A paradigm shift in acute pain assessment and management

We have embarked upon a unique strategy to assess and manage pain. “Opioids Rarely Help Bodily Pain” is not a catchy phrase but a mnemonic related to educational learning which serves as the cornerstone of a new acute-pain management paradigm. As is known, the evaluation of pain is extremely difficult due to its subjective nature. However, this new evaluation not only accounts for the patients’ self-assessment but, for the first time in a hospital policy format, incorporates objective measures of pain into a global assessment algorithm.

Historically, when we asked a patient to rate their pain, the answer was a number. We now follow up by asking whether that “number” equates or qualifies their pain as tolerable or intolerable. Our goal is to render the pain tolerable, that allows the patient to meet the daily goals or specific milestones while progressing towards discharge. To finish our assessment, the objective component must be completed before any changes in analgesic therapy. The following are the five pillars based on the Opioids Rarely Help Bodily Pain treatment plan:

  1. Observation
  2. Respiratory Rate
  3. Heart Rate
  4. Blood Pressure
  5. Pupil Size

In most cases, if two out of five of the objective signs are positive, it may confirm intolerable pain. On the contrary, if there are objective signs which suggest overtreatment then the need to de-escalate analgesic therapy may be suggested.

This new kind of acute pain assessment, with its de-emphasis on the numeric scale and incorporation of objective measures, would not be complete without a change in analgesic management. Gone are the days where orders are written based solely on the patients’ self-assessed numeric values that are equated with a medication for mild, moderate, or severe pain. After three decades of using this methodology, there have been no improvements in the management of pain, while the complications of opioid overtreatment have continued to escalate.

Our approach is to take the results of the pain assessment and use them as a guide for analgesic therapy. Thus, we have implemented an analgesic pain ladder based on four tiers. Tier I includes non-opioids, tier II are low-dose opioids, tier III are higher-dose opioids, and tier IV are PCA options. Within tiers I–III are PO and IV alternatives. In addition to the tiers, there is a list of adjunct medications. Tier I and its adjuncts are scheduled medications, while tiers II and III are PRNs.

This new assessment and management algorithm allows for nursing to migrate between the analgesic tiers, resulting in escalation, maintenance, or de-escalation of analgesic therapy. While it is beyond the scope of this article to go into more detail, it must be stressed be that high-risk patients should be managed in a higher-acuity setting with commensurate monitoring.

Our hope is that this new methodology for the assessment and management of acute pain will serve as a template for the rest of the country. Our metrics for success are less morphine milligram equivalents (MMEs) per day and less Narcan use. I am happy to report that after going live with our protocols on November 27th, 2018, we have seen a 25 percent decrease in MMEs and a 50 percent decrease in Narcan use. This has certainly exceeded our expectations.

Myles Gart is an anesthesiologist.

Image credit: Shutterstock.com

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