after burn
excision, donor skin harvesting, and grafting, due to the creation of new and painful
wounds in the process. The duration of pain is typically two to five days.
● Chronic pain – Pain that lasts longer than six months or remains after all burn wounds and
skin graft donor sites have healed. The most common form of chronic pain is neuropathic
pain, which is the result of damage sustained by the nerve endings in the skin.
CHALLENGES IN MANAGING BURN PAIN
Acute and chronic burn pain is challenging to treat because of multiple components that must
be addressed and the changing patterns of pain with time:
● Variability of pain – Burn pain is variable among patients and within each individual.
Adequate pain management must be directed toward the current situation. As an example,
burn pain can be excruciating with dressing changes and physical therapy but less painful
when the burn sites are undisturbed (background pain).
● Dosing of analgesics – Opioid analgesic dosing is based on patient weight, which is

variable in the burn patient due to physiologic fluid shifts. (See "Hypermetabolic response
to moderate-to-severe burn injury and management", section on 'Hypermetabolic
response'.)
● Pharmacokinetics – Burn injuries result in variable and often unpredictable changes in

volume of distribution and clearance of anesthetics and analgesics, including morphine [6].
● Route of drug administration – Options include intravenous, inhalation, oral,

transmucosal, enteral tube, or rectal. The intravenous route provides rapid onset and short
duration of pain relief and is used for patients with moderate-to-severe burns, and
monitoring of vital signs is mandatory. Oral administration is ideal for the outpatient
setting.
● Opioid tolerance – Tolerance to analgesic effects generally occurs after more than two
weeks of opioid use. The frequency of opioid tolerance has not been objectively
documented in burn patients, but clinical experience is that the majority of burn patients
receiving opioids on a daily basis develop analgesic tolerance during the initial weeks of
treatment [5], possibly due to pharmacodynamic changes at the opioid receptor [7]. Over
time, a higher dose of medication is needed to achieve the same level of pain relief.
● Hyperalgesia – Hyperalgesia is an increased sensitivity to pain and is induced by the acute

inflammatory response of a burn injury. Primary hyperalgesia occurs in the tissues directly
damaged by the burn. Secondary hyperalgesia occurs in the normal tissues adjacent to the
burn. Continued or repeated painful stimuli associated with background pain or repeated
procedural pain can cause central nervous system adaptations that amplify the pain
experience (ie, windup). Such pain may be opioid resistant and become irreversible and
thus contribute to ineffective opioid analgesia [8]. Patients with a history of opioid use may
experience hyperalgesia, and the pain management protocol will need to be adjusted
accordingly.
DRUGS AND DOSING
Drug options and dosing for opioids, nonopioids, benzodiazepines, and adjuvant analgesics are
provided separately. (See "Management of acute perioperative pain" and "Use of opioids in the
management of chronic non-cancer pain" and "Pain control in the critically ill adult patient".)
Optimizing pharmacotherapy — The principles for optimizing opioid pharmacotherapy in

burn patients are [4]:
● Treat burn pain based upon the five components of the burn pain paradigm: background,
procedural, breakthrough, postoperative, and chronic. (See 'Burn pain paradigm' above.)
● Individualize dosage, set a flexible dosing schedule, and use frequent dose adjustments as
needed to account for variability in analgesic requirements.
● Assess and document the effectiveness of the pain regimen at regular intervals to adjust
dosages and dosing intervals.
● Monitor side effects and prevent or treat them; do not undermedicate.
● Consider using nonopioids in conjunction with potent opioids to enhance analgesia and
reduce risks of opioid side effects. (See "Management of burn wound pain and itching",
section on 'Pharmacologic treatment options'.)
● Monitor anxiety and changes in mood.
● Apply nonpharmacologic interventions to complement, not replace, analgesia. (See

"Management of burn wound pain and itching", section on 'Nonpharmacologic treatment
options'.)
PARADIGM-BASED MANAGEMENT
We, and many other burn centers, advocate a structured approach to analgesia that
incorporates both pharmacologic and nonpharmacologic therapies, targets the specific clinical
pain settings unique to the burn patient, and is individualized to meet specific patient needs
and institutional capabilities [9,10]. The sections below provide an approach to treatment of
burn pain based upon the five phases of the burn pain paradigm. The regimens used at our
institution are illustrated in the table ( table 1).
Selection of an analgesic regimen is based upon the clinical setting, the effectiveness of the
approach in alleviating pain, and clinician and institutional preferences. No regimen is
appropriate in all settings, and there is no high-quality evidence that any particular regimen is
more effective than another. (See "Management of burn wound pain and itching", section on
'Pharmacologic treatment options' and "Management of burn wound pain and itching", section
on 'Nonpharmacologic treatment options'.)
In addition, the regular use of a weight-based medication worksheet (placed at the bedside and
in the patient record) containing all analgesic and resuscitation drugs provides a supplemental
safeguard against accidental overdose in pediatric patients. This is particularly important in the
young pediatric age group, where risks from analgesia and clinical unfamiliarity are both
elevated [11].
Background pain — Pharmacologic and nonpharmacologic management strategies relieve

