PAIN CARE
One Size Does Not Fit All: Opioid Dose Range Orders Chris Pasero, MS, RN-BC, FAAN WITH THE INTRODUCTION of The Joint Commission (TJC) pain assessment standards 14 years ago, hospitals nationwide implemented initiatives to improve pain management.1 The ongoing evaluation of pain management practices by TJC and Centers for Medicare and Medicaid (CMS) surveyors during hospital accreditation visits not only continues to fuel attempts to improve the way pain is managed in hospitals, but also has introduced unexpected and concerning consequences. The combination of a focus on reducing undertreated pain, obtaining pain intensity ratings as the primary (and sometimes only) method of pain assessment, and the prevalence of opioid-only pain treatment plans has resulted in an increase in life-threatening opioid-related adverse events.2-6 In 2012, TJC published a sentinel event alert presenting concerns related to opioid administration in hospitals.7 Based on its 2004 to 2011 database of reported opioid-related sentinel events, 47% of the reported events were the result of wrong dose, 29% from improper monitoring, and 11% owing to other factors such as excessive dosing, medication interactions, and adverse effects.7 Research has also shown that opioid-related adverse effects occur most frequently in patients receiving higher doses of opioids and that these events result in increased hospital length of stay and cost of care.8-10 A new concern for health care providers is the inclusion of the patient’s perception of pain control during hospitalization as one of the indicators used Chris Pasero, MS, RN-BC, FAAN, Pain Management Educator and Clinical Consultant in El Dorado Hills, CA. Conflict of interest: Chris Pasero is a member of the speaker bureau for Cadence Pharmaceuticals and Cumberland Pharmaceuticals. Address correspondence to Chris Pasero, 1252 Clearview Drive, El Dorado Hills, CA 95762; e-mail address: cpasero@ aol.com. Ó 2014 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.03.004
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to determine global patient satisfaction with the hospital experience in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which is distributed to patients after discharge11 (Table 1). As part of the Affordable Care Act, the HCAHPS survey scores are publicly available and linked to hospital reimbursement for care.12 This action has led to even more aggressive pain treatment with opioids in an attempt to improve patient satisfaction. As the patient’s primary pain managers, nurses feel responsible for the HCAHPS scores related to pain control and thus, indirectly, for hospital reimbursement. They often describe feeling tremendous pressure to control pain and are compelled to administer high opioid doses in an effort to achieve a favorable HCAHPS score (Table 1: ‘‘.did staff do all they could.?’’). It is important to note that although research has shown a correlation between patient perception of pain control and global satisfaction with hospital stay,13 there is no evidence that higher opioid doses improve the patient’s perception of either of these measures. All health care providers must remember that the ultimate quality indicator for most patients is to experience an uneventful hospital stay and expeditious discharge.
Improving Safety and Effectiveness of Pain Management There are a number of actions hospitals can take to improve the safety and effectiveness of pain management. These actions may help to improve the patient’s perception of pain control and ultimately global satisfaction with the hospital experience. An important first step is to form a multidisciplinary task force with instructions to evaluate current pain management practices. This begins by asking the following questions: Are practices in place that help to identify and monitor patients at high risk for opioidinduced respiratory depression?
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Table 1. HCAHPS Survey Pain Control Questions During this hospital stay, how often was your pain well controlled? B Never B Sometimes B Usually B Always During this hospital stay, how often did the hospital staff do everything they could to help you with your pain? B Never B Sometimes B Usually B Always HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems.
Do prescribers use a multimodal analgesia approach that seeks to administer the lowest effective opioid dose or to avoid opioids altogether in all patients with pain? Are dangerous practices, such as order sets that link pain intensity to opioid dose, in place that discourage nurses from considering multiple patient and iatrogenic factors before the administration of an opioid dose? Are patients and families educated about the importance of achieving both effective and safe pain control?
Identify, Monitor, and Control Risk It is imperative for members of the health care team to appreciate that all patients are at risk for opioid-induced respiratory depression14; however, a number of patient characteristics and iatrogenic practices have been identified that further elevate risk for patients during opioid administration7,15,16 (Table 2). As with other medication prescribing, it is essential to identify patients who have high risk factors before the prescription and administration of an opioid. Careful review of the patient’s general state of health, current medication use, and pertinent laboratory and radiology findings as well as talking with patients and their families about risk (eg, patient functionality or smoking habits) can help to identify high-risk patient factors.15 Asking patients if anyone has ever told them they snore or pause in
Table 2. Risk Factors for Opioid-Induced Respiratory Depression*
Age .55 y Obesity (eg, body mass index .30 kg/m2) Untreated obstructive sleep apnea History of snoring or witnessed apnea Excessive daytime sleepiness Retrognathia Neck circumference .17.5 Preexisting pulmonary/cardiac disease or dysfunction, for example, chronic obstructive pulmonary disease and congestive heart failure Major organ failure (albumin level , 30 g/L and/or blood urea nitrogen .30 mg/dL) Dependent functional status (unable to walk four blocks or two sets of stairs or requiring assistance with ambulation) Smoker (.20 pack-years) American Society of Anesthesiologists patient status classification 3 to 5 Increased opioid dose requirement Opioid-na€ıve patients who require a high dose of opioid in short period of time, for example, 10 mg IV morphine or equivalent in postanesthesia care unit (PACU) Opioid-tolerant patients who are given a significant amount of opioid in addition to their usual amount, such as the patient who takes an opioid analgesic before surgery for persistent pain and receives several IV opioid bolus doses in the PACU followed by highdose IV patient-controlled analgesia (PCA) for ongoing acute postoperative pain First 24 h of opioid therapy (eg, first 24 h after surgery is a high-risk period for surgical patients) Pain is controlled after a period of poor control Prolonged surgery (.2 h) Thoracic and other large incisions that may interfere with adequate ventilation Concomitant administration of sedating agents, such as benzodiazepines or antihistamines Large single-bolus techniques, for example, singleinjection neuraxial morphine Continuous opioid infusion in opioid-naive patients, for example, IV PCA with basal rate Naloxone administration: Patients who are given naloxone for clinically significant respiratory depression are at risk for repeated respiratory depression
IV, intravenous. *Patient may have one or more of the following to be considered high risk. Modified and used with permission from Pasero et al,16 Copyright 2011.
