Morphine Often Underdosed in Emergency Medicine

[Ridryder 911]

http://www.merginet.com/index.cfm?pg=medical&fn=morphine

Morphine Often Underdosed in Emergency Medicine

By Bryan E. Bledsoe, DO, FACEP

January 2006, MERGINET—Pain is the number one reason people summon EMS or visit a hospital emergency department. Analgesic therapy is usually prescribed based upon the severity of the patient's perceived pain. Opiates, such as morphine, are often used for severe pain. Typically, the initial intravenous dose for adults is between two and five milligrams. But is this adequate? Researchers at the Albert Einstein College of Medicine in the Bronx, NY, evaluated the effectiveness of morphine dosing in the emergency department. The most frequently used dose of morphine—0.1 milligram per kilogram (mg/kg) body weight—was chosen as the test dose for the study.

Patients in the emergency room who were prescribed morphine for severe pain were approached by a researcher and asked to rate their pain on an 11-point visual analog scale (0-10). There were 119 patients enrolled in the study and they all rated pre-treatment pain at 10/10 on the visual analog score. The patients then received intravenous morphine at a dosage of 0.1 mg/kg. Overall, only 67 percent of the study group reported that their pain was less than 50 percent better with the 0.1 mg/kg morphine dose. There were no differences in regard to age, sex, ethnicity, location of the pain, or associated nausea and vomiting. The researchers concluded that a morphine dose of 0.1 mg/kg was generally inadequate for most emergency patients.

This study reinforces the growing awareness that we in EMS and emergency medicine do a very poor job of treating pain. EMS must assure that the pain needs of our patients are met. Unwarranted concerns about addiction, respiratory depression, and masking of abdominal findings have resulted in many patients receiving nearly homeopathic doses of analgesics for severe pain. EMS is an empathetic profession and we must assure that we are adequately meeting the pain needs of our patients. Perhaps it is time to revisit and revise protocols for prehospital pain management.

Reference

Bijur PE. Kenney MK. Gallagher EJ. “Intravenous Morphine at 0.1 mg/kg is Not Effective for Controlling Severe Acute Pain in the Majority of Patients.” Annals of Emergency Medicine

[JakeEMTP]

http://www.merginet.com/index.cfm?pg=medical&fn=morphine

Morphine Often Underdosed in Emergency Medicine

By Bryan E. Bledsoe, DO, FACEP

This study reinforces the growing awareness that we in EMS and emergency medicine do a very poor job of treating pain. EMS must assure that the pain needs of our patients are met. Unwarranted concerns about addiction, respiratory depression, and masking of abdominal findings have resulted in many patients receiving nearly homeopathic doses of analgesics for severe pain. EMS is an empathetic profession and we must assure that we are adequately meeting the pain needs of our patients. Perhaps it is time to revisit and revise protocols for prehospital pain management.

Reference

Bijur PE. Kenney MK. Gallagher EJ. “Intravenous Morphine at 0.1 mg/kg is Not Effective for Controlling Severe Acute Pain in the Majority of Patients.” Annals of Emergency Medicine

Although I have been in EMS for a short time, I have witnessed this fairly often. The Medic administers the amount of morphine aloud by our protocols, and when asking the pt if they feel better, most of the time they report marginally. I understand the addiction to morphine, I had knee surgery before there was arthroscopic, and believe me, it is a powerful drug. Every 4 hours I was on that buzzer, reminding them it was time for my shot. According to the research done in this study we are not providing pt's with enough relief, which is why we were there in the first place, as Dr. Bledsoe stated. Obviously, the amount of morphine we give is not enough, but hey, that's all we're allowed to give. :wink:

Spell checked for your convenience

[flight-lp]

Interesting study, but the 33%who did not report improvement only got 1 dose fo MS. I'd be interested to see what the % is for subsequent doses.

I am fortunate to have very liberal pain mangement protocols. PRN is a pain patients best friend!

Plus with the increase in Fentanyl usage, hopefully this statistic will improve in the future.......

[AZCEP]

There have been numerous articles regarding pain relief in general. The item that I have found the most interesting is that if pain is not controlled in the first hour, then it probably won't be at all. As providers, we tend to think that a narcotic is the only thing we have to control pain, but there are others as well.

The pathogenesis of pain involves a number of different items occurring in a bit of a sequence. Histamine is released, prostaglandins are produced, inflammation occurs. If we can manage any of these, we can do a better job of managing the pain in indicated circumstances.

I will agree that a little of the opioid happy juice is a powerful agent that needs to be considered early, but as an adjunctive therapy, not as the sole treatment option.

[flight-lp]

Deleted, sorry wrong thread......

[Dustdevil]

Great point, AZ. I would hate for the results of current research calling for better pain management to be oversimplified into a call for nothing more than more narcotics. To do so would be a disservice to our patients.

[medic429]

in the last two weeks, I have had 3 pain control calls...not one person would let me give them ANYTHING.....we have morphine, nitrous, and fentanyl. I tried everything I could think of to convince the people to let me help with pain control...two were 'afraid' and one was concerned it would 'mess with her coumadin'.....after explaining the benefits of ALL the medications, each one declined. Two were dislocated shoulders (one with an accompanying break-this patient has since died....eek!) and one was severe back pain. All three were in very obvious distress......

Anyone have any suggestions there?? Is there a better way to explain the medications? Just curious.

[nsmedic393]

If the patient does not want it there is precious little they can do about it. In recent conversations I have stated my opinion about how in some circumstances when a patient refuses treatment they should be pushed into it if their life is potentially on the line.

I do not share that same sentiment for analgesics. I will offer it. Give them enough information to consider them "informed". If they refuse I'm not going to push the issue. It won't kill them. If they want to live with the pain, i will do everything else I can for them. ie. fluff pillow repeatedly.

Withholding pain control to abdo pain patients is BS. Withholing pain control because you suspect the person is an addict is also BS. We have had a previous discussion here about how you can judge how much pain a person is in and how you should treat them based on their presentation. My line of thought, if they say they are in pain than they are in pain. Irregardless of facial expression, tachycardias, sweating, or whatever indicators you use to judge pain. I ask them ?/10 and go with that.

I would rather give pain meds to an addict than withold them from someone who needed them.

[Yummymedic05]

:roll: People seem to be big babies now and will get a papercut or cough too hard and cry until they get pain meds....good grief!

[aussie_rn]

Withholding pain control to abdo pain patients is BS. Withholing pain control because you suspect the person is an addict is also BS. My line of thought, if they say they are in pain than they are in pain. Irregardless of facial expression, tachycardias, sweating, or whatever indicators you use to judge pain. I ask them ?/10 and go with that.

Here here, finally I've found someone who agrees with me! I found here, in Australia that morphine has been used as the first line towards pain relief (esp. in Emergency dept). Dr's seem to think it is the only thing that can help with the pain instead of choosing something else first that may not cause so many side effects ie Buscopan/ Tramadol...

Here we have a "pain protocol" towards giving morphine where it is titrated until the patient's pain is under control, I've given up to 60mg (over several hrs) of morphine to a patient with pancreatitis, and surprisingly the patient was still able to walk around (much to my dislike) and not have have any other side effects from the high dosage!