Pain management protocol

[ErinS, BSN, RN]

Tell me about how pain medicine is used in your hospice. This is for a school project. Do you have a protocol, or just a known standard of practice for titrating meds? What meds do you normally use and why? Which do you dislike and why? Any other pain medicine info you have? What would you like to see in a pain protocol? Thanks!

[RehabRedRN]

HI

Our pain management is based off the world health organizations'e pain control ladder. This would give you a good start with your project.

http://www.who.int/cancer/palliative/painladder/en/

[tewdles, RN]

We have protocols. We have standing orders. We use whatever the patient needs to be comfortable...nothing is dismissed without careful consideration.

We start low and go slow. Our medical directors are very available, engaged, and pro-active in the pursuit of comfort.

[ErinS, BSN, RN]

Tewdles-

Why do you go slow? I know this seems like a stupid question, but I have done lots of research that gives an overall picture that rapid titration of meds is safe and desirable in end of life. We are pretty aggressive in our titration, but I think this is the exception rather than norm. Even starting low has been questioned in some studies. One was an ER study where they started with 1mg dilaudid and repeated every 15 minutes until pt stated no when asked if they wanted more pain medicine. How do you decide what dose to start on a opioid naive pt? For example, in my hospice unless someone has had reactions to 'normal' doses of medication (like lortab 5), we start with 5 mg roxanol and double until pain is controlled.

Sorry to ask so many obvious questions, but as I get into this project I realize there are not many obvious answers. Thanks so much for the discussion!

RehabRedRN- I have looked over the WHO protocol, which is quite good and explicit, but this is not routinely used in the community I work in. Mine will likely follow the WHO protocol closely.

[tewdles, RN]

Tewdles-

Why do you go slow? I know this seems like a stupid question, but I have done lots of research that gives an overall picture that rapid titration of meds is safe and desirable in end of life. We are pretty aggressive in our titration, but I think this is the exception rather than norm. Even starting low has been questioned in some studies. One was an ER study where they started with 1mg dilaudid and repeated every 15 minutes until pt stated no when asked if they wanted more pain medicine. How do you decide what dose to start on a opioid naive pt? For example, in my hospice unless someone has had reactions to 'normal' doses of medication (like lortab 5), we start with 5 mg roxanol and double until pain is controlled.

Sorry to ask so many obvious questions, but as I get into this project I realize there are not many obvious answers. Thanks so much for the discussion!

RehabRedRN- I have looked over the WHO protocol, which is quite good and explicit, but this is not routinely used in the community I work in. Mine will likely follow the WHO protocol closely.

We go slow because so many of our new patients are opioid naive, and we create too many side effects. If the patient warrants it we bang, bang, bang the doses...BUT...that is a VERY individualized plan of care. Our standard is start low and go slow to achieve pain relief and minimize SE. Yes, we begin with 5mg morphine for the "newbie" to opiates...although some can only tolerate 2.5mg for the first dose or two. Nuthin worse than taking a poor painful patient and giving them morphine till they puke...their pain is better but their general quality of life is not so...

Also, it is much easier for us to attack intractable pain aggressively when we have the patients in our IPU rather than in the field.

It sounds, actually, like our protocols are probably pretty similar Erin.