Oligoanalgesia: What is the Correct Dose of Morphine?
abstract & commentary
Source: Todd KH, et al. Ethnicity and analgesic practice. Ann Emerg Med 2000;35:11-16.
One of the most essential and humane skills emergency physicians should possess is the ability to alleviate pain. Yet, in our daily practice, statements such as "you shouldn’t give so much pain medication because the patient might get addicted," "please don’t medicate the patient until I’ve had a chance to examine their abdomen," or "that patient doesn’t look like they’re in so much pain" are routinely echoed throughout the emergency department. Although these ancient, dogmatic and frankly barbaric concepts have been scientifically disproved, the tendency toward undermedication persists. While the phenomenon, known as oligoanalgesia, has been recognized for more than 10 years, Todd and colleagues have recently shed new light on this dark subject.
Using a retrospective design, the charts of 217 patients with isolated long-bone fractures were analyzed to identify trends in analgesic use. Shockingly, white patients were statistically more likely to receive analgesics than African-American patients (74% vs 57%). These results were unfortunately comparable to a previous study by the same authors, which demonstrated a similar relationship between analgesic use for hip fractures in Hispanic white patients and non-Hispanic white patients.1
Comment by Robert Hoffman, MD
Two immediate problems warrant discussion. First, we should all be vocally appalled that the charts of only somewhere between 57% and 74% of patients with long-bone fractures documented the need for and administration of analgesics. It is incumbent upon us all to begin quality assurance projects that expect no less than 100% compliance with the standard to assess, medicate, and reassess pain. Second, we should strive to increase our awareness of our own biases with regard to how we assess the need for and the choice of analgesics in all patients. Specifically, we must learn and then teach that how patients "look" may have little bearing on their need for analgesia. Routinely giving patients culturally meaningful scales to help them express and quantify their pain for us and allowing patients to have a more active role in the choice and amounts of their medication seem like easy first steps.
This week, I asked 10-15 emergency medicine residents a simple question: "What is the analgesic dose of morphine?" Some said nothing, some admitted they did not know, and a few said 0.1 mg/kg. Not a single one responded correctly that the analgesic dose of morphine is as much as is required to relieve the patient’s pain. While I was glad for my patients that there would always be an attending physician at their bedside, I was concerned that such a fundamental concept was never learned on day one of our education.
1. Todd KH. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA 1993;269: 1537-1539.
24. A recent study of analgesia practices in ED patients with long-bone fractures:
a. demonstrated analgesia was not given equally to black and white patients.
b. found analgesia to be adequate in all patients.
c. found analgesia to be adequate in all white patients.
d. demonstrated age differences in analgesia.