Finally, Dr. Ling advises hospitalists to examine their own beliefs about using opioids for pain control. “Narcotics, in general, have a social stigma attached to them,” he points out. “I think most doctors, without additional experience and training [in prescribing IV opioids], will have a natural built-in response of, ‘Do I really want to give them that much?’ ”
Dr. Ling admits even he sometimes becomes a little uncomfortable with titrating to larger doses. “But some patients—especially those with a new diagnosis of metastatic cancer—or cancer that is invading an organ system, have appropriately high requirements for pain medication,” he stresses. Dr. Ling recalls one educational video made by the colleague of a patient who required a 400-mg dose of IV morphine daily. While the patient’s surgeon, anesthesiologist, and internist did not believe that the patient required that much morphine, her hospitalist finally convinced the treatment team by achieving adequate pain control using her own pain management skill.
“It’s not the dose so much as looking at the patient and talking with the patient” that should guide dosing decisions, says Eva Chittenden, MD, assistant director of the UCSF Palliative Care Service and chair of SHM’s Palliative Care Task Force. “You will know within 10 to 15 minutes if a dose is working.”
Adds Howard R. Epstein, MD, medical director of Care Management and Palliative Care at Regions Hospital in St. Paul, Minn., and also a member of SHM’s Palliative Care Task Force, “You have to assess your intervention: Was it effective? Did it relieve the patient’s pain? How long did it last?”
Dr. Bookwalter says hospitalists have an edge with pain patients. “The advantage that hospitalists have is that they can do more frequent monitoring,” he says. “The choice of drug is key, but frequent monitoring is even more key: You have to know if the patient is getting nauseated, or is still in pain, or how much the pain decreased with a certain dose.”
Multiple variables influence a clinician’s decision to prescribe IV opioids for a patient—and at what dose and frequency. Basic principles of pain management dictate administering an initial IV bolus by a provider or by using patient-controlled analgesia (PCA) at lower doses if the patient is opioid-naïve, and at higher doses if a patient has already been taking oral narcotics. The NCCN recommends starting doses of 1-5 mg of IV morphine or equivalent for opioid-naïve patients, or a dose 10%-20% of a daily IV morphine equivalent for those already on opioids.2
The clinician should reassess the patient at 15 minutes to determine whether the pain score is unchanged, increased, or decreased. “If, after 15 minutes, that patient is still in severe pain, you want to be giving another dose,” emphasizes Dr. Chittenden. “You want to get the pain under control and then figure out what the standing dose should be.” The NCCN advises increasing the dose by 50%-100% if the pain score is unchanged or has increased after the initial dose.
IV opioids can also be indicated in elderly patients, unless they suffer from renal insufficiency. Palliative care specialists usually follow the maxim “start low and go slow” for elderly patients, and a 0.5 to 1-mg initial dose would be a reasonable place to begin treating an elderly patient in pain, says Dr. Chittenden. In addition to reassessing every 15 minutes for changes in the pain score, the hospitalist should also closely monitor the patient for sedation, respiratory rate, and other untoward side effects.
Hospitalists as Advocates
Hospitalists can play a vital role in advocating for better pain control for hospitalized patients. “Unfortunately,” notes Dr. Epstein, “pain management is not very well taught in most residency programs. But it’s an essential skill—not to mention a core competency—for hospitalists. If they don’t feel comfortable with their current fund of knowledge, there are plenty of resources out there to gain the skills or develop a higher comfort level and provide more competent pain management—to palliative as well as non-palliative patients.”