Pharmacy & Therapeutics- July 2008 - (Page 420) The Law of Unintended Consequences When Pain Management Leads to Medication Errors Steven Hanks, MD, MMM, FACP Introduction • recognize the right of individuals to receive appropriate Pain has been described as “the fifth vital sign” since the late assessment and management of pain. 1990s.1 Unlike the traditional vital signs of temperature, pulse, • assess the existence of, and (evaluate) the nablood pressure, and respiratory rate, pain is not a sign ture and intensity of, pain in all patients, resiper se but rather a symptom; as such, it is entirely subdents, or clients. jective.2 When clinicians make treatment decisions for • establish policies and procedures that would patients, objective signs can be reliably monitored, support the appropriate prescribing or orderthey are typically reproducible, and the effects of intering of effective pain medications. ventions on such objective measures can be precisely • educate patients, residents, clients, and their observed. However, when the same approach is applied families about effective pain management. to an entirely subjective symptom like pain, hazards are • address the patient’s needs for managing bound to result if there is overreliance on the subjecsymptoms in the discharge-planning process. tive measurement. Steven D. Hanks, • incorporate pain management into the organiPain is most commonly measured on a 10-point LikMD, MMM, FACP zation’s performance measurement and imert scale, ranging from zero to 10, with 10 being the worst pain the patient can conceive and zero being pain-free. provement program. Yet we have all seen patients who seem to be in little distress when they rate their pain as a 10, whereas others with obvious This enhanced focus of The Joint Commission has been painful conditions seem to be more judicious in their ratings. reflected in perceptions of the public. Extensive education Even obviously somnolent patients have been observed to call campaigns have been conducted to inform people that pain out a 10 through an oversedated haze. reduction is a “right” to expect from health care providers. InActually, a subjective measurement through use of a Likert deed, in one case, a well-meaning clinician was found liable for scale has inherent limitations.3,4 There is no simple way to elder abuse as a result of cautious dosing of pain medication in an 85-year-old patient who had sustained a near-respiratory deduce whether an intervention to reduce pain has “good” or arrest in the emergency department following administration “bad” effects. The patient’s subjective rating can assist a cliniof morphine. During the subsequent admission, the patient’s cian only in determining what the effect has been. Many other pain was consistently rated between 7 and 10 despite treatment variables must be considered, such as other sympathomimetic with multiple opioids through several routes. The fact that signs and the level of sedation or consciousness, for a complete the patient’s pain score had not diminished, however, was assessment of pain and response to interventions to alleviate enough for a jury to levy a $1.5 million judgment against the it. If clinicians rely too much on only the subjective numbers, attending physician for criminal elder abuse.8 This case illusthe risk of overdosing or underdosing is increased. trates the need for clinicians to actively manage the expectaUndertreatment of Pain tions of patients and families when it comes to pain reduction. Leads The Joint Commission to Act If pain is not adroitly handled, clinicians may find themselves between a rock and a hard place. Recognition of the undertreatment of pain in the inpatient setting dates to the early 1970s,5 yet it was not until the midOpioid Use Is on the Rise 1990s that the breadth and depth of this problem drew the interest of a larger audience and that treatment guidelines and Coinciding with this collective recognition of inadequately policies began to attract larger attention.6 Not long after that, treated pain, the prevalence of opioid prescribing has grown in the U.S. every year since the mid-1990s.9,10 Table 1 shows The Joint Commission (then known as the Joint Commission on Accreditation of Healthcare Organizations) accelerated the the dramatic increase in the number of grams distributed per response to the problem by releasing new pain-management 100,000 persons for the eight most commonly prescribed opistandards for hospitals.7 These standards, which became oids in the U.S. between 1997 and 2005, with a near-doubling in the total distribution. Over this time period, only codeine and effective in 2001, require hospitals to: meperidine (Demerol, Sanofi-Synthelabo) distribution fell, with stunning increases in the distribution of the six others (oxycodone, hydromorphone, hydrocodone, methadone, morDr. Hanks is Senior Vice President of Medical Affairs and Chief phine, and fentanyl). Medical Officer at Central Connecticut Health Alliance, in New Britain, Connecticut.He is a member of P&T’s editorial board. Disclosure: The author has no financial or commercial relationships to disclose in regard to this article. Accepted for publication May 21, 2008. 420 P&T® • July 2008 • Vol. 33 No. 7
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