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breathing during sleep, or asking a loved one who would have knowledge of these characteristics helps to identify patients with possible sleepdisordered breathing.16,17 (Snoring represents airway obstruction, and responding promptly when it is detected during the hospital stay can be a life-saving action.16,17) The routine use of tools such as the STOP-Bang questionnaire, which screens patients for conditions such as obstructive sleep apnea, is recommended and can be easily implemented in all patients on admission.7,18 Practices that introduce risk (ie, iatrogenic risk) should be avoided whenever possible. Nurses must recognize that opioid-only treatment plans are innately high risk, and that aggressive opioid administration (eg, opioid doses greater than the equivalent of 10 mg of intravenous [IV] morphine or 1.5 mg of IV hydromorphone within a short period of time, such as in the postanesthesia care unit [PACU]) significantly increases a patient’s risk status.4,16,19 A primary culprit in opioid-related adverse events is the concomitant administration of other sedating medications such as general anesthetics, benzodiazepines, and some antihistamines (eg, diphenhydramine [Benadryl]) and antiemetics (eg, promethazine [Phenergan], and hydroxyzine [Vistaril]).15,16 The American Society for Pain Management Nursing recommends careful consideration of patient and iatrogenic risk factors to determine the type and frequency of monitoring during opioid administration.15 The identification of risk is an ongoing nursing responsibility throughout the continuum of care. Identification of new risk from deterioration in patient status or the introduction of dangerous practices indicates the need to obtain orders for more aggressive monitoring. Alternately, changes in the type and frequency of monitoring may be warranted as patients improve and near discharge from the hospital. Systematic assessment of respiratory status and sedation level should be conducted in all patients who receive opioids, regardless of the route of administration.7,15-17,19,20 Mechanical monitoring, such as pulse oximetry and capnography, is essential in patients with high risk.14,15 If the level of monitoring indicated by patient risk is not possible on the current nursing unit, nurses must advocate for orders to move the patient to a
unit where the appropriate level of monitoring is possible.16,17
Use Multimodal Analgesia Opioids are effective analgesics for the treatment of acute pain, but when used alone can result in numerous adverse effects, including excessive sedation and life-threatening respiratory depression.4,10,15-17,19,20 Numerous professional organizations have released evidence-based guidelines that emphasize the importance of avoiding opioid-only treatment plans and using instead a multimodal analgesia approach that allows lower opioid doses (‘‘opioid dose-sparing’’) or avoids opioids altogether.15,21-23 Multimodal analgesia combines drugs with different underlying mechanisms of pain-relieving action.16 The rationale behind multimodal analgesia is that combinations of analgesics produce better pain relief at lower doses of each analgesic than is possible with any single analgesic administered alone. The primary advantage of a multimodal approach is that lower analgesic doses can result in fewer adverse events.16 Research has shown that multimodal techniques can produce economic benefits through reduced resource utilization (eg, less nursing time spent on the management of opioid side effects and unrelieved pain) and improved clinical outcomes (eg, earlier oral intake and ambulation and shorter length of stay).10 The most common analgesics combined in acute pain treatment plans are nonopioids (eg, acetaminophen and nonsteroidal anti-inflammatory drugs), opioids, local anesthetics, and increasingly anticonvulsants.16 Nurses must learn to view opioid-only treatment plans as extremely dangerous and promptly advocate for the addition of nonopioid analgesics, preferably before the administration of an opioid.4 Nonopioids should be the foundation of the pain treatment plan rather than an afterthought. Multimodal analgesia also involves the use of nonpharmacologic methods, such as the application of hot or cold packs, music therapy, and relaxation breathing, among many others.7,24,25 A principle of pain management is that nonpharmacologic methods are used to complement, not replace pharmacologic methods for moderate-to-severe pain.16,21
PAIN CARE
Implement Opioid Dose Range Orders Opioid dose range orders are medication orders in which the selected dose varies over a prescribed range according to the patient’s situation and status.16,26,27 Range orders have been used for decades to manage pain and are considered essential to effective pain treatment.16,28 It has long been recognized that there is wide interindividual variability in analgesic requirements and response to a given analgesic dose.16,29 Range orders allow the flexibility needed to address patients’ unique and varying opioid requirements.28 The use of range orders is supported by the American Society for Pain Management Nursing and the American Pain Society in a joint consensus statement, which was reviewed by TJC (see end of the statement).28 Some boards of nursing have addressed this issue and recognized that the selection of a dose from a properly written range order is within the scope of nursing practice (personal e-mail communication between author and California Board of Registered Nursing). Readers are advised to contact their own state board of nursing as practice may vary. Table 3 provides guidelines for proper prescription and implementation of opioid dose range orders. Hospitals that implement these guidelines and have an educational plan that supports nurses in the implementation of the orders have successfully passed TJC and CMS surveys. Linking Dose to Pain Intensity An alarming trend in hospitals nationwide is to replace opioid dose range orders with standardized orders that link specific opioid doses to specific pain intensities. For example, a common standardized opioid order for acute pain might be: 2 mg of IV morphine for pain ratings of 1 to 3 (on 0-to-10 scale) 4 mg of IV morphine for pain ratings of 4 to 6 6 mg of IV morphine for pain ratings higher than 6 This type of standardized order is particularly dangerous because it discourages nurses from using their assessment skills to evaluate other important patient factors, such as age, sedation level, respiratory status, and comorbidities, in addition