background pain. Background pain decreases with time as the burn wound and associated
donor skin graft sites heal, and analgesics can be slowly tapered as the pain lessens in severity
and frequency. The optimal treatment of background pain is mildly to moderately potent
analgesics administered so that plasma drug concentrations remain relatively constant [5].
Pharmacologic approaches:
● Continuous intravenous (IV) opioid infusions, such as patient-controlled analgesia (PCA)
● Oral administration of long-acting opioids with prolonged elimination (methadone) or

prolonged enteral absorption (sustained-release morphine)
● Oral administration on a regular schedule of short-acting oral opioid analgesics or

nonsteroidal anti-inflammatory agents (NSAIDs)
(See "Management of burn wound pain and itching", section on 'Pharmacologic treatment
options'.)
Nonpharmacologic approaches:
● Relaxation techniques including meditation, progressive muscle relaxation, and guided

imagery
● Hypnosis
● Information provision
● Enhanced coping skills
(See "Management of burn wound pain and itching", section on 'Nonpharmacologic treatment
options'.)
Procedural pain — Anticipatory anxiety is an important issue that can develop with the
repeated performance of wound care. When adequate analgesia is not provided for an initial,
painful procedure, the effectiveness of analgesia for subsequent procedures is reduced, in large
part due to anticipatory anxiety and heightened arousal [12,13]. Thus, efforts to provide
effective procedural burn pain management should begin with the first wound care procedure.
Dressing changes produce pain that is more intense and shorter in duration than background
pain and are optimally managed using potent sedation, analgesia, anxiolytics, and/or general
anesthesia [14]. However, it is impractical to use general anesthesia on a daily basis.
Nonetheless, the provision of deep sedation with carefully titrated inhaled or IV anesthetic
agents, brief general anesthetics, and regional analgesic techniques can have a role in
procedural burn pain settings. Nonpharmacologic techniques (eg, information provision,
distraction, relaxation) serve as an adjunct to pharmacologic management [15].
Administration of moderate or deep sedation should follow institutional guidelines developed

for safety and efficacy. Such guidelines have been established by the American Society of
Anesthesiologists (ASA) [16] and adopted by the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) [17]. These guidelines dictate the safety monitoring
requirements and specific agents that can be used for procedural analgesia, as some of the
more potent opioids (eg, remifentanil) or anesthetics (eg, ketamine) may result in excessive
sedation.
Typical pharmacologic analgesic regimens include moderately to highly potent opioids with a
short duration of action, often in combination with anxiolytics (eg, benzodiazepines). However,
nonopioid agents such as ketamine are used in some centers, particularly in children. The use
of potent opioid analgesics and anxiolytics can occur in settings with or without intravenous
access, yet always requires adequate monitoring, personnel, and resuscitation equipment. For
most burn wound debridement procedures, opioid analgesia with or without the concurrent
use of anxiolytic sedatives (eg, benzodiazepines) will often produce mild-to-moderate sedation.
The following illustrate the pharmacologic approaches to procedural pain, based upon
anticipated severity of pain:
● Severe procedural pain – General anesthesia, deep sedation, or regional anesthesia is

useful for severely painful dressing changes or ones that require extreme cooperation in a
noncompliant patient (eg, face debridement in a young child) [18,19].
● Mild-to-moderate procedural pain – Intravenous and inhalation medications have a rapid

onset of action and a short duration of activity, while oral agents have a prolonged onset of
action and duration. Inhalation anesthetics can be used if intravenous (IV) access is not
possible. The following oral, IV, and inhaled analgesics are used to control mild-to-
moderate procedural pain [20-26]:
• Nonopioid analgesics, anti-inflammatory agents (eg, acetaminophen, ibuprofen)

