Sunday, August 31, 2008
There is an interesting pair of studies in Quality Management in Health Care on the use of a simple Microsoft Excel-based simulation tool for teaching medical residents to manage pain crisis in cancer inpatients. 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.
- 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