Pain management project includes hospital pathway

Pain expert describes how it works

A quality improvement team that focused on ways clinicians could better manage patients’ pain developed a one-page clinical pathway that clearly shows what needs to be done. “Our job now is to promulgate that pathway throughout our hospital, and to share it with anyone who wants to use it,” says Frank Forte, MD, director of medical oncology/hematology and director of palliative medicine at Staten Island (NY) University Hospital.

One side of the pathway includes written guidelines, including general principles. (See pathway.) One of the general principles is for clinicians to be familiar with the analgesic ladder, which is part of the World Health Organization’s (WHO’s) recommendations for palliative care.1 The idea behind the analgesic ladder is there are three levels of pain and three types of medications and ways for treating it, including assessing the pain, using a drug appropriately, and not managing it continuously, Forte says.

The guidelines also address what should be done with initial opioid treatment, reassessment, adequate pain control, and partial intolerance. “For some reason, when someone goes into the hospital they’re immediately put on IVs, and it makes no sense,” Forte says. “So, one of our comments is to use IVs only when necessary and to use the appropriate dose for breakthrough pain.”

The pathway has two main categories of opioid-naïve and nonopioid-naïve. Under the opioid-naïve flowchart section, there are two choices to be made, depending on whether a patient is able to take medication by mouth. Only if the patient is not able to do so, does the algorithm direct the clinician to the box for choosing an opioid that would be given intravenously.

“We looked at those who could take medication orally, and then the algorithm says if they can take it orally, they should choose an opioid, such as morphine and have a breakthrough dose,” Forte says. “The breakthrough dose is provided at 10%-15% of the total daily dose.”

The next major step in the algorithm is to reassess the patient in 18-24 hours, unless the patient’s pain requires an assessment before then, he notes. “If the patient’s pain is controlled, we keep the patient on dose and consider changing to a long-acting medication, and if the pain is not controlled, then we go over the cycle again,” Forte says.

For nonopioid-naïve patients, the only difference is that the dose might be different, so the clinician works with a bigger dose at baseline and makes adjustments as needed, he says. “For example, we took care of a lady several months ago who was on a methadone maintenance program, so we had to start her on much bigger doses than someone who wasn’t on opioids before,” Forte says.

“Physicians in general are very hesitant about making changes in opioids because of a fear of side effects and addiction, but addiction in patients with chronic pain due to ultimately progressive terminal diseases is not a great problem,” he notes. “They’re also afraid of respiratory depression, but if you watch someone closely, that’s a very unusual occurrence.”

Finally, when the patient has reached the algorithm step where the pain is controlled, then it’s time to switch to a long-lasting medication and have the patient stay on that dose as long as is needed,” Forte says.


1. The World Health Organization. Palliative Care: Symptom management and end-of-life care. World Health Organization’s interim guidelines for first-level facility health workers. December 2003; pp. 1-52. Available on WHO web site: