Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

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Comment on Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients

Also posted over at Paramedicine 101. Go check out the rest of what is there.

In response to Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients, there is a comment by medic.

thank you for your post. i’d like to add a few thoughts, and please feel free to comment on them.

Thank you.

1. i have a suspicion that pts who rate their pain 7-8/10 tend to be more honest about their pain than the ones who rate their pain 10/10 (worst pain ever), which perhaps partially explains the study’s findings when sorted by initial pain rating.

That may be. Pain is subjective. Out of 119 patients, only 5 rated their pain 7 out of 10, so this is a small fraction that may not indicate anything. If we wish to draw conclusions about patients with 7 out of 10 pain, we need to set up a much larger study and propose our hypotheses before the study is begun.

Even if a report of 7 out of 10 pain is more honest than a report of 10 out of 10 pain, does that make it any less appropriate to treat 10 out of 10 pain aggressively?

2. competence is a huge factor is any setting, not just ems. there are plenty of (supposedly better-trained) docs and nurses who are clearly retarded.

Retarded is not the right word. However many doctors, nurses, and medics just do not get it. Maybe pain management has not been explained to them in the right way.

Many doctors do seem to become much more comfortable using opioids to treat pain after experiencing severe pain themselves.

We never seem to hear about doctors becoming less comfortable using opioids after experiencing severe pain.

This suggests that there is something important that is not understood by the doctors until after experiencing severe pain.

I suspect that studying this might require a huge sample of doctors, just to be able to track the change in prescribing/ordering habits vs. personal experience of severe pain, whether their own pain or the pain of someone they care deeply about.

3. i personally have a high threshold for when i break the narcs open, as i too work in a poor area. that’s not to say poor people can’t have pain; that’s just taking into account other factors such as a seemingly higher rate of drug use/abuse.

It isn’t our pain threshold that matters, but the patients’ pain threshold.

Opioids are not the appropriate treatment for all pain, but it is appropriate to treat severe pain aggressively with opioids when nothing else works (such as when nothing else is available). Nitrous oxide is something that can be safely used that might significantly decrease the amount of morphine needed to manage severe pain.

4. once i make the decision to use narcs, i am not stingy with them as experience shows that prehospital morphine doses are clearly inadequate. the more important issue here is a training crews for a heightened awareness of the potential for respiratory depression and allergic reactions (just had one last week).

And what did you need to do for the allergic reaction? Diphenhydramine?

Just because something happened last week, does not mean that it is common. We need to be aware of the potential for allergic reactions with all of our medications.

One of the many advantages of fentanyl, over morphine, is that fentanyl is much less likely to produce an allergic reaction.

Recognizing and dealing with respiratory depression should not require anything more than competently monitoring the patient.

Many, but not all, patients will experience respiratory depression with appropriate pain management, because pain tends to stimulate a sympathetic response. Having respirations decrease to normal is a good thing, even though this is respiratory depression.

If the patient shows signs of inadequate oxygenation/ventillation due to respiratory depression, then all that needs to be done is to get the patient to talk. Find a subject that the patient is interested in, people love to talk about themselves, and get them to keep talking. Or just keep asking questions that are not answered with a nod, or shake, of the head. Ask orientation questions. Even just telling the patient to take a deep breath every so often will work.

A talking patient is a breathing patient.

5. it’s a big training issue to get crews to recognize those pts who are in pain and those who are trying to score narcs. this is where experience counts and it’s difficult to teach. that being said, it’s risky to presume that people are trying to score narcs.

We should not presume that people are trying to manipulate us to give them drugs inappropriately. We should be aggressively looking for indications that the patient has legitimate pain.

If I need to give out morphine and fentanyl to a bunch of junkies in order to avoid missing some patients with legitimate pain, then I will be the candy man.

Let me put this in perspective.

If I need to give out albuterol nebulizer treatments to a bunch of people who do not need nebulizer treatments in order to avoid missing some patients with legitimate asthma/emphysema/bronchitis, then I will be the nebulizer man.

If I need to give out IV dextrose to a bunch of people who do not need to receive dextrose through an IV in order to avoid missing some patients with legitimate hypoglycemia and an inability to take glucose by mouth, then I will be the dextrose infusion man.

If I need to take some people with minor injuries to a trauma center in order to avoid missing some critical trauma patients, then I will be the minor trauma man.

I am not encouraging over-treatment, for the sake of over-treatment. We do need to be much better at assessment, rather than treating mechanism. How much training do we have at recognizing drug seekers, who are not seeking drugs for legitimate pain? If we are trained at this in paramedic school, or on the job, what are the qualifications of the person providing this training? What research has been done to demonstrate the accuracy of the methods of differentiating between legitimate drug seekers and illegitimate drug seekers?

The best way to make someone a drug seeker may be to under-treat their pain.

Our concern needs to be much less on being police and much more on being paramedics.