Tending to the "fifth vital sign" can get inpatients back on their feet faster by Michael S. Krivda
Published in the December 2003 issue of Today's Hospitalist
A number of studies and surveys on pain management have all come to the same conclusion: Despite strides in therapies to ease pain, too many inpatients experience significant levels of continuous pain during the course of their treatment. A recent report from the World Health Organization, for example, found that at least 25% of all cancer patients who die in a hospital die without adequate pain relief.
The good news is that several other studies have shown that physicians can manage pain effectively in most patients by using some relatively simple strategies.
Patient controlled analgesia pumps are an ideal way to control postoperative pain.
Of particular interest to inpatient physicians, researchers say that pain management plays a critical role in the recovery process.
"Pain management is the key to faster and better recovery," says B. Eliot Cole, MD, director of education for the American Academy of Pain Management. "Patients who are pain-free are more likely to follow instructions, more willing to participate in therapy, and better able to assist with their own recovery."
We talked to some experts in pain management for an overview of how to treat pain--and for some specifics on what types of drugs you should consider giving hospitalized patients.
At the Heart Hospital of New Mexico in Albuquerque, hospitalists follow an institution-wide pain management model that relies on two basic elements: regular assessments of patient pain and ongoing adjustments to reflect patient input.
David Gonzales, MD, director of the hospitalist program and director of patient care, says that physicians at the hospital view pain as the "fifth vital sign," treating it aggressively and prophylactically. (The hospital performs more than 3,600 heart procedures a year.)
Every patient room, for example, has a pain intensity chart with both a numeric scale and a color scale. Physicians re-assess the patients on an ongoing basis, and they respond immediately to any change in the level of pain.
"We don't treat pain on an as-needed basis," Dr. Gonzales explains. "We anticipate the pain and treat the patients accordingly. We routinely use opioids peri- and postoperatively for up to two or three days. This controls patients' pain, their appetites return faster, they can mobilize sooner, and we see fewer cases of common postoperative conditions such as pneumonia. Use of the opioids has significantly reduced our length of stay and improved the recovery of our patients."
To determine what kind of pain management is appropriate, you need to start with an assessment. A popular tool is an intensity scale that asks patients to rate pain from 0 to 10. Pictorial scales are particularly good for patients with low literacy levels.
While a patient's own reporting of pain is important, if you feel the person is in more pain than he or she is expressing, treat accordingly. For example, an unmedicated post-operative patient who reports only mild pain may have an extremely high tolerance for pain or may be minimizing the pain because of fears about using opioids. In either case, reducing what may be severe pain is essential to recovery.
Before choosing a pain treatment, you need to conduct a careful analgesic history. Make sure to ask about prior and present medications; analgesic response (time to onset of peak effect, duration of action, level of pain relief on a 0 to 10 scale); and side effects.
Experts offer the following advice to keep in mind when assessing pain:
• Once you've done the initial evaluation, keep at it. Re-evaluate your patients' pain frequently.
• While it's critical to make a careful and thorough assessment, don't wait until the assessment is complete to provide some form of pain relief.
• Never use a placebo to determine if a patient's pain is real.
A tiered approach
While you have many options to manage patient pain, experts say that opioids typically offer the best approach to short-term pain management in an inpatient setting. Many physicians, however, avoid opioids because of side effects, the potential for addiction, tolerance and possible respiratory failure.
Many experts say these concerns are exaggerated and should not keep you from prescribing opioids to patients who are in pain. "When properly used and monitored, opioids offer the most effective pain relief available with limited risk to patients," says Eugenie Obbens, MD, associate attending neurologist at the Memorial Sloan-Kettering Cancer Center in New York.
When choosing pain relief, recognize the difference between mild opioids like codeine, hydrocodone and oxycodone in combinational products containing acetaminophen, aspirin or ibuprofen, and major single-entity opioids like morphine, meperidine, hydromorphone, fentanyl and methadone.
While mild and major opioids are full receptor antagonists (blockers, agonists, binders), mild opioids offer relatively low analgesic efficacy. Because they are usually administered orally in combination with other products like aspirin or acetamino¬phen, there are limits to how much you can administer daily without creating problems associated with the co-analgesics.
As a result, pain experts suggest using these lower potency combinational medica¬tions primarily for mild to moderate intense pain that you think will subside relatively quickly. They also point out that these drugs tend to offer only limited efficacy for chronic pain.
