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Pain scales don't weigh every risk

From the July 24, 2002 issue

PROBLEM: Spurred by the 2001 Joint Commission pain management standards, many health systems have revamped the way they manage pain and, rightfully so, made patient comfort a high priority. But in our noble efforts to alleviate pain, has safety been compromised? Although literature supports that patients are under-treated for pain, error reports in the past year show a glimpse of perhaps overaggressive attempts to ensure that patients experience no discomfort. Most recently, we heard about a 24-year-old woman who died from fentanyl toxicity less than 24 hours after giving birth by Cesarean section. She had been given several doses of fentanyl IV before and after the birth. That evening, she fed and cared for her daughter. In the early morning, she again complained of pain and the dose of fentanyl IV was increased. She asked for a blanket 30 minutes later, but was found in cardiac arrest within half an hour . While this is an extreme example of what can go wrong with pain management, clinicians at several hospitals have reported concern to us about an alarming increase in oversedation of patients who are receiving pain medications.

Problems with pain management can be linked to insufficient patient monitoring. Too often pain scores are elicited from patients, but not closely associated with each dose of analgesic. Respiratory rates are counted, but depth and quality may not be considered. Treatment and monitoring may not be altered for patients with a history of sleep apnea. The cumulative effects of narcotics given at the end of a surgical procedure and then again in PACU may not be considered, especially after the patient is transferred to a nursing unit.

An equally serious problem is that many patients are prescribed a virtual cornucopia of pain management options in multiple routes and dosages linked only to the patient's assessment of pain. For example, a patient may be prescribed acetaminophen 650 mg PO q4h for pain scale 1-3; codeine 30 mg PO q4h for pain scale 4-6, morphine 2 mg IV q3h for pain scale 7-8; and morphine 4 mg IV q4h for pain scale 9-10. Thus, if a patient with a low threshold for pain reports discomfort on the high end of the scale, the nurse may administer morphine at the higher dose without careful consideration of the patient's clinical status and cumulative effects of drug therapy. Likewise, if a patient with a high threshold for pain rates his discomfort on the low end of the pain scale, the nurse may simply administer the acetaminophen. While clinicians should not substitute their judgment for the patient's self-report of pain, perhaps we have left too little room to integrate the patient's assessment of pain with the clinician's objective evaluation of the patient's response to the medication and, most importantly, safety considerations.

SAFE PRACTICE RECOMMENDATION: First, organizations need to know how well they are managing pain. In addition to patient satisfaction evaluations, hospitals should seek out episodes of oversedation by monitoring adverse drug reaction reports, investigating all use of narcotic reversal agents, and reviewing patient records to determine the effectiveness of pain management therapy. Hold focus groups with clinicians, especially nurses, to discuss the many challenges with managing pain and carefully monitoring patients. Clearly determine the variables that should be considered when selecting the most effective and safe pain management therapy (patient's pain assessment, cultural and ethnic beliefs, clinical observations, patient monitoring parameters). Reduce the variety of analgesics prescribed to patients and evaluate the medications and methods of delivery that are being used frequently. For example, morphine 4 mg IV is commonly prescribed, but fluctuating peak and trough levels make pain management difficult. Hydromorphone (DILAUDID) 1-4 mg IV is another common order, but it is equivalent to 8-32 mg of morphine.
PCA is prescribed often without thoughtful one or four hour limits. Promethazine or hydroxyzine may be added to the regimen, which increases sedation but not analgesic efficacy. NSAIDs and nonpharmacological approaches may be underutilized.

It's also important to eliminate orders with dosage ranges and link specific dosages to the patient's overall response to therapy and clinical status, not to the patient's self assessment of pain alone. Finally, pharmacists should play a more active role in pain management. In our last issue, we mentioned that pain management was the least frequent area for pharmacy interventions. Yet, it is ripe for expanded clinical pharmacy services because of the dire consequences of errors when using powerful narcotics. Even if a physician-driven pain management service is currently available, consider having both a pharmacist and a nurse join the team to broaden the coverage to more routine types of pain management and to enhance patient assessment and monitoring.

Managing pain has never been more complicated. There's a wide variety of different analgesics available on the market; dosage forms that range from lollipops to patches; an assortment of delivery vehicles from implantable devices to patient controlled analgesia (PCA); and varying routes of administration. Now more than ever, it's imperative for healthcare organizations to revisit this issue to ensure a safe, effective, and realistic approach to managing pain.

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