• IV opioid analgesics (eg, fentanyl, remifentanil)
• IV anesthetic agents (eg, ketamine, dexmedetomidine, lidocaine)
• Orally administered opioid analgesics (eg, oxycodone, hydromorphone)
• Oral ketamine
• Oral transmucosal fentanyl
• Inhaled nitrous oxide
● Minor procedure pain – Minor procedures may also require analgesia and/or sedation,
particularly for children. These procedures include removal of numerous staples from
grafted sites, meticulous wound care of recently grafted sites and/or donor sites, and
wound care involving the face and/or neck. Either ketamine or propofol can be used for
minor procedures, depending on the surgeon's preference. Historically, IV or intramuscular
ketamine has been used in children and adults [27,28].
• Oral ketamine is an option for pediatric burn patients without IV access [20]. However,
ketamine use is limited by the potential risk of associated emergence delirium
reactions (5 to 30 percent incidence), particularly in older adults.
• When administered by appropriately trained and experienced personnel (eg,

anesthesia providers), propofol is a safe and effective alternative in the burn pain
management setting [29] and is being evaluated as a potential drug for PCA delivery
for less aggressive wound care procedures [30]. Propofol is particularly advantageous
as it can be titrated to effect both in terms of level of consciousness and duration of
action using continuous IV infusion techniques and has the additional benefit of a
rapid awakening with a minimal risk of nausea. However, propofol is more rapidly
cleared and has a higher volume of distribution in burn patients, necessitating careful
increases in dose [31,32].
Nonpharmacologic approaches:
● Relaxation techniques, including meditation, progressive muscle relaxation, and guided

imagery
● Hypnosis
● Distraction – media (iPad games, videos, etc.), bubbles, songs
● Information provision
● Enhanced coping skills
Breakthrough pain — Breakthrough pain occurs when the comfort provided by background
pain management is exceeded [33]. The cause of breakthrough pain includes inadequate
background analgesic management, development of opioid tolerance, and/or changes in the
burn wound that increase pain (eg, proliferation of epidermal skin buds during the
spontaneous burn healing process, burn wound infection). A change in the pharmacologic
and/or nonpharmacologic pain management is based upon the correct diagnosis for the
breakthrough pain. As an example, an adult patient hospitalized with a partial-thickness burn
covering 10 percent total body surface area is receiving 10 mg oral methadone every 12 hours
for background pain. After one week, as painful new skin buds start to appear, the patient
consistently requests (and receives) 1 to 2 doses of 10 mg oral oxycodone between methadone
administration times. After confirming that the burn wound is not infected, the oral methadone
should be temporarily increased to 15 mg every 12 hours until epidermal coverage is complete.
Postoperative pain — Pharmacologic management of postoperative pain includes a temporary

(approximately one to four days) increase in background opioid analgesic support. The optimal
management includes the use of continuous regional block techniques and additional opioid
dosing [34]. (See "Management of acute perioperative pain".)
One of the most useful nonpharmacologic analgesic techniques in this setting is information
provision, so that patients anticipate both the increase and temporary nature of the
postoperative pain. (See "Management of burn wound pain and itching", section on
'Information provision'.)
Chronic pain — Pain is considered chronic if it exists between three to six months after the
wound has healed. The study of chronic pain and hyperalgesia in the burn patient population is
in the early stages of investigation, as most of the research has focused on acute pain.
Retrospective reviews found that 33 to 50 percent of burn patients have chronic pain that
persists for years after the burns are healed [35-37].
The most common form of chronic pain is neuropathic pain. Neuropathic pain is the result of
damage sustained by the nerve endings in the skin. Other causes of chronic pain are likely from
musculoskeletal pain associated with deconditioning. Patients report that chronic pain is
exacerbated by temperature change, dependent position, or weight-bearing activities. (See
"Pharmacologic management of chronic non-cancer pain in adults", section on 'Pharmacologic
therapy for neuropathic pain'.)
No data from randomized trials have identified the optimal management of chronic pain in
burn patients. Chronic pain is best managed with nonopioid analgesics and
nonpharmacological approaches. Extreme caution should be taken if opioids are to be used for
chronic pain, with careful supervision for safety and adjustments of the doses and dosing
schedule based upon response. Medication options also include pregabalin [38] and
gabapentin [39]. Nonsteroidal anti-inflammatory drugs (NSAIDs) can also be used as a
nonopioid option. (See "NSAIDs: Therapeutic use and variability of response in adults".)
For patients who do not have relief of chronic pain or hyperalgesia with opioids and
nonsteroidal anti-inflammatory agents, clinical experience and case studies have shown efficacy
with antidepressants (eg, duloxetine) and/or anticonvulsant analgesics (eg, gabapentin)
following burn injuries [39-41]. (See "Pharmacologic management of chronic non-cancer pain in
adults", section on 'Antiepileptic medications' and "Pharmacologic management of chronic non-
cancer pain in adults", section on 'Pharmacologic therapy for neuropathic pain'.)
Nonpharmacologic approaches should focus on the impact of chronic pain. These approaches
include diversion techniques and relaxation techniques and can target healthy lifestyle choices
and more adaptive thinking styles. (See "Management of burn wound pain and itching", section
on 'Nonpharmacologic treatment options'.)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Chronic pain
management" and "Society guideline links: Acute pain management".)
SUMMARY AND RECOMMENDATIONS
Pain management is a central component of the treatment of patients with burns. Despite
advances in various aspects of burn care, control of burn pain is often inadequate during the
acute and chronic rehabilitation phases of burn care. Pain is among the most common causes
of distress during the first year after recovery and, hence, should be aggressively managed.
● Optimal management of burn pain requires a structured approach that incorporates both
pharmacologic and nonpharmacologic therapies, targets the specific clinical pain settings
unique to the burn patient, and is individualized to meet specific patient needs and
institutional capabilities. (See 'Paradigm-based management' above.)
● A burn pain paradigm can be used to guide management of the different phases and
variability of burn pain. This paradigm is based upon five phases of burn pain occurrence:
background, procedural, breakthrough, postoperative, and chronic. (See 'Burn pain
paradigm' above.)
● For background pain management, the combination of pharmacologic and