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Table 3. Considerations for the Prescription and Implementation of Opioid Dose Range Orders2,16,19,27,28 Use multimodal analgesia to facilitate the administration of the lowest effective opioid dose, that is, insure nonopioids, such as acetaminophen and nonsteroidal anti-inflammatory drugs, if not contraindicated, are the foundation of the pain treatment plan for all patients with acute pain. B Do not exceed the maximum daily dose of the nonopioids in the treatment plan. The maximum dose in the opioid dose range order should be at least two times but generally no more than four times the lowest dose in the range. B An example of an acceptable opioid dose range for an adult is 2 to 8 mg of IV morphine. Orders should specify a specific dosing interval and indication, for example, every 2 h when necessary for pain. If the patient is opioid na€ıve, the first dose should be the lowest dose in the range order. Consider multiple factors, including the patient’s pain intensity, age, sedation level, respiratory status, comorbidities and organ function, concurrent medications and anesthesia, presence of underlying chronic pain, whether the patient is opioid na€ıve or opioid tolerant, and the kinetics (onset, peak, and duration) of the opioid to be administered, when selecting a dose from a range order (Figure 1). For the very young and old, ‘‘start low and go slow.’’ Anticipate a more pronounced opioid peak effect and longer duration of action in patients with hepatic or renal insufficiency. Recognize that comorbidities may affect the patient’s response to an opioid dose, for example, patients who are debilitated or those with respiratory insufficiency are at higher risk for hypoxia. Recognize that concomitant administration of other sedating drugs, such as general anesthetics, sedating muscle relaxants, benzodiazepines, diphenhydramine, and promethazine, have an additive effect and should be used with caution with opioid pain management therapies; systematic sedation assessment is essential with the understanding that increased sedation precedes respiratory depression. Evaluate how well the patient tolerated a previous opioid dose, that is, how well did the prior dose relieve the pain and were there any side effects? Contact the prescriber for alternative orders if the dose options within the prescribed range pose a threat to patient safety or are inadequate for the achievement of optimal pain control. IV, intravenous.
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to pain intensity, before administering a dose of opioid2,16 (Figure 1). This practice compromises patient safety by mandating the administration of doses that could easily result in an overdose in some patients. Such orders have legal implications for nurses who implement them and hospitals that allow their implementation.
appropriate range orders and supports nurses in safe and effective implementation of the orders are recommended.16,27 As the patient’s primary pain managers and the specialty that is ultimately held liable for safe medication administration, nurse managers and bedside nurses must be involved in this process and provide strong input.
Furthermore, this practice is not evidence based.16 Research has shown that the relationship between pain intensity scores and dose requirements during and after titration is not linear, suggesting that many factors influence pain and its relief and that there is no specific dose that will relieve pain of a specific intensity.28-31 This evidence underscores that ‘‘one size does not fit all.’’ Other research has shown that no single pain intensity can reliably predict a given patient’s analgesic requirement or desire for more analgesia.32 This is why dosing to a specific pain intensity is dangerous and strongly discouraged.2,3,5,16,19,28,30
The ‘‘It Depends Campaign’’
Rather than eliminating opioid dose range orders and placing patients at risk for respiratory depression with standardized orders that link doses to pain intensity, a multidisciplinary effort to establish policies and procedures that align with the recommendations in Table 3, and an educational process that teaches prescribers how to write
Hospitals nationwide are taking creative approaches to help insure the safety surrounding the use of opioid range orders. One example is the ‘‘It Depends Campaign,’’ which consists of teaching nurses the many factors in addition to pain intensity that must be considered when selecting an opioid dose from a range order (Figure 1 and Tables 2 and 3). For example, age is considered a valid consideration when determining opioid dose; doses should be adjusted for patients at the extremes of the age spectrum, such as neonates, who have lower protein binding than older infants, and older adults, who are at greater risk for drug accumulation than younger adults.15,16 Hepatic and renal dysfunction can dramatically affect the metabolism and elimination of opioids.15,16 Opioid-na€ıve patients (those who have not taken regular daily doses of opioids for several days) have not developed tolerance to the
Type(s) of Pain Age
Pain Intensity
Respiratory & Sedation Status
Underlying Pathology
Individualized Therapy Organ Function
Opioid Tolerance
Persistent (Chronic) Pain
Anesthesia & Other Meds
Kinetics of Analgesic
Figure 1. Individualized dose selection: ‘‘It Depends campaign.’’ Copyright 2013, Chris Pasero. This figure is available in color online at www.jopan.org.