Major single-entity opioids, on the other hand, offer a significantly stronger analgesic effect. Some are so powerful that they can relieve nearly any type of pain. Many also have no ceiling dose, so there are few limits as to how much can be administered.
Experts say that continually assessing pain and adjusting your treatments is key. To relieve cancer pain, for example, the World Health Organization calls for a simple three-step process for titrating pharmacologic therapy.
The first step is to prescribe acetaminophen, aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve mild to moderate pain. If pain persists or increases, the second step of the process calls for adding a mild opioid such as codeine or hydrocodone to the acetaminophen, aspirin or NSAID.
When pain persists or increases, the third step is to replace the mild opioid with a more potent single-entity opioid such as morphine, oxycodone, fentanyl or hydromorphone.
Because you can expect many inpatients to have persistent pain, experts say, use opioids on a regular schedule, not just when the patient reports feeling pain. Experts emphasize that the goal is to use these drugs time contingently, not pain contingently.
In some cases, you may need to prescribe relatively large doses of opioids to provide adequate pain relief. When starting a new drug, initially give some of the medication on a fixed schedule and then give as-needed doses for the first 24 to 48 hours for breakthrough or incident pain. You'll then be able to determine the best total daily dosing requirements for that individual patient.
Opioids act differently depending on how you administer them. Here is a look at some of the advantages and disadvantages of each technique.
• Intravenous. Intravenous administration offers the quickest and most precise way to relieve patient pain and monitor for potential toxicity.
If you don't have intravenous access to a patient, one practical alternative is continuous subcutaneous opioid infusion. This route of administration provides opioid levels in blood comparable to those achieved through intravenous doses.
Because of the similarity between intramuscular and subcutaneous dosing, you can typically use the intravenous dosing recommendations. There will be a slight delay between subcutaneous administration and clinical effect, so allow 15 to 20 minutes between subcutaneous administrations before giving the next dose.
Dr. Obbens says that when available, patient controlled analgesia (PCA) pumps are an ideal way to control postoperative pain and admissions for severe uncontrolled pain.
These devices deliver a small, constant flow of pain medication intravenously. When patients feel pain, they simply press a button to receive a pre-set amount of medication. PCA machines have safety features and an alarm system to make sure patients don't accidentally—or deliberately—overmedicate themselves.
For surgical patients, the PCA machine can be used for a few days. You can then switch patients to an oral medication.
"We have found PCA machines to be very effective in both controlling pain and in allowing our patients to participate in their own pain management," says Mark J. Lema, MD, chairman of the department of anesthesiology and pain medicine at the Roswell Park Cancer Institute in Buffalo, N.Y. "In general, we have found that our patients do better with PCA machines, both in terms of the amount of medication required to control their pain and their recovery."
Dr. Lema is also professor and chair of the department of anesthesiology at the University at Buffalo school of medicine and biomedical sciences.
• Oral. Oral opioids are available in tablet, capsule and liquid forms, and in immediate and controlled-release formulations. Keep in mind that if you're going to give your patient a controlled-release agent, you may also need to prescribe an immediate-release analgesic to address breakthrough or incident pain. (Dr. Gonzalez advises caution when using this approach with opioid-naive patients.)
For patients who have nausea, who are vomiting or who may be fasting either preoperatively or postoperatively, suppositories of morphine, hydromorphone and oxymorphone can provide an effective alternative to oral medication.
When converting from oral to rectal administration, start with approximately the same amount as the oral dose and titrate. (Keep in mind that some opioids are 10% to 15% more potent when given rectally.)
• Transdermal. Fentanyl is currently the only opioid commercially available in a transdermal form (TDS-fentanyl). Four patch sizes deliver the drug at 25, 50, 75 or 100 mcg/hr.
In general, the maximum recommended daily dose is 300 mcg per hour, although larger doses can be given. Dr. Obbens says that while giving higher doses is inconvenient because it requires more than three patches, he has put up to six patches on a patient at one time.
If your patient needs more than 300 pg/hour of fentanyl, you can also consider switching to an equianalgesic dose of an oral or subcutaneous administered opioid. Keep in mind that patients may need rapidly-acting short-duration opioids to manage breakthrough pain.
