Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

A paradigm shift in acute pain assessment and management

Myles Gart, MD
Meds
March 8, 2019
Share
Tweet
Share

We have embarked upon a unique strategy to assess and manage pain. “Opioids Rarely Help Bodily Pain” is not a catchy phrase but a mnemonic related to educational learning which serves as the cornerstone of a new acute-pain management paradigm. As is known, the evaluation of pain is extremely difficult due to its subjective nature. However, this new evaluation not only accounts for the patients’ self-assessment but, for the first time in a hospital policy format, incorporates objective measures of pain into a global assessment algorithm.

Historically, when we asked a patient to rate their pain, the answer was a number. We now follow up by asking whether that “number” equates or qualifies their pain as tolerable or intolerable. Our goal is to render the pain tolerable, that allows the patient to meet the daily goals or specific milestones while progressing towards discharge. To finish our assessment, the objective component must be completed before any changes in analgesic therapy. The following are the five pillars based on the Opioids Rarely Help Bodily Pain treatment plan:

  1. Observation
  2. Respiratory Rate
  3. Heart Rate
  4. Blood Pressure
  5. Pupil Size

In most cases, if two out of five of the objective signs are positive, it may confirm intolerable pain. On the contrary, if there are objective signs which suggest overtreatment then the need to de-escalate analgesic therapy may be suggested.

This new kind of acute pain assessment, with its de-emphasis on the numeric scale and incorporation of objective measures, would not be complete without a change in analgesic management. Gone are the days where orders are written based solely on the patients’ self-assessed numeric values that are equated with a medication for mild, moderate, or severe pain. After three decades of using this methodology, there have been no improvements in the management of pain, while the complications of opioid overtreatment have continued to escalate.

Our approach is to take the results of the pain assessment and use them as a guide for analgesic therapy. Thus, we have implemented an analgesic pain ladder based on four tiers. Tier I includes non-opioids, tier II are low-dose opioids, tier III are higher-dose opioids, and tier IV are PCA options. Within tiers I–III are PO and IV alternatives. In addition to the tiers, there is a list of adjunct medications. Tier I and its adjuncts are scheduled medications, while tiers II and III are PRNs.

This new assessment and management algorithm allows for nursing to migrate between the analgesic tiers, resulting in escalation, maintenance, or de-escalation of analgesic therapy. While it is beyond the scope of this article to go into more detail, it must be stressed be that high-risk patients should be managed in a higher-acuity setting with commensurate monitoring.

Our hope is that this new methodology for the assessment and management of acute pain will serve as a template for the rest of the country. Our metrics for success are less morphine milligram equivalents (MMEs) per day and less Narcan use. I am happy to report that after going live with our protocols on November 27th, 2018, we have seen a 25 percent decrease in MMEs and a 50 percent decrease in Narcan use. This has certainly exceeded our expectations.

Myles Gart is an anesthesiologist.

Image credit: Shutterstock.com

Prev

The commodification of health care is destroying the doctor-patient relationship

March 7, 2019 Kevin 4
…
Next

Alex Trebek reminds us to go beyond fear of pancreatic cancer

March 8, 2019 Kevin 1
…

Tagged as: Hospital-Based Medicine, Medications, Pain Management

Post navigation

< Previous Post
The commodification of health care is destroying the doctor-patient relationship
Next Post >
Alex Trebek reminds us to go beyond fear of pancreatic cancer

ADVERTISEMENT

More by Myles Gart, MD

  • Cutting opioid use in half: a hospital’s pain management breakthrough

    Myles Gart, MD
  • The burden of shadowing and volunteering in medical school admissions: a hurdle, not a measure of commitment

    Myles Gart, MD
  • How objective pain management can save lives and prevent addiction

    Myles Gart, MD

Related Posts

  • Using low-dose naltrexone to treat pain

    Alex Smith
  • Why staying ahead of your pain with opioids is the wrong advice

    Myles Gart, MD
  • 5 things I wish I had known earlier about chronic pain

    Tom Bowen
  • Suboxone for pain makes sense. Why don’t more doctors prescribe it?

    Hans Duvefelt, MD
  • How do we manage pain in the era of the opioid crisis?

    Rita Agarwal, MD
  • Want to stop the opioid epidemic? Stop prescribing opioids.

    Jenny Hartsock, MD

More in Meds

  • From stigma to science: Rethinking the U.S. drug scheduling system

    Artin Asadipooya
  • How drugmakers manipulate your health from diagnosis to prescription

    Martha Rosenberg
  • The food-drug interaction risks your doctor may be missing

    Frank Jumbe
  • Why retail pharmacies are the future of diverse clinical trials

    Shelli Pavone
  • Why does rifaximin cost 95 percent more in the U.S. than in Asia?

    Jai Kumar, MD, Brian Nohomovich, DO, PhD and Leonid Shamban, DO
  • A world without antidepressants: What could possibly go wrong?

    Tomi Mitchell, MD
  • Most Popular

  • Past Week

    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
  • Past 6 Months

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
  • Recent Posts

    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Decoding your medical bill: What those charges really mean

      Cheryl Spang | Finance
    • The emotional first responders of aesthetic medicine

      Sarah White, APRN | Conditions
    • Why testosterone matters more than you think in women’s health

      Andrea Caamano, MD | Conditions
    • A mind to guide the machine: Why physicians must help shape artificial intelligence in medicine

      Shanice Spence-Miller, MD | Tech
    • How subjective likability practices undermine Canada’s health workforce recruitment and retention

      Olumuyiwa Bamgbade, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 6 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
  • Past 6 Months

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
  • Recent Posts

    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Decoding your medical bill: What those charges really mean

      Cheryl Spang | Finance
    • The emotional first responders of aesthetic medicine

      Sarah White, APRN | Conditions
    • Why testosterone matters more than you think in women’s health

      Andrea Caamano, MD | Conditions
    • A mind to guide the machine: Why physicians must help shape artificial intelligence in medicine

      Shanice Spence-Miller, MD | Tech
    • How subjective likability practices undermine Canada’s health workforce recruitment and retention

      Olumuyiwa Bamgbade, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

A paradigm shift in acute pain assessment and management
6 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...