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respiratory depressant effects of opioids and thus are at the risk for respiratory depression during opioid administration.15,16 However, it is important for nurses to remember that respiratory depression can occur in opioidtolerant patients who have been given a significant amount of opioid in addition to their usual daily amount.16 Tables 2 and 3 can be posted in areas where analgesic orders are written to remind prescribers of the important patient and iatrogenic risk factors and how to write an appropriate opioid dose range order. Figure 1 can be copied, laminated, and placed in nurses’ stations and on medication carts and attached to name badges to serve as a reminder to consider the many factors that influence decision making with regard to opioid dose selection. Patient and family education about how pain will be managed is critical to the success of such campaigns. They should be informed on admission that the patient’s unique characteristics are considered when developing and implementing a pain treatment plan that is both effective and safe. It is important to show the pain rating scale and explain that it is a communication tool that allows patients to tell the health care team how severe their pain is and whether or not pain-relieving measures are helpful. It is equally important to explain that the intensity of pain is one of the many factors that are assessed when optimizing the pain treatment plan. Nurses can show a laminated copy of Figure 1 to patients
and families during teaching sessions. Patients and families are usually receptive when staff members explain the negative consequences of unrelieved pain as well as the potential for adverse effects from overmedication. Explaining the relationship between pain control and optimal function is critical. Nurses play a key role in explaining that the ultimate goal of pain control is to maximize the patient’s ability to participate in the care plan and that the pain treatment plan will be adjusted to optimize participation.
Summary The health care team is increasingly challenged in its efforts to provide patients with pain management that is both effective and safe. The stakes have been raised as health care moves from volume-based to value-based reimbursement. Patients’ perceptions of the quality of multiple aspects of their hospital stay, including the quality of the pain control they received, impacts hospital reimbursement. Efforts to improve patient satisfaction with pain control must focus on requiring the use of multimodal analgesia techniques and avoiding standardized order sets (ie, dose linked to pain intensity) that place patients at great risk for lifethreatening opioid-related adverse events and pose a huge liability to nurses who must implement them. Pain intensity is one of the many factors that must be considered when selecting an opioid dose. The use of opioid dose range orders allows nurses to consider multiple patient and iatrogenic factors and use their judgment to select a dose that reflects each patient’s unique characteristics and status at that moment in time.
References 1. Phillips DM. JCAHO pain management standards are unveiled. JAMA. 2000;284:428-429. 2. Institute for Safe Medication Practices (ISMP). Pain Scales Don’t Weigh Every Risk. ISMP MEDICATION SAFETY ALERT!. Institute for Safe Medication Practices. 2002. Available at: https:// www.ismp.org/newsletters/acutecare/articles/20020724.asp. Accessed February 2, 2014. 3. Lucas CE, Vlahos AL, Ledgerwood AM. Kindness kills: The negative impact of pain as the fifth vital sign. J Am Coll Surg. 2007;205:101-107. 4. Pasero C. The perianesthesia nurse’s role in the prevention of opioid-induced sentinel events. J Perianesth Nurs. 2013;28:31-37. 5. Vila H Jr., Smith RA, Augustyniak MJ, et al. The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: Is patient safety
compromised by treatment based solely on numerical pain ratings. Anesth Analg. 2005;101:474-480. 6. White PF, Kehlet H. Improving pain management: Are we jumping from the frying pan into the fire? Anesth Analg. 2007; 105:10-12. 7. The Joint Commission. Safe use of opioids in hospitals. The Joint Commission Sentinel Event Alert. 2012;49 (August 8):1-5. Available at: http://www.jointcommission.org/sea_ issue_49/. Accessed April 3, 2014. 8. Oderda GM, Evans RS, Lloyd J, et al. Cost of opioid-related adverse drug events in surgical patients. J Pain Symptom Manage. 2003;25:276-283. 9. Oderda GM, Said Q, Evans RS, et al. Opioid-related adverse drug events in surgical hospitalizations: Impact on costs and length of stay. Ann Pharmacother. 2007;41:400-406.