Dr. Gonzalez, however, says the transdermal approach can be problematic for several reasons. For one, drugs administered this way can be difficult to titrate. The drug may also take up to eight hours to reach therapeutic blood levels, he adds, so be sure to have an alternative analgesic on board as well.
Side effects of transdermal fentanyl administration include nausea, mental clouding and skin irritation.
Tolerance and addiction
With opioids, patients often develop what might appear to be a tolerance to the medication. Experts say this initial tolerance is almost always temporary, however, and they note that physicians should not be reluctant to increase the dose in the first few days.
Dr. Cole says it's important to note that there is no initial tolerance to the analgesic effects of opioids. "We sometimes see tolerance to the toxicity of opioids in the first few days of therapy, and we may then see a need to increase doses over time," he explains. "This usually reflects the extent of the disease process more than a pharmacological tolerance to the opioid itself. This is commonly misunderstood by many clinicians."
Patients typically reach an effective dosage to relieve their pain in a single day or so. They usually remain comfortable at that level of medication and only infrequently require a greater dose, most often when they suffer from chronic pain from a condition such as cancer.
If significant pain persists after your initial efforts, titrate the opioid to a higher dose. If the increased dose (potentially 50% to 100% more of the medication) does not relieve the pain, consider changing to a different opioid (usually at one-half to two-thirds of the equianalgesic dose).
Monitor the patient to see if the second medication produces a better analgesic effect. (This technique is referred to as opioid rotation.) Patients often respond differently to different opioid medications.
When it comes to using opioids, physicians often worry that patients may become addicted to these powerful medications. Experts say that in truth, it is extremely unlikely that any patient who does not have a predisposition to addiction will become addicted to pain relievers in an inpatient setting.
For one, you are going to prescribe the medicine for a relatively short period of time. In addition, addiction in such a stressful situation is nearly impossible.
"For addiction to take place, there has to be some pleasurable component to the experience," says Dr. Obbens. "Patients receiving opioids for relief from severe pain do not have that pleasurable experience and are therefore unlikely to become addicted, especially after short-term use."
A greater concern with prescribing opioids can occur when treating patients who need pain relief, but who are already addicted to opioids or were already using opioids to control their pain before they were hospitalized. In these cases, you may have to administer an unusually high dose of an opioid medication to achieve the desired level of pain relief.
"Even drug addicts deserve pain relief if they are suffering," points out Dr. Lema from Roswell Park Cancer Institute in Buffalo. "It's unrealistic to try to detoxify patients after surgery. The key is to recognize that you have to start at their normal level of medication then add the dose that provides the level of pain relief they need."
When pain won't quit
Though opioids relieve most types of pain, you'll occasionally find that some pain is not easily treated. In these instances, carefully consider the possible reasons for this lack of relief. If the patient is not sedated, you must ensure that the patient has had an adequate dose of an opioid before concluding that the patient is not responding to the opioid.
Because codeine and hydrocodone are "pro-analgesics" that the body must metabolize to morphine and hydromorphone respectively, make certain that patients are not taking medications that block the pathway (cytochrome P-450 2D6), or this conversion may be blocked.
One you've determined that you've given the appropriate dose, the next step is to re-evaluate the cause of the pain. Neuropathic pain is often less responsive to opioid medications and may be better managed with anticonvulsants and antidepres¬sants. Bone-related pain is another common cause of seemingly opioid-resistant pain that usually responds better to anti-inflam¬matory agents.
These and other types of pain may require the use of adjuvant analgesics (antidepressants or corticosteroids, for example) and other techniques, including nerve blocks, ablation, chemotherapy, radiotherapy or even counseling, to obtain relief. Experts say that even for these patients, however, opioids usually remain part of the regimen of pain relief.
Michael Krivda is a freelance writer specializing in health care and technology. He is located in Perkasie, Pa.
Strategies to treat four common side effects of opioids
As is the case with virtually all medications, opioids come with side effects. These side effects vary in both their severity and duration, depending upon the medication used. In most cases, however, these side effects are transitory and can be readily managed or eliminated in a hospital setting with proper use of medications and other therapies.
"Opioid-related side effects are well-known and relatively easy to manage," says Eugenie Obbens, MD, associate attending neurologist at the Memorial Sloan-Kettering Cancer Center in New York. "Any physician who is going to use opioids on a regular basis should make an effort to edu¬cate him or herself about the side effects and develop effective protocols for dealing with them."
