Pain Management Protocol

[webblarsk]

I was wondering if anyone uses a protocol for pain management. For instance using a milder pain medication and working up to what is needed. The hospice I work for goes straight for a Duragesic patch when pain becomes a issue. My question is would it be better for the patient if we started out less and worked up. I was just curious if any hospice's have a protocol for pain and some examples that I could present! Or if we are doing the right thing using Duragesic patches all the time! TIA!

[dojahrn]

Webblarsk,

Our Hospice usually takes Duragesic patches off if pt. comes into our inpatient unit, from home care, or the hospital for pain mgmt. We usually start subq around the clock based on an equalanalgesic amount of the patch/parental/ oral dose the patient was on previously...then we use a range to tweek it for comfort. So if 5mg subq is the equal dose...we'll use a range from 5-8mg, increasing it if necessary until the patient is comfortable. If the pt is not terminal..(because the pt's pain usually increases when dying), we convert the satisfactory dose to oral or pca pump for outpatient.

we use methadone frequently, it's cheap and effective. We also use morphine, and dilaudid. We do use all the adjuvant drugs like versed, neurontin, etc.

Dojah

[doodlemom]

Depending on how much and what kind of pain a pt has, we will start them on different regimens. Obviously if it's a cancer pt and they are telling us they are having severe pain then we might start them on something stronger right off. We frequently will start a pt on a small amount of methadone with something for breakthru and go up from there. We use a lot of methadone. Yes, it is cheap...but it works better than anything I have ever seen. Methadone 10 mg/ml liquid can be given sl making it easy to dose a pt with a long acting that cannot swallow. We have phased out duragesic patches and rarely use them - unless the attending physician insists. Most hospices that I know of are not using them anymore. They are way too expensive and they don't work very well on many of our pt's.

[webblarsk]

Depending on how much and what kind of pain a pt has, we will start them on different regimens. Obviously if it's a cancer pt and they are telling us they are having severe pain then we might start them on something stronger right off. We frequently will start a pt on a small amount of methadone with something for breakthru and go up from there. We use a lot of methadone. Yes, it is cheap...but it works better than anything I have ever seen. Methadone 10 mg/ml liquid can be given sl making it easy to dose a pt with a long acting that cannot swallow. We have phased out duragesic patches and rarely use them - unless the attending physician insists. Most hospices that I know of are not using them anymore. They are way too expensive and they don't work very well on many of our pt's.

I have heard alot about Methadone and how good it is, and would love to try it. But I am in a rural area with a bunch of doc's that seem afraid of Methadone! Have you run into a problem like that where you are? Do you have any tips of how to get the Doc's approval?

[suebird3]

My facility starts out with the lowest dose of pain meds and works up. If the patient and/or family agrees to Hospice, we work with Hospice on the pain management suggestions.

Suebird :)

[doodlemom]

I have heard alot about Methadone and how good it is, and would love to try it. But I am in a rural area with a bunch of doc's that seem afraid of Methadone! Have you run into a problem like that where you are? Do you have any tips of how to get the Doc's approval?

We are lucky in that our medical director is very well respected (by most physicians - there are always those that just don't get it). When we fax a request to start a pt on methadone, we will usually say Dr._____ recommends starting pt on ...At first there was some hesitation, but now many of our docs have seen the benefit - especially the oncologists. They don't even question the dosing anymore. Is your medical director trained in hospice and palliative medicine?

[webblarsk]

We are lucky in that our medical director is very well respected (by most physicians - there are always those that just don't get it). When we fax a request to start a pt on methadone, we will usually say Dr._____ recommends starting pt on ...At first there was some hesitation, but now many of our docs have seen the benefit - especially the oncologists. They don't even question the dosing anymore. Is your medical director trained in hospice and palliative medicine?

The medical director is great! Very willing to try new things. The problem in this area is the other doc's. They get so upset if the medical director suggests anything. Its a big power struggle!

[doodlemom]

Maybe it would be helpful to your hospice if your Medical Director would do inservices (on various subjects regarding end of life care) for physicians. That way other physicians get to know him/her. We've done a lot of PR in the hospitals and the physicians, as well as hospital staff have really come to respect our medical director.

[webblarsk]

Maybe it would be helpful to your hospice if your Medical Director would do inservices (on various subjects regarding end of life care) for physicians. That way other physicians get to know him/her. We've done a lot of PR in the hospitals and the physicians, as well as hospital staff have really come to respect our medical director.

We are implementing something like that! So maybe that will be helpful! Thanks for all the suggestions, I appreciate it!

[aimeee, BSN, RN]

Its really a shame how underused methadone is in this country. I would love to have a medical director who was experienced in using it. Because there is no one in our area who is truly skilled in its use, it is a last resort usually.

[doodlemom]

Its really a shame how underused methadone is in this country. I would love to have a medical director who was experienced in using it. Because there is no one in our area who is truly skilled in its use, it is a last resort usually.

If you feel comfortable, I would push your administrators to spend the $ educating your Medical Director. I work for a non profit, so the switch to methadone was a necessity for us to decrease our costs. It will save your hospice a LOT of money. Methadone costs pennies. The reason it is so underused is because there aren't a bunch of drug reps selling it to physicians and training them on using it. The only way a physician gets to learn how to use it is by learning about it on their own. I will ask our medical director where to look for training and I will report back here.