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10. Philip BK, Reese PR, Burch SP. The economic impact of opioids on postoperative pain management. J Clin Anesth. 2002;14:354-364. 11. U.S. Department of Health and Human Services, Centers for Medicare and Medicaid. HCAHPS: Patients’ perspectives of care survey. Available at: http://cms.gov/Medicare/Quality-Ini tiatives-Patient-Assessment-Instruments/HospitalQualityInits/ HospitalHCAHPS.html. Accessed January 3, 2014. 12. Department of Health and Human Services Centers for Medicare & Medicaid Services. Hospital inpatient value-based purchasing program; final rule. Federal Register 2011;76: 26489-26547. Available at: http://www.gpo.gov/fdsys/pkg/FR2011-05-06/pdf/2011-10568.pdf. Accessed April 3, 2014. 13. Gupta A, Daigle S, Mojica J, et al. Patient perception of pain care in hospitals in the United States. J Pain Res. 2009;2: 157-164. 14. Weininger MB, Lee LA. No patient shall be harmed by opioid-induced respiratory depression. APSF Newsletter. 2011;26:21. 26-28. 15. Jarzyna D, Jungquist C, Pasero C, et al. American Society for Pain Management Nursing evidence-based consensus guideline on monitoring of opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011;12:118-145. 16. Pasero C, Quinn TE, Portenoy RK, et al. Opioid analgesics. In: Pasero C, McCaffery M, eds. Pain Assessment and Pharmacologic Management. St. Louis, MO: Mosby/Elsevier; 2011: 277-622. 17. Pasero C. Assessment of sedation during opioid administration. J Perianesth Nurs. 2009;24:186-190. 18. Chung F, Yang Y, Liao P. Predictive performance of the STOP-Bang score for identifying obstructive sleep apnea in obese patients. Obes Surg. 2013;23:2050-2057. 19. Pasero C. Safe IV opioid titration for severe acute pain. J Perianesth Nurs. 2010;25:314-318. 20. Noble KA, Pasero C. Opioid induced ventilatory impairment (OIVI). J Perianesth Nurs. 2014;29:143-151. 21. American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. Glenview, IL: American Pain Society; 2008.
CHRIS PASERO 22. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: An updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116:248-273. 23. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013; 41:263-325. 24. Bruckenthal P. Integrating nonpharmacologic and alternative strategies into a comprehensive management approach for older adults with pain. Pain Manag Nurs. 2010;11(2 Suppl):S23-S31. 25. McCaffery M. What is the role of nondrug methods in care of patients with acute pain? Pain Manag Nurs. 2002;3: 77-80. 26. Manworren RC. A call to action to protect range orders. Am J Nurs. 2006;106:65-68. 27. Pasero C, Manworren RC, McCaffery M. IV opioid range orders for acute pain management. Am J Nurs. 2007;107: 52-59. 28. Gordon DB, Dahl J, Phillips P, et al. The use of ‘‘asneeded’’ range orders for opioid analgesics in the management of acute pain: A consensus statement from the American Society for Pain Management Nursing and the American Pain Society. Pain Manag Nurs. 2004;5:53-58. 29. Bijur PE, Kenny MK, Gallagher EJ. Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients. Ann Emerg Med. 2004;46:362-367. 30. Aubrun F, Langeron O, Quesnel C, et al. Relationships between measurement of pain using visual analog score and morphine requirements during postoperative intravenous morphine titration. Anesthesiology. 2003;98:1415-1421. 31. Aubrun F, Riou B. In reply to ‘‘The pain visual analog scale: Linear or nonlinear?’’. Anesthesiology. 2004;100:745. 32. Blumstein HA, Moore D. Visual analog pain scores do not define desire for analgesia in patients with acute pain. Acad Emerg Med. 2003;10:211-214.
One Size Does Not Fit All: Opioid Dose Range Orders Chris Pasero, MS, RN-BC, FAAN WITH THE INTRODUCTION of The Joint Commission (TJC) pain assessment standards 14 years ago, hospitals nationwide implemented initiatives to improve pain management.1 The ongoing evaluation of pain management practices by TJC and Centers for Medicare and Medicaid (CMS) surveyors during hospital accreditation visits not only continues to fuel attempts to improve the way pain is managed in hospitals, but also has introduced unexpected and concerning consequences. The combination of a focus on reducing undertreated pain, obtaining pain intensity ratings as the primary (and sometimes only) method of pain assessment, and the prevalence of opioid-only pain treatment plans has resulted in an increase in life-threatening opioid-related adverse events.2-6 In 2012, TJC published a sentinel event alert presenting concerns related to opioid administration in hospitals.7 Based on its 2004 to 2011 database of reported opioid-related sentinel events, 47% of the reported events were the result of wrong dose, 29% from improper monitoring, and 11% owing to other factors such as excessive dosing, medication interactions, and adverse effects.7 Research has also shown that opioid-related adverse effects occur most frequently in patients receiving higher doses of opioids and that these events result in increased hospital length of stay and cost of care.8-10 A new concern for health care providers is the inclusion of the patient’s perception of pain control during hospitalization as one of the indicators used Chris Pasero, MS, RN-BC, FAAN, Pain Management Educator and Clinical Consultant in El Dorado Hills, CA. Conflict of interest: Chris Pasero is a member of the speaker bureau for Cadence Pharmaceuticals and Cumberland Pharmaceuticals. Address correspondence to Chris Pasero, 1252 Clearview Drive, El Dorado Hills, CA 95762; e-mail address: cpasero@ aol.com. Ó 2014 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.03.004
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to determine global patient satisfaction with the hospital experience in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which is distributed to patients after discharge11 (Table 1). As part of the Affordable Care Act, the HCAHPS survey scores are publicly available and linked to hospital reimbursement for care.12 This action has led to even more aggressive pain treatment with opioids in an attempt to improve patient satisfaction. As the patient’s primary pain managers, nurses feel responsible for the HCAHPS scores related to pain control and thus, indirectly, for hospital reimbursement. They often describe feeling tremendous pressure to control pain and are compelled to administer high opioid doses in an effort to achieve a favorable HCAHPS score (Table 1: ‘‘.did staff do all they could.?’’). It is important to note that although research has shown a correlation between patient perception of pain control and global satisfaction with hospital stay,13 there is no evidence that higher opioid doses improve the patient’s perception of either of these measures. All health care providers must remember that the ultimate quality indicator for most patients is to experience an uneventful hospital stay and expeditious discharge.