In some cases, family members may object to what they perceive as unacceptable side effects, especially the temporary sedation that can accompany opioids. Talk to family members, experts say, and explain the role—and the importance of—pain relief.
"Dealing with side effects is part of pain management," says Dr. Obbens. "More often than not, patients are willing to tolerate the relatively minor side effects to receive the larger benefit of relief from severe pain."
While opioids can produce a variety of side effects, you should watch for four primary side effects: constipation, nausea, sedation and respiratory depression.
• Constipation. Experts say this is easily the most common and persistent side effect of opioid use. Manage it systematically with a planned schedule of interventions before starting an opioid. Remember to increase the level of any medications you're using to treat constipation as you increase opioid dosages.
Untreated constipation may lead to abdominal distention, additional pain and possibly intestinal obstruction. Constipation can be best treated by stimulant laxatives (bisacodyl, casanthranol, senna) and stool softeners (docusate).
In more active patients, exercise, fluids, and bulk laxatives can also help.
• Nausea. Nausea is a common side effect for some patients just starting opioids, but it generally passes after repeated dosing. If symptoms are mild, consider waiting up to a few days and consulting with the patient before treating. If symptoms persist, consider treating with antiemetics or neuroleptics such as prochlorperazine (Compazine) or haloperidol (Haldol). Some experts also recommend metoclopramide (Reglan) and other promotility agents.
Sedation or lethargy.
When initially medicated, many patients, especially opioid-naive individuals, experience mild to moderate sedation or lethargy, depending on the dosage. This lethargy typically passes in a matter of days, and properly medicated patients should not experience a recurrence. If the condition persists, consider lowering the dosage or adjusting the time intervals.
"Many patients, and especially their families, will complain about the lethargy, but properly educating everyone involved is the key to calming everyone's fears," says Mark J. Lema, MD, chairman of the department of anesthesiology and pain medicine at Roswell Park Cancer Institute in Buffalo, N.Y. "Only patients who are taking massive doses of medications, which would only typically be found in end-stage cancer patients, would experience these types of symptoms."
• Respiratory depression. The potential for respiratory depression—and respiratory failure—is often cited as a reason why physicians avoid opioids for pain management. Experts say that the dosage required to induce respiratory failure is so high that it is unlikely it could be administered accidentally. Because the threshold for respiratory depression is so well above the threshold for pain relief, respiratory depression is rarely a problem as long as you're titrating opioids appropriately.
Legal aspects of pain management: considerations for hospitalists
Fear of trouble from law enforcement agencies and regulatory boards makes many physicians think twice about using opioids, but hospitalists typically have little to worry about when it comes to appropriately prescribing painkillers.
"Hospitalists are unlikely to attract the attention of law enforcement because they are not seeing the same patients regularly," says Sandra Johnson, JD, LLM, professor of law and Tenet endowed chair in health law and ethics at St. Louis University. "Certainly, hospitalists should not let that impact their decision to use opioids to treat patients."
While community practitioners worry that prescribing large volumes of opioids might attract the attention of regulatory boards, hospitalists have the benefit of working in institutions that generally keep excellent records. Pain experts say that documenting the use of painkillers—particularly when using an aggressive approach—is key to handling scrutiny from either a regulatory board or law enforcement agencies.
"With appropriate procedures and docu¬mentation in place, a physician won't have any difficulties dealing with regulatory bodies," says B. Eliot Cole, MD, director of education for the American Academy of Pain Management.
What about legal trouble from patients and their families? Some physicians worry that they may be sued if the patient concludes that opioids created or exacerbated a health problem. To prevent that kind of problem, experts say, talk to patients and (with their permission) family members before prescribing the drugs. You need to educate them about the risks and benefits of the medications.
Physicians and lawyers who have handled these types of cases say that families tend to file lawsuits over physicians' use of opioids because they didn't understand what was going to happen.
Besides, many lawyers say, you're more likely to be sued these days for undertreating—not overtreating—pain.
"We have seen an increase in the num¬ber of suits brought by patients or families who felt that the physician did a bad job of managing pain," says Ms. Johnson. "Now, a physician is probably more likely to be sued for bad pain management than for any other issues related to the use of opioids."