Wednesday, May 22, 2013

More pain, please?

Have we gone overboard in hospitals in our desire to minimize pain?  Several years ago, there was a lot of effort to require hospitals to inquire of patients where on the 0-10 pain scale they fell.  This was a good idea for many reasons.

But has it led to overuse of opiates like morphine, particularly those self-administered using patient-controlled analgesia (PCA) pumps?

There have many articles on this topic expressing concern about depression of respiration to the point that the patient dies.  The Happy Hospitalist explains:

Why is PCA morphine dangerous?  Too much medication can cause patients to stop breathing. Opiates, often inappropriately referred to as narcotics by doctors and nurses, suppress the central nervous system's respiratory drive and increases the risk of life threatening apnea.  This is the cause of death in a heroin overdose.  This is the cause of death in the epidemic of prescription opiate drug overdoses heard about on the news.  Many PCA morphine order sets require continuous oxygen saturation monitoring and frequent documentation of respiratory rate as safety mechanisms.  This is to protect the patient from experiencing prolonged hypoxemia as a result of too much sedation when no family is available at the bedside. 

The Joint Commission published a sentinel event alert on the matter in August 2012.  The JC addresses the question of monitoring by suggesting that hospitals should:

Create and implement policies and procedures for the ongoing clinical monitoring of patients receiving opioid therapy by performing serial assessments of the quality and adequacy of respiration and the depth of sedation. The organization will need to determine how often the assessments should take place and define the period of time that is appropriate to adequately observe trends.  Monitoring should be individualized according to the patient’s response.

We have to recognize, though, that while ICU patients might have continuous monitoring of respiration, the vast majority of patients on PCA pumps are those on the regular medical/surgical floors of the hospital.  They include "normal" (i.e., otherwise healthy) people recovering from orthopaedic surgery and other procedures.  But that normality does not exempt them from the kind of respiratory depression cited in the literature.

What is the systemic solution to ensure that the possibility of such a result is minimized? The patients with PCA pumps might have continuous oxygen saturation monitoring, but most certainly do not have continuous respiratory monitoring.  The "frequent documentation of respiratory rate" can fall victim to the many other responsibilities and distractions that nurses face.  (It was Anita Tucker at Harvard, I believe, who documented that nurses only spend 20% of their time at the bedside.  As this article reports, "She learned that nurses' time ticks by in minutes or fractions of minutes; their average task took just two minutes.")  Given the demands on nurses and the poor design of work flows with which most of them live, there is a some probability that a percentage of nurses will not accurately assess patients' respiratory rates.

While there are technical fixes to the problem of continuous respiratory monitoring that might prove useful*, I wonder how much of this problem is related to the antecedent decision to reduce pain to a very low level.  Is there a standard of care that is presumed to be appropriate by hospitals?  Is the goal to drive the pain level down to a 1 or 2, or is the goal to reach a level of 3 or 4?  Is there a thought given to the relative risks of different doses for a patient on a PAC morphine pump when the two goals are compared? For sure, reaching a pain level of 0 is noteworthy, but not if it is achieved by killing the patient.


Disclosure:  I am on the advisory board of a company that makes and sells instruments of this sort.


Neville Sarkari MD, FACP said...

I think that most of us try for a pain goal of 3 or 4.

John said...

Very interesting perspective. Hospitals are driven, and graded, by patient satisfaction scores. These frequently ask" was your pain treated to your satisfaction". Thus the loop of having non clinical metrics drive clinical decision making is created.

Your blog is spot on to many of the challenges healthcare faces.

Paul Levy said...

Thanks, Neville. So whether it is 3 or 4 or whatever, is there an explicit consideration of a trade-off with the level of narcotic needed and the possible adverse impact of that dosage? I'm guessing the decision is based on a rough rule of thumb--often influenced by the point John makes about patient satisfaction.

And thanks very much, John.

Neville Sarkari MD, FACP said...


Generally, as the need for higher doses occurs, the patient develops tolerance to the respiratory sedation. If you are following accepted practice you usually can't get in trouble. Trouble comes when you don't pay attention to details. For example, sleep apnea and narcotics can be a bad combination, so you have to pay attention.

However, the biggest thing I've seen cause a problem with PCA pumps is actually family messing with it. They see their loved one toss and turn and push the button "to help them rest". Since one of the key protective mechanisms of a PCA is that the patient gets too sedated to push the button *before* respiratory depression sets in, having someone else push it can be fatal.

I'm not blaming family members, but education when the PCA is set up is key. More education to physicians and nurses on how to dose correctly is also critical.

Paul Levy said...

Thanks (again), Neville, for those insights.

Helen Golding said...

From Facebook:

On a related note, after recent surgeries, my son and I were each sent home with a large quantity of narcotic pain meds, when a day's worth of OTC stuff was really all we needed. A needless expense (and one that may give insurer an excuse to deny coverage for some other prescription drug coverage that's actually necessary), and now I have to remember to check for the next town-sponsored prescription drug collection!

Nancy said...

From Facebook:

I agree with this commentary! We have gone from controlling pain to giving people the false illusion that we can eliminate pain. The end result of this "pain-free movement" being the creation of an opiate dependent population with increased pain receptors and an increased need for narcotics.

As nurses, we openly talk about generational differences in pain tolerance or even willingness to accept medication as a method for treating pain; the "boomers" and seniors seemingly reject narcotics more frequently and consistently than younger generations do in my experience. Well, it appears we have contributed to that with the advent of synthetics, PCA's, etc as means to manage pain- both acute and chronic. Since the young adults now have grown up in a world where we address pain so frequently and heavy-handedly, who is to fault them for not having the "tolerance" of a WWII vet for a sprained ankle or headache?

We certainly don't want to leave anyone suffering or unable to manage daily activities due to pain, but I also hate to think I am helping create a dependency issue. When I insist patients give me a pain score and feel forced to see that it has decreased on re-assessment so that during a chart audit we are not guilty of leaving pain untreated, it makes me wonder why we aren't asking instead "what number is manageable for YOU" instead of holding every person to the same scale. Just my two cents!

Side note--a better way to monitor a pt on PCA would be capnography which gives an earlier indication of hypo ventilation/hypoxemia than oximetry or CRM alone. I understand this is costly and would require additional training for med-surge nurses, but seems safer and should be more widely used.

Neville Sarkari MD, FACP said...

Nancy, I agree with you about generational differences.

At our hospice we do base pain control goals on a patient defined goal.