Improving Safety and Effectiveness of Pain Management There are a number of actions hospitals can take to improve the safety and effectiveness of pain management. These actions may help to improve the patient’s perception of pain control and ultimately global satisfaction with the hospital experience. An important first step is to form a multidisciplinary task force with instructions to evaluate current pain management practices. This begins by asking the following questions: Are practices in place that help to identify and monitor patients at high risk for opioidinduced respiratory depression?
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Table 1. HCAHPS Survey Pain Control Questions During this hospital stay, how often was your pain well controlled? B Never B Sometimes B Usually B Always During this hospital stay, how often did the hospital staff do everything they could to help you with your pain? B Never B Sometimes B Usually B Always HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems.
Do prescribers use a multimodal analgesia approach that seeks to administer the lowest effective opioid dose or to avoid opioids altogether in all patients with pain? Are dangerous practices, such as order sets that link pain intensity to opioid dose, in place that discourage nurses from considering multiple patient and iatrogenic factors before the administration of an opioid dose? Are patients and families educated about the importance of achieving both effective and safe pain control?
Identify, Monitor, and Control Risk It is imperative for members of the health care team to appreciate that all patients are at risk for opioid-induced respiratory depression14; however, a number of patient characteristics and iatrogenic practices have been identified that further elevate risk for patients during opioid administration7,15,16 (Table 2). As with other medication prescribing, it is essential to identify patients who have high risk factors before the prescription and administration of an opioid. Careful review of the patient’s general state of health, current medication use, and pertinent laboratory and radiology findings as well as talking with patients and their families about risk (eg, patient functionality or smoking habits) can help to identify high-risk patient factors.15 Asking patients if anyone has ever told them they snore or pause in
Table 2. Risk Factors for Opioid-Induced Respiratory Depression*
Age .55 y Obesity (eg, body mass index .30 kg/m2) Untreated obstructive sleep apnea History of snoring or witnessed apnea Excessive daytime sleepiness Retrognathia Neck circumference .17.5 Preexisting pulmonary/cardiac disease or dysfunction, for example, chronic obstructive pulmonary disease and congestive heart failure Major organ failure (albumin level , 30 g/L and/or blood urea nitrogen .30 mg/dL) Dependent functional status (unable to walk four blocks or two sets of stairs or requiring assistance with ambulation) Smoker (.20 pack-years) American Society of Anesthesiologists patient status classification 3 to 5 Increased opioid dose requirement Opioid-na€ıve patients who require a high dose of opioid in short period of time, for example, 10 mg IV morphine or equivalent in postanesthesia care unit (PACU) Opioid-tolerant patients who are given a significant amount of opioid in addition to their usual amount, such as the patient who takes an opioid analgesic before surgery for persistent pain and receives several IV opioid bolus doses in the PACU followed by highdose IV patient-controlled analgesia (PCA) for ongoing acute postoperative pain First 24 h of opioid therapy (eg, first 24 h after surgery is a high-risk period for surgical patients) Pain is controlled after a period of poor control Prolonged surgery (.2 h) Thoracic and other large incisions that may interfere with adequate ventilation Concomitant administration of sedating agents, such as benzodiazepines or antihistamines Large single-bolus techniques, for example, singleinjection neuraxial morphine Continuous opioid infusion in opioid-naive patients, for example, IV PCA with basal rate Naloxone administration: Patients who are given naloxone for clinically significant respiratory depression are at risk for repeated respiratory depression
IV, intravenous. *Patient may have one or more of the following to be considered high risk. Modified and used with permission from Pasero et al,16 Copyright 2011.
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breathing during sleep, or asking a loved one who would have knowledge of these characteristics helps to identify patients with possible sleepdisordered breathing.16,17 (Snoring represents airway obstruction, and responding promptly when it is detected during the hospital stay can be a life-saving action.16,17) The routine use of tools such as the STOP-Bang questionnaire, which screens patients for conditions such as obstructive sleep apnea, is recommended and can be easily implemented in all patients on admission.7,18 Practices that introduce risk (ie, iatrogenic risk) should be avoided whenever possible. Nurses must recognize that opioid-only treatment plans are innately high risk, and that aggressive opioid administration (eg, opioid doses greater than the equivalent of 10 mg of intravenous [IV] morphine or 1.5 mg of IV hydromorphone within a short period of time, such as in the postanesthesia care unit [PACU]) significantly increases a patient’s risk status.4,16,19 A primary culprit in opioid-related adverse events is the concomitant administration of other sedating medications such as general anesthetics, benzodiazepines, and some antihistamines (eg, diphenhydramine [Benadryl]) and antiemetics (eg, promethazine [Phenergan], and hydroxyzine [Vistaril]).15,16 The American Society for Pain Management Nursing recommends careful consideration of patient and iatrogenic risk factors to determine the type and frequency of monitoring during opioid administration.15 The identification of risk is an ongoing nursing responsibility throughout the continuum of care. Identification of new risk from deterioration in patient status or the introduction of dangerous practices indicates the need to obtain orders for more aggressive monitoring. Alternately, changes in the type and frequency of monitoring may be warranted as patients improve and near discharge from the hospital. Systematic assessment of respiratory status and sedation level should be conducted in all patients who receive opioids, regardless of the route of administration.7,15-17,19,20 Mechanical monitoring, such as pulse oximetry and capnography, is essential in patients with high risk.14,15 If the level of monitoring indicated by patient risk is not possible on the current nursing unit, nurses must advocate for orders to move the patient to a
unit where the appropriate level of monitoring is possible.16,17
Use Multimodal Analgesia Opioids are effective analgesics for the treatment of acute pain, but when used alone can result in numerous adverse effects, including excessive sedation and life-threatening respiratory depression.4,10,15-17,19,20 Numerous professional organizations have released evidence-based guidelines that emphasize the importance of avoiding opioid-only treatment plans and using instead a multimodal analgesia approach that allows lower opioid doses (‘‘opioid dose-sparing’’) or avoids opioids altogether.15,21-23 Multimodal analgesia combines drugs with different underlying mechanisms of pain-relieving action.16 The rationale behind multimodal analgesia is that combinations of analgesics produce better pain relief at lower doses of each analgesic than is possible with any single analgesic administered alone. The primary advantage of a multimodal approach is that lower analgesic doses can result in fewer adverse events.16 Research has shown that multimodal techniques can produce economic benefits through reduced resource utilization (eg, less nursing time spent on the management of opioid side effects and unrelieved pain) and improved clinical outcomes (eg, earlier oral intake and ambulation and shorter length of stay).10 The most common analgesics combined in acute pain treatment plans are nonopioids (eg, acetaminophen and nonsteroidal anti-inflammatory drugs), opioids, local anesthetics, and increasingly anticonvulsants.16 Nurses must learn to view opioid-only treatment plans as extremely dangerous and promptly advocate for the addition of nonopioid analgesics, preferably before the administration of an opioid.4 Nonopioids should be the foundation of the pain treatment plan rather than an afterthought. Multimodal analgesia also involves the use of nonpharmacologic methods, such as the application of hot or cold packs, music therapy, and relaxation breathing, among many others.7,24,25 A principle of pain management is that nonpharmacologic methods are used to complement, not replace pharmacologic methods for moderate-to-severe pain.16,21
PAIN CARE
Implement Opioid Dose Range Orders Opioid dose range orders are medication orders in which the selected dose varies over a prescribed range according to the patient’s situation and status.16,26,27 Range orders have been used for decades to manage pain and are considered essential to effective pain treatment.16,28 It has long been recognized that there is wide interindividual variability in analgesic requirements and response to a given analgesic dose.16,29 Range orders allow the flexibility needed to address patients’ unique and varying opioid requirements.28 The use of range orders is supported by the American Society for Pain Management Nursing and the American Pain Society in a joint consensus statement, which was reviewed by TJC (see end of the statement).28 Some boards of nursing have addressed this issue and recognized that the selection of a dose from a properly written range order is within the scope of nursing practice (personal e-mail communication between author and California Board of Registered Nursing). Readers are advised to contact their own state board of nursing as practice may vary. Table 3 provides guidelines for proper prescription and implementation of opioid dose range orders. Hospitals that implement these guidelines and have an educational plan that supports nurses in the implementation of the orders have successfully passed TJC and CMS surveys. Linking Dose to Pain Intensity An alarming trend in hospitals nationwide is to replace opioid dose range orders with standardized orders that link specific opioid doses to specific pain intensities. For example, a common standardized opioid order for acute pain might be: 2 mg of IV morphine for pain ratings of 1 to 3 (on 0-to-10 scale) 4 mg of IV morphine for pain ratings of 4 to 6 6 mg of IV morphine for pain ratings higher than 6 This type of standardized order is particularly dangerous because it discourages nurses from using their assessment skills to evaluate other important patient factors, such as age, sedation level, respiratory status, and comorbidities, in addition
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Table 3. Considerations for the Prescription and Implementation of Opioid Dose Range Orders2,16,19,27,28 Use multimodal analgesia to facilitate the administration of the lowest effective opioid dose, that is, insure nonopioids, such as acetaminophen and nonsteroidal anti-inflammatory drugs, if not contraindicated, are the foundation of the pain treatment plan for all patients with acute pain. B Do not exceed the maximum daily dose of the nonopioids in the treatment plan. The maximum dose in the opioid dose range order should be at least two times but generally no more than four times the lowest dose in the range. B An example of an acceptable opioid dose range for an adult is 2 to 8 mg of IV morphine. Orders should specify a specific dosing interval and indication, for example, every 2 h when necessary for pain. If the patient is opioid na€ıve, the first dose should be the lowest dose in the range order. Consider multiple factors, including the patient’s pain intensity, age, sedation level, respiratory status, comorbidities and organ function, concurrent medications and anesthesia, presence of underlying chronic pain, whether the patient is opioid na€ıve or opioid tolerant, and the kinetics (onset, peak, and duration) of the opioid to be administered, when selecting a dose from a range order (Figure 1). For the very young and old, ‘‘start low and go slow.’’ Anticipate a more pronounced opioid peak effect and longer duration of action in patients with hepatic or renal insufficiency. Recognize that comorbidities may affect the patient’s response to an opioid dose, for example, patients who are debilitated or those with respiratory insufficiency are at higher risk for hypoxia. Recognize that concomitant administration of other sedating drugs, such as general anesthetics, sedating muscle relaxants, benzodiazepines, diphenhydramine, and promethazine, have an additive effect and should be used with caution with opioid pain management therapies; systematic sedation assessment is essential with the understanding that increased sedation precedes respiratory depression. Evaluate how well the patient tolerated a previous opioid dose, that is, how well did the prior dose relieve the pain and were there any side effects? Contact the prescriber for alternative orders if the dose options within the prescribed range pose a threat to patient safety or are inadequate for the achievement of optimal pain control. IV, intravenous.
