Establishing the safety and efficacy of an opioid titration protocol

Nancy Wells, DNSc, RN, Barbara Murphy, MD, Stacey Douglