Acute on chronic cancer related pain can be difficult to manage in the emergency department setting. Patients may have significant opioid tolerance, thus rendering the routine doses administered in the emergency department ineffective. Most emergency medicine physicians and nurses are not familiar with the calculations necessary to dose intravenous opioid medication appropriately in the opioid tolerant patient with severe pain. Baseline data from our institution indicate that our patients with severe cancer pain wait a median time of 133 minutes until they receive their first dose of pain medication and 72 minutes until they receive their second dose. Our data also show that a vast majority of our physicians use a “one time” order for their opioid medication rather than an order set with scheduled dosing. To address this, we initiated an ED Cancer Pain Protocol order set with scheduled intravenous opioid medication every 15 minutes until the patients pain score is to their satisfaction or until they have a reduction in their pain score to <5. The protocol accounts for opioid naïve patients and opioid tolerant patients. We also posted an educational worksheet for conversion of common outpatient opioid medications to oral morphine equivalents and calculating the appropriate acute pain dose for opioid tolerant patients. We found that although this practice is common in palliative care settings this was a novel concept for many of our emergency medicine physicians. Our preliminary data indicate that after the protocol was initiated the median time to administration of second opioid dose decreases from 72 min to 41 min. We hope this pilot data will serve as rationale for large scale implementation of this protocol in future collaborating community or academic centers. This project was funded by a grant from the American Cancer society.
© 2013 Published by Elsevier Inc.