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to pain intensity, before administering a dose of opioid2,16 (Figure 1). This practice compromises patient safety by mandating the administration of doses that could easily result in an overdose in some patients. Such orders have legal implications for nurses who implement them and hospitals that allow their implementation.
appropriate range orders and supports nurses in safe and effective implementation of the orders are recommended.16,27 As the patient’s primary pain managers and the specialty that is ultimately held liable for safe medication administration, nurse managers and bedside nurses must be involved in this process and provide strong input.
Furthermore, this practice is not evidence based.16 Research has shown that the relationship between pain intensity scores and dose requirements during and after titration is not linear, suggesting that many factors influence pain and its relief and that there is no specific dose that will relieve pain of a specific intensity.28-31 This evidence underscores that ‘‘one size does not fit all.’’ Other research has shown that no single pain intensity can reliably predict a given patient’s analgesic requirement or desire for more analgesia.32 This is why dosing to a specific pain intensity is dangerous and strongly discouraged.2,3,5,16,19,28,30
The ‘‘It Depends Campaign’’
Rather than eliminating opioid dose range orders and placing patients at risk for respiratory depression with standardized orders that link doses to pain intensity, a multidisciplinary effort to establish policies and procedures that align with the recommendations in Table 3, and an educational process that teaches prescribers how to write
Hospitals nationwide are taking creative approaches to help insure the safety surrounding the use of opioid range orders. One example is the ‘‘It Depends Campaign,’’ which consists of teaching nurses the many factors in addition to pain intensity that must be considered when selecting an opioid dose from a range order (Figure 1 and Tables 2 and 3). For example, age is considered a valid consideration when determining opioid dose; doses should be adjusted for patients at the extremes of the age spectrum, such as neonates, who have lower protein binding than older infants, and older adults, who are at greater risk for drug accumulation than younger adults.15,16 Hepatic and renal dysfunction can dramatically affect the metabolism and elimination of opioids.15,16 Opioid-na€ıve patients (those who have not taken regular daily doses of opioids for several days) have not developed tolerance to the
Type(s) of Pain Age
Pain Intensity
Respiratory & Sedation Status
Underlying Pathology
Individualized Therapy Organ Function
Opioid Tolerance
Persistent (Chronic) Pain
Anesthesia & Other Meds
Kinetics of Analgesic
Figure 1. Individualized dose selection: ‘‘It Depends campaign.’’ Copyright 2013, Chris Pasero. This figure is available in color online at www.jopan.org.
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respiratory depressant effects of opioids and thus are at the risk for respiratory depression during opioid administration.15,16 However, it is important for nurses to remember that respiratory depression can occur in opioidtolerant patients who have been given a significant amount of opioid in addition to their usual daily amount.16 Tables 2 and 3 can be posted in areas where analgesic orders are written to remind prescribers of the important patient and iatrogenic risk factors and how to write an appropriate opioid dose range order. Figure 1 can be copied, laminated, and placed in nurses’ stations and on medication carts and attached to name badges to serve as a reminder to consider the many factors that influence decision making with regard to opioid dose selection. Patient and family education about how pain will be managed is critical to the success of such campaigns. They should be informed on admission that the patient’s unique characteristics are considered when developing and implementing a pain treatment plan that is both effective and safe. It is important to show the pain rating scale and explain that it is a communication tool that allows patients to tell the health care team how severe their pain is and whether or not pain-relieving measures are helpful. It is equally important to explain that the intensity of pain is one of the many factors that are assessed when optimizing the pain treatment plan. Nurses can show a laminated copy of Figure 1 to patients
and families during teaching sessions. Patients and families are usually receptive when staff members explain the negative consequences of unrelieved pain as well as the potential for adverse effects from overmedication. Explaining the relationship between pain control and optimal function is critical. Nurses play a key role in explaining that the ultimate goal of pain control is to maximize the patient’s ability to participate in the care plan and that the pain treatment plan will be adjusted to optimize participation.
Summary The health care team is increasingly challenged in its efforts to provide patients with pain management that is both effective and safe. The stakes have been raised as health care moves from volume-based to value-based reimbursement. Patients’ perceptions of the quality of multiple aspects of their hospital stay, including the quality of the pain control they received, impacts hospital reimbursement. Efforts to improve patient satisfaction with pain control must focus on requiring the use of multimodal analgesia techniques and avoiding standardized order sets (ie, dose linked to pain intensity) that place patients at great risk for lifethreatening opioid-related adverse events and pose a huge liability to nurses who must implement them. Pain intensity is one of the many factors that must be considered when selecting an opioid dose. The use of opioid dose range orders allows nurses to consider multiple patient and iatrogenic factors and use their judgment to select a dose that reflects each patient’s unique characteristics and status at that moment in time.
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