nonpharmacologic techniques can be used. We suggest using continuous or scheduled
intravenous morphine for pain management in the critical care setting (Grade 2B). For
patients who are tolerating oral intake, the regimen can be adjusted to include scheduled
methadone, extended release morphine, and eventually nonsteroidal anti-inflammatory
drugs (NSAIDs)/acetaminophen. (See 'Background pain' above.)
● For procedural pain management (eg, dressing changes), the combination of

pharmacologic and nonpharmacologic techniques can be used. The approach depends on
the anticipated pain caused by the procedure. For procedures that are severely painful, we
suggest general or regional anesthesia (Grade 2B). For mildly-to-moderately painful
procedures, a drug with rapid onset and short duration in combination with a
nonpharmacologic technique (eg, information provision) may be sufficient. Appropriate
regimens are shown in the table ( table 1). For procedures that cause minor pain, mild
pharmacologic sedation with nonpharmacologic approaches will usually suffice. (See

'Procedural pain' above.)
● For postoperative pain management, a transient increase in dosing of opioids and the use
of regional anesthetics can be added as needed. We suggest using intravenous morphine
or fentanyl for the critical care setting (Grade 2B). For noncritical care settings, when
intravenous (IV) access is not available, postoperative pain can be managed with
oxycodone. Nonpharmacologic techniques that were effective prior to the operation and
that matched a person's coping style should continue to be used in the postoperative
period. A particularly helpful technique is information provision. (See 'Postoperative pain'
above.)
● For chronic and neuropathic pain management, the combination of pharmacologic and
nonpharmacologic techniques may be useful in managing pain. We suggest nonopioid
regimens, with adjustments of the doses and dosing schedule based upon response (Grade
2B). Nonpharmacologic options, such as cognitive distraction, hypnosis, and relaxation
techniques, should focus on decreasing the impact of chronic pain and enhancing quality of
life. (See 'Chronic pain' above.)
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Topic 16505 Version 16.0
GRAPHICS
University of Washington Burn Center Pain Medication Guidelines
Non-critical
Critical care Critical care Non-critical care
care
treatment treatment treatment (small
treatment
(without oral (with oral open
(large open
intake) intake) areas/predischarge)
areas)
Background Continuous Scheduled Scheduled Scheduled
pain morphine sulfate methadone or methadone or NSAIDs/acetaminophen,
(IV) drip or extended-release extended-release oxycodone or none
scheduled doses morphine or PCA morphine or PCA
or PCA
Procedural General or Oxycodone, Oxycodone, Oxycodone or ketamine

pain regional fentanyl IV, or oral fentanyl (IV), or propofol
anesthesia or transmucosal nitrous oxide
deep sedation for fentanyl or (IH), or oral
severe pain ketamine transmucosal
fentanyl or
Morphine sulfate
ketamine or
(IV), fentanyl (IV),
propofol
ketamine and
dexmedetomidine
(IV)
Breakthrough Morphine sulfate Oxycodone Oxycodone NSAIDs/acetaminophen

pain (IV) or fentanyl or oxycodone
(IV)
Postoperative Continuous Scheduled Scheduled Scheduled

pain morphine sulfate methadone or methadone or NSAIDs/acetaminophen,
(IV) drip or extended-release extended-release oxycodone or none
scheduled doses morphine or PCA morphine or PCA
or PCA
Chronic pain Gabapentin or Gabapentin or anxiolysis

