The authors had previously determined through surveys of residents and nurses that residents were unprepared for and uncomfortable with managing pain with opioids. Specifically, they were afraid of respiratory depression, especially with escalating doses and long-acting opioids, and had no preparation for converting to other routes or drugs. The informal practice was to manage all cancer pain with intermittent short-acting opioids. The result was that patients complained of uneven pain control marked by "peaks & valleys" and that average pain scores actually increased among hospitalized cancer patients. Not surprisingly, patients, residents and nurses were dissatisfied with pain management. Outcomes, by the way, were unchanged following standard educational interventions such as grand rounds presentations. The authors then developed a "case-based Microsoft Excel program with an interface from which the user selects from a list of medications, orders a dose, and chooses a follow-up interval to assess pain response." Cases are based on 15 actual patients who had been admitted for treatment of pain exacerbation. All opioids, doses, and times given, and pain score responses for these patients were entered. I'm unclear as to what happened next [I'm not a math or computer guy]. Noting that "patients did not respond the same to any given dose of narcotic" [the grinding teeth you hear are mine] they somehow, using a variety of sources, derived a range of "sensitivities of response to equivalent morphine doses." Operationally, they applied a random number generator to select a sensitivity to each starting dose applied to each patient. One hundred sensitivities are possible. Applied to the 15 patients, this translates to 1500 different cases.
The interface provides a dose-response curve that shows the user what happened when a dose was administered in a particular case. If the user chooses a reassessment interval that is too long, the graph may trend back up into higher pain scores.
The graph above shows one possible dose-response curve for a single dose of opioid. As the case develops, the curve reflects response to all doses over time (48 hours in this study).
Principles of care taught didactically, then reinforced by simulator (Goal: rapid induction of pain relief):
- morphine is the default opioid (ok, so I translated the archaic "narcotic" to the preferred modern term)
- do not define a specific starting dose; instead, assess, start low, rapidly titrate using early close follow up to each dose
- use standard conversion table
- reassess every 30 - 60 minutes during titration
- convert to long-acting opioid as soon as possible ("early in care") to stabilize pain and medication regimen
- use 8-hour intervals for long-acting agents
I won't go into the details, but they tested the simulator against seven actual patients admitted solely for pain control and found that the pre-determined dose-responses programmed into the simulator included those exhibited by the patients. In a pilot study 31 residents completed 2-3 simulations. Results were independently evaluated by 7 reviewers. The finding was that 90% of the residents improved their pain care.
A follow up study (the 2nd article) of several small groups of residents entering their oncology rotation showed that, after simulator training, pain scores--of actual patients they cared for on the oncology unit--decreased (over the first 48 hours after admission for pain control), more patients were prescribed long acting agents, and less naloxone was used.
We have known for many years that providing information alone, and that teaching skills such as safe opioid conversion, does not translate into improved pain control. Even a standard case-based approach is not "real" enough for clinicians to apply the critical thinking and get the feedback they need in order to overcome the endemic fear these drugs evoke. The approach these articles describe is a relatively simple, relatively inexpensive intervention that allows barriers to be broken down in a safe environment.
It wasn't always clear when the authors were describing intravenous vs oral medication administration. But if the reassessment interval for intravenous and oral opioids was the same (30-60 minutes), the patient receiving the intravenous medication is potentially left in unnecessary pain long after the peak effectiveness could have been assessed. In the first article the authors stated that nurses and residents are the primary care providers for patients on the oncology unit. There was no description of the clinical role that nurses played in the care of patients in pain. It is pretty clear to most of us that "the team" needs to include the bedside nurse. The early reassessment of intravenous opioid administration is surely part of the nursing role.
References:1. Harting B, Hasler S, Abrams R, Odwazny R, McNutt R. Computer-based simulation as a teaching tool for residents treating patients with cancer-related pain crises. Qual Manag Health Care. 2008 Jul-Sep;17(3):192-9.
2. Harting B, Abrams R, Hasler S, Odwazny R, McNutt R. Effects of training on a simulator of pain care on the quality of pain care for patients with cancer-related pain. Qual Manag Health Care. 2008 Jul-Sep;17(3):200-3.
4 comments:
Tom: I don't have access to this article - I'm curious as to what was behind the 'use 8 hour intervals for long acting meds'? Did they mean dose, e.g. morphine ER q8hours instead of q12 hours, or something else?
The authors report that they use and teach a default 8-hour interval for ER morphine because they typically see an increased use of breakthrough meds toward the end of a 12-hour interval.
Personally, this is an area in which I prefer to individualize, rather than make a blanket policy or standard practice. I start with the 12-hour interval, then depending on the pattern of breakthrough pain, either increase the 12-hour dose or switch to 8 hours.
TQ
That's interesting and not within my experience as a 'typical' response to morphine ER (maybe ?10% of patients I see benefit from q8h dosing).
Anyway it's an interesting idea and I look forward to reading the articles. It's kind of like case-based learning although qualitatively taken to a next level. Not that pain is treated well in general but severe acute pain is definitely not: lack of quick re-assessment, lack of a dose-finding phase in which people rapidly titrate a pain med to find an effective dose, over-reliance on long-acting/continously delivered opioids in the acute phase, fear of dose escalation, etc. I have seen patients (e.g. with chronic cancer pain) be admitted in a pain crisis and get put on lower equianalgesic pca doses than what they were taking at home because people were afraid of the magnitude of the doses. I tell residents that it's "fine" with me if they are terrified of writing for 10mg/hour of morphine initially (it's not 'fine' but i accept their discomfort) but that writing for inadequate bolus opioids AND NOT FOLLOWING UP is inexcusable - if they're going to stop breathing or get deeply obtunded it's going to happen within minutes of a large bolus and if they can tolerate a dose and it doesn't give them much analgesia dose-escalation is safe/mandatory. It's the lack of follow-up and initial dose-titration which is problematic, and I worry that an over-promotion of PCAs has worsened the problem.
That's enough rambling for one night.
I agree with your teaching point about pain crisis admissions with poor equianalgesic dosing. You can unfortunately see the same thing happen when patients are transferred off their PCA's in the hospital. Going from a 5mg/hr morphine basal PCA to lortab PRN when the pain was not controlled even on the PCA does not make sense. After they have a new pain crisis is when the palliative care team is usually consulted.
I also agree start with q12 then move to q8 if you have evidence of 'interval failure'. And the 10% rate is about right for my practice, maybe even 5%.
It would be nice if there was programmed into this Excel spreadsheet pain program an occasional hiccup. For example: you check that you would like to follow-up in one hour, but the program then tells you about a 'new admission' and your follow-up is delayed and the nurse was too understaffed to call you. Some real life curve balls like that would be interesting to see.
I will email the author of the paper and see if we can get a shot at the Excel program.
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