Sequential Administration of Analgesics

PLEASE NOTE:   Posts made to this forum should not be considered as the expressed opinions of, nor should be considered endorsed by, the Medication Safety Officer’s Society (MSOS) or the Institute for Safe Medication Practices (ISMP). 

Make sure your email is up-to-date
In order to continue to receive updates from MSOS, as well as forum posts and other valuable information as a member of MSOS, please be sure to update your email address with us, whenever it changes. If you need assistance doing so, please send an email to

5 posts / 0 new
Last post
Mike Lewandowski
Mike Lewandowski's picture
Last seen: 1 year 2 weeks ago
Joined: 07/10/2014 - 12:47
Sequential Administration of Analgesics

Hi all,

We're currently reviewing some of our pain management methods given the increased scrutiny over nursing scope of practice. We are trying to strike that difficult balance of maximizing the bedside nurse's ability to assess patients without veering into nurse prescribing, while also providing sufficient policy guidance. I'm looking for input on how others might be handling the numerous ways analgesics might be sequentially used. Is your hospital policy very "strict" and directive, or does it account for specific instances?

Here's an example of some of the scenarios that are currently undefined for us.
A patient has the following medications ordered:
- Oxycodone 5 mg PO every 6 hours as needed for severe pain (rating 7-10)
- Fentanyl 25 mcg IV every 1 hour as needed for severe pain (rating 7-10)
- Hydrocodone/APAP PO 1 tablet every 6 hours as needed for moderate pain (rating 4-6)

If oxycodone is given, can you administer fentanyl two hours later for ongoing severe pain, or are you "locked out" from giving anything for severe pain until the 6 hour oxycodone interval has passed?

Can the RN, at his/her discretion, give both oxycodone and fentanyl together? Or is it always one or the other based on NPO status, etc.?

If oxycodone is given, and two hours later the patient now reports only moderate pain, can hydrocodone be given, even though the patient is receiving two opioids relatively close together?

I realize that these questions are incredibly nuanced and specific, and in many cases also clinically appropriate for pain management. My concern is that trying to account for every possible scenario results in a convoluted policy or set of orders that no one can realistically follow. Any input would be greatly appreciated.