other nonopiods or NSAIDS or
or antidepressants
antidepressants
Anxiolysis
medications
for
background
and/or
procedure
management
Background Scheduled Scheduled None or None

anxiolysis lorazepam (IV) or lorazepam scheduled
continuous lorazepam
lorazepam (IV)
drip
Procedural Lorazepam or Lorazepam None or None

anxiolysis midazolam (IV) lorazepam
Post-
hospitalization
pain control
Discharge or N/A For transfer to Oxycodone for Oxycodone or NSAIDs

transfer pain non-critical care procedural pain; for procedural pain
medications treatment: wean methadone taper
drips; establish PO or extended-
pain medication release
early; anticipate morphine; taper
dose tapering as if applicable
needs decrease
Representative pain and sedation management guideline for adult (nonpediatric, nongeriatric) burn
patients from the University of Washington Burn Center. General medication recommendations are
provided for specific pain and anxiolysis needs encountered in various intensive care units and ward-care
settings. Medication options are intentionally limited (for simplicity) and do not include specific dose
recommendations (to allow for individual patient variability). Complex or refractory cases are managed
through special consultation with the burn care team and/or pain specialists.
PCA: patient-controlled analgesia; IV: intravenously; NSAIDs: nonsteroidal antiinflammatory drugs; IH:
inhalation.
Graphic 59472 Version 6.0
Contributor Disclosures
Shelley Wiechman, PhD Nothing to disclose Sam R Sharar, MD Nothing to disclose Marc G Jeschke,
MD, PhD Patent Holder: MyScarTape [Scars]. Kathryn A Collins, MD, PhD, FACS Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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9/29/21, 10:12 AM Paradigm-based treatment approaches for burn pain control - UpToDate

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Paradigm-based treatment approaches for burn pain

BURN PAIN PARADIGM

CHALLENGES IN MANAGING BURN PAIN

● Dosing of analgesics – Opioid analgesic dosing is based on patient weight, which is

● Pharmacokinetics – Burn injuries result in variable and often unpredictable changes in

● Route of drug administration – Options include intravenous, inhalation, oral,

● Hyperalgesia – Hyperalgesia is an increased sensitivity to pain and is induced by the acute

DRUGS AND DOSING

Optimizing pharmacotherapy — The principles for optimizing opioid pharmacotherapy in

● Monitor side effects and prevent or treat them; do not undermedicate.

● Monitor anxiety and changes in mood.

● Apply nonpharmacologic interventions to complement, not replace, analgesia. (See

Background pain — Pharmacologic and nonpharmacologic management strategies relieve

● Continuous intravenous (IV) opioid infusions, such as patient-controlled analgesia (PCA)

● Oral administration of long-acting opioids with prolonged elimination (methadone) or

● Oral administration on a regular schedule of short-acting oral opioid analgesics or

● Relaxation techniques including meditation, progressive muscle relaxation, and guided

● Enhanced coping skills

Administration of moderate or deep sedation should follow institutional guidelines developed

● Severe procedural pain – General anesthesia, deep sedation, or regional anesthesia is

● Mild-to-moderate procedural pain – Intravenous and inhalation medications have a rapid

• Nonopioid analgesics, anti-inflammatory agents (eg, acetaminophen, ibuprofen)

• When administered by appropriately trained and experienced personnel (eg,

● Relaxation techniques, including meditation, progressive muscle relaxation, and guided

● Distraction – media (iPad games, videos, etc.), bubbles, songs

● Enhanced coping skills

Postoperative pain — Pharmacologic management of postoperative pain includes a temporary

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● For background pain management, the combination of pharmacologic and

● For procedural pain management (eg, dressing changes), the combination of

pharmacologic sedation with nonpharmacologic approaches will usually suffice. (See

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18. Dimick P, Helvig E, Heimbach D, et al. Anesthesia-assisted procedures in a burn intensive

24. Choiniere M, Grenier R, Paquette C. Patient-controlled analgesia: a double-blind study in

University of Washington Burn Center Pain Medication Guidelines

Procedural General or Oxycodone, Oxycodone, Oxycodone or ketamine

Breakthrough Morphine sulfate Oxycodone Oxycodone NSAIDs/acetaminophen

Postoperative Continuous Scheduled Scheduled Scheduled

Chronic pain Gabapentin or Gabapentin or anxiolysis

Background Scheduled Scheduled None or None

Procedural Lorazepam or Lorazepam None or None

Discharge or N/A For transfer to Oxycodone for Oxycodone or NSAIDs

Graphic 59472 Version 6.0

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