Problem: Managing pain has never been more complicated. For instance, a wide variety of analgesics are available for this purpose: dosage forms range from lollipops to patches; delivery vehicles include implantable devices and patient-controlled analgesia (PCA); and varying routes of administration abound.
But in our noble efforts to alleviate pain, has safety been compromised? Although the literature suggests that patients are undertreated for pain, error reports over the past few years reveal a glimpse of perhaps overly aggressive attempts to ensure that patients experience no discomfort.
The Institute for Safe Medication Practices (ISMP) received a report about a 24-year-old woman who died of fentanyl toxicity less than 24 hours after giving birth by cesarean section. She had received several doses of intravenous (IV) fentanyl 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 IV fentanyl was increased. She asked for a blanket 30 minutes later, but she was discovered to be in cardiac arrest within half an hour.
Although this scenario is an extreme example of what can go wrong with pain management, clinicians at several hospitals have conveyed their concerns about an alarming increase in the 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 these scores are not closely associated with each dose of analgesic. Respiratory rates are counted, but their depth and quality are not always considered. Treatment and monitoring might 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 a post-anesthetic care unit (PACU), are not always considered, especially after the patient has been transferred to a nursing unit.
An equally serious difficulty is that many clinicians prescribe a virtual cornucopia of pain-management options consisting of multiple routes and dosages linked only to the patient’s assessment of pain. For example, acetaminophen 650 mg by mouth every four hours might be prescribed for a patient with a score of 1 to 3 on the pain scale; codeine 30 mg by mouth might be ordered every four hours with a score of 4 to 6; IV morphine 2 mg might be given every three hours with a score of 7 to 8; and IV morphine 4 mg ever y four hours might be prescribed with a score of 9 to 10.
Therefore, if patients with a low threshold for pain report discomfort on the high end of the scale, the nurse might administer morphine at the higher dose without carefully considering the patient’s clinical status and cumulative effects of drug therapy. Similarly, if patients with a high threshold for pain rate their discomfort on the low end of the pain scale, the nurse might simply administer acetaminophen.
Although clinicians should not substitute their judgment for a patient’s self-report of pain, perhaps we have left too little room to integrate patients’ assessment of their pain with the clinician’s objective evaluation of the patient’s response to the medication and, most important, safety considerations.
Safe Practice Recommendations:
The following strategies may be helpful in improving pain management: