In part I of this 2-part article we focused on the paramedic’s perception of pain and the assessment of pain. Part II will examine the Theory of Planned Behaviour of paramedics, which Weber et al., (2012) used to identify influencing factors with respect to the administration of analgesia; specifically morphine [1 p. 1393]. Secondly, the article aims to highlight the tools of the trade available to paramedics in treating pain and the possible existence of a misunderstanding of how these tools work and contribute to oligoanalgesia.
Pain, secondary to illness or procedures is noted to be one of the most common symptoms experienced by patients in the prehospital setting [1 p. 1393]. While paramedics play an important role in assessing and managing pain, pain management itself continues to be a rather key prehospital health issue as described by Weber et al., (2012). It has been well established, through the work of Hennes (2006), “that failure to provide adequate pain management to patients could have immediate deleterious physiological, biochemical and behavioural effects [1 p. 1393]. Weber et al., (2012) highlight that the Theory of Planned Behaviour (TPB) has been demonstrated to be useful in predicting behaviours in patients but also amongst healthcare providers with the model being able to predict the treatment intentions of nurses and physicians [1 p. 1394]. While Weber et al., (2012) specifically examined the administration of morphine byp, and hypothesized that attitudes towards Morphine and the role it plays in treating pain may actually influence a paramedic’s decision to administer this type of analgesic for pain management. Perhaps another contributing angle is the level of control paramedics have when it come to their administration decisions. This may be influenced by external factors noted to include drug therapy protocols, clinical procedure guidelines, or education strategies.
Additionally, Paramedic “consider the beliefs of other individuals and groups (such as patients, peers, nurses and medical officers) in their decision-making to administer this type of opioid analgesic” [1 p. 1394]. However, it could also be hypothesized that same attitudes may exist with respect to other pain control medications administered by paramedics.
Weber et al., (2012) noted a significant negative correlation between attitudes and behavioural intention [1 p. 1394]. Relevant findings and factors that negatively impacted intentions to administer morphine to patients with pain included concern by paramedics with respect to the auditing of cases, the danger and complications to patients as well as extra responsibility [1 p. 1394]. An interesting finding uncovered by Weber et al., (2012) also included the fact that Paramedic peers were identified, “to be of great importance when a decision was made to administer morphine” [1 p. 1395]. Paramedics identified peers as being important in their decision-making process and supported the decision to administer morphine. Weber et al., (2012) highlighted the findings of Hennes (2006). It was postulated that, “paramedics would fake their behaviours in order to gain acceptance of peers and supervisors” [1 p. 1395]. The subsequent evidence demonstrated that, 37% of the participants stated they intended to administer morphine, however in practice only 4% of participants in reality engaged in the behaviour [1 p. 1395]. Further compounding the issue of oligoanalgesia vis-à-vis the Paramedic’s behaviour is the traditional value that Paramedic practice was largely influenced by the belief that the medical profession was unsupportive of the administration of opioids for patients with specific medical conditions, for example the acute abdomen [1 p. 1395]. Weber et al., (2012) noted this hypothesis to be reinforced further by a publication with respect to Nurses’ intention to administer opioid analgesics for pain relief [1 p. 1395]. It was revealed that, “ nurses were more likely to comply with requests from colleagues, 68% when intending to administer morphine to patients” [1 p. 1395]. So how do we then change the tide with respect to Paramedic perception and attitude toward pain management in an effort to reduce oligoanalgesia? Weber et al., (2012) propose the development of a supportive peer learning environment, in turn this will result in a positive pain management behaviour [1 p. 1396]
Another dangerous ingredient in the oligoanalgesia recipe is the practitioner’s misunderstanding (through the lack of education) of efficacy and potency in addition to the theory of equi-analgesic conversion (and the notion of using higher morphine doses via titration) when it comes to medications such as morphine and fentanyl [2 p. 2]. Dr. Sergei Motov describes this perfectly by comparing the use of morphine and Dilaudid (hydromorphone) in the Emergency Department (ED). Dr. Motov noted that research supporting the use of Dilaudid in the ED had been conducted between 2006 and 2012. Because of a lack in education on efficacy and potency, clinicians became “morphinophobic” and increasingly more “hydromorphonophillic” [2 p. 2]. What Dr. Motov was driving at in this example of Dilaudid versus morphine is that Dilaudid is approximately 8 to 11 times more potent (via IV) and 10 times more lipophilic than morphine, therefore translating into a much quicker onset of analgesia. While the standard IV dose of Dilaudid is 1 mg, this is considered to be a significant dose when administered to an opioid-naïve patient – clinicians do not routinely administer 8 to 10 mg of morphine IV, but by comparison that is what 1 mg of Dilaudid is equal to [2 p. 2].
If we consider the theory of equi-analgesic conversion, the results appear to vary. Galinski et al., (2005) noted that morphine and fentanyl “appeared to be clinically comparable for treatment of severe, acute pain in a prehospital setting” [2 p. 117]. Additionally, there was no significant difference the intensity of the pain between their groups after 30 minutes from the time of administration and found that there was no difference in the incidence of side effects either [2 p. 117]. It is interesting to note that Galinski et al., (2005) administered both morphine and fentanyl with an initial loading dose, in the case of the morphine group, morphine was administered as 0.1 mg/kg dose and a 3 mg dose every 5 minutes if required. The fentanyl group received a 1 mcg/kg dose and a 3 mcg dose every 5 minutes if required [3 p.115]. While Galinski et al., (2005) states they did not, at any time detect a difference between these two opioids; one advantage of morphine is noted to be its longer duration of action when compared to other opioids, in this case fentanyl [3 p.118]. The duration of action of morphine is noted to last approximately 3 to 4 hours, while the duration of action of fentanyl is noted to last 30 minutes to 2 hours (however, half-lives are 114 minutes and 185 to 220 minutes, respectively [3 p. 118]).
A military study conducted by Shackelford et al., (2015) similarly concluded that fentanyl was as safe as morphine while also evaluating ketamine. From a historical point of view morphine has been administered on the battlefield by auto injectors, which are capable of delivering an IM dose of 10 mg. However, this route of administration is limited by variable rates of absorption, because of this there is a potential for delayed adverse reactions and events [4 p. 306]. Shackelford et al., (2015) noted that while, “morphine may be associated with reparatory depression and hypotension” [4 p. 306]; the likelihood of these reactions occurring could potentially be increased when morphine is administered intramuscularly due to the administration of multiple doses resulting in a delayed onset of action [4 p. 306].
And Then There Was Ketamine…
The results of Schackelford et al., (2015) do support current TCCC recommendations for the use of Ketamine (IV or IM) or oral transmucosal fentanyl citrate (OTFC) as primary choice of medications in the prehospital setting [4 p. 309]. These medications were noted to be, “at least as safe as the previous standard of care using morphine” [4 p. 309]. Casualties who received Ketamine were found to have a lower starting SBP; SBP increased after administration. This is observation is noted to support the current guidelines with respect to using Ketamine as the first-line analgesic for patients in shock or at risk of shock [4 p. 309].
One other notion that has contributed to oligoanalgesia as well has been the idea of perpetuating an addicts’ drug addiction to creating new drug addicts in opioid-naïve patients. So how should we, as practitioners, best deal with the whole picture or problem of oligoanalgesia? Well when it comes to individual Paramedic we must consider a culture change in order to deal with our own biases and attitudes toward analgesia. Dr. Motov suggests that, we must begin to acknowledge the pain of our patients and “engage them in shared-decision making with respect to their pain syndrome” [2 p. 4]. We must set clear expectations and consider beneficial treatments that include non-opioid and if required opioid analgesics. Analgesics and pain management should be tailored to the individual patient. It should be considered based on side effects [2 p. 4]. Dr. Motov highlights Ketorolac, sub-dissociative dose Ketamine as practical solutions. However, if opioids are to be considered for use, he suggests the titration of intravenous morphine or fentanyl. Galinski et al., (2015) noted that, “the ideal prehospital opioid should have a rapid onset of action”, while being able to provide rapid pain control with a duration of action long enough to avoid repeated injections [3 p. 118].
Only by changing our culture toward analgesia and pain management in addition to considering the tools available to us as practitioners and understanding how they differ from one another can we begin to solve the problem of oligoanalgesia. After all, “obtaining high-quality analgesia in prehospital patients with severe pain is an important treatment objective not only for psychological but also for physiological reasons. [3 p. 117]
1. Weber A, Dwyer T, Mummery K. Morphine administration by Paramedics: An application of the Theory of Planned Behaviour [Internet]. Injury. Elsevier; 2011 [cited 2019Nov1]. Available from: https://www.sciencedirect.com/science/article/pii/S0020138310008247
2. Genes N, Motov S. Dilaudid in Detail: The Problem with Hydromorphone. Emergency Physicians Monthly [Internet]. 2018Jan31 [cited 2019Oct5]; Available from: http://epmonthly.com/article/dilaudid-detail-problem-hydromorphone/
3. Galinski M, Dolveck F, Borron SW, Tual L, Laer VV, Lardeur J-Y, et al. A randomized, double-blind study comparing morphine with fentanyl in prehospital analgesia. The American Journal of Emergency Medicine. 2005;23(2):114–9.
4. Shackelford SA, Fowler M, Schultz K, Summers A, Galvagno SM, Gross KR, et al. Prehospital Pain Medication Use by U.S. Forces in Afghanistan. Military Medicine. 2015;180(3):304–9.