NORFOLK, Neb. — Amid efforts to walk back opioid prescribing, one area has gotten less attention, says a Norfolk, Nebraska, anesthesiologist.
The piece of the puzzle that’s often left out, said Dr. Myles Gart, director of acute pain management at Faith Regional Health Services in Norfolk, is proper pain assessment.
Faith Regional in November launched a new strategy for assessing and managing acute pain, the kind that can come with illness or injury and typically goes away with treatment. That strategy has cut inpatient opioid use by about 30%.
Instead of relying solely on patients’ subjective rating of their pain on a familiar 1 to 10 scale, nurses also ask whether that number rates as tolerable or intolerable.
The goal, Gart said, is to control pain so patients can meet their physical therapy goals or other milestones needed to return home, such as walking to the restroom unaided.
But before making any changes to a patient’s medications, nurses also factor in five objective signs. Those include their observations of how the patient is behaving — grimacing and tossing in bed, or calmly eating lunch and watching Oprah — and vital signs such as breathing rate and blood pressure.
If two of the five signs indicate intolerable pain, nurses can increase pain medications using a tiered list that starts with non-opioids such as acetaminophen and ibuprofen and advances through lower- and then higher-dose opioids. If the signs don’t indicate a need for change, they stay the course and offer non-drug comfort and relaxation options. If a patient appears over-sedated, they de-escalate pain meds.
During the first three months since rolling out the system in November, Gart said, the 131-bed hospital reduced inpatient opioid use by about a third over the same months the preceding year.
“That far exceeds what I thought we’d see,” Gart said.
Margaret Woeppel, vice president for quality initiatives with the Nebraska Hospital Association, said all of the state’s hospitals are looking to decrease opioid use and assess pain more comprehensively.
Critical care units, such as the intensive care unit, long have married subjective and objective assessments, she said.
But for years, she said, the health care system as a whole put too much focus on the numeric pain assessment. Now the nation is shifting back to taking into account both patients’ assessment of their pain and bodily indications.
“I think we’re just getting back to that more holistic assessment of pain,” said Woeppel, a former trauma, emergency room and flight nurse.
Gart said most other hospitals’ drug orders still are tied to the number.
A hospital consulting group said last year that using numeric scales alone increases the use of opioids in order to lower pain scores.
Dr. Thomas Nicholas, director of the acute pain service at the Nebraska Medical Center, agreed that providers can’t continue to administer opioids based on a subjective pain score alone, just as they can’t continue to rely on an opioid-based pain regimen.
“Pain is more complex than one number,” he said.
The medical center’s pain scale, he said, includes many of the same factors as well as a behavior scale. The medical center also has a group that trains nurses in pain assessment, as well as in pain management protocols.
Woeppel said components of Faith Regional’s approach should be used in other hospitals.
“They’ve packaged it in a very unique way that makes it a very user-friendly format for staff,” she said.