Skill Sets to Acquire
In addition to postgraduate and conference courses on pain control, another good first step in educating oneself about pain is to become familiar with equianalgesic doses of opioids. It is also mandatory to know not only how to convert between different opioids but between different routes of administration, Dr. Artz emphasizes. This step is crucial when patients have been stabilized and are ready for discharge. When conversions from IV opioids to equianalgesic doses of oral opioids are performed incorrectly, patients get the idea that the oral medication doesn’t work as well and that they need the IV pain medicine, “when, in reality, we didn’t give them an equivalent dose of oral pain medicine.”
Equianalgesic tables for use in converting 24-hour standing doses of an IV opioid to an oral formulation are readily available. Dr. Bookwalter offers a cautionary note about the use of conversion charts: “These charts are based on single-dose studies. The thing to remember is that these are ballpark numbers. Every place and every practitioner will use them in a slightly different way. The key thing is close monitoring to make sure the pain is relieved and that side effects are kept at a minimum.”
Familiarity with various pain intensity scales is also necessary. The Wong numerical rating scale—either written or verbal (0 = no pain and 10 = worst pain imaginable)—is the most commonly used. The Wong-Baker FACES Pain Rating Scale is helpful when assessing patients who are not English speakers or who have other impairments.3 Dr. Artz reminds hospitalists never to guess by just looking at their patients what their levels of pain are. Many patients have developed coping strategies to mask their pain.