Efficacy of an Acute Pain Titration Protocol Driven by Patient Response to a Simple Query: Do You Want More Pain Medication?

Abstract

We assess the efficacy of a simple pain titration protocol of 1-mg increments of intravenous hydromorphone, given at fixed intervals, driven solely by patient response to a yes/no question. This was a prospective interventional cohort study of nonelderly adults with acute severe pain defined asrequiring intravenous opioids in the judgment of the attending emergency physician. All patients received 1 mg intravenous hydromorphone and 30 minutes later were asked, "Do you want more pain medication?" Patients responding yes received an additional 1 mg of intravenous hydromorphone and were asked the same question 30minutes after receiving it. Those responding no did not receive additional opioid and were asked the question again 30minutes later. Each patient was queried 4 times. The primary endpoint was the proportion of patients achieving satisfactory pain control, defined as declining additional pain medication on 1 or more occasions. Of 215 patients enrolled, there were 8 protocol violations, leaving 207 patients with analyzable data; 205 of207 patients (99%; 95% confidence interval 97% to 100%) achieved satisfactory analgesia at 1 or more points during the study. Nine patients desaturated below 95% on room air, 2 had respiratory rates less than 10 breaths/min, and 2had pulse rates less than 50 beats/min. No adverse events were associated with amount of hydromorphone received. A pain protocol, based on titration of 1 mg intravenous hydromorphone, driven solely by patient response to a simple standardized question repeated at intervals, resulted in achievement of satisfactory analgesia on at least 1occasion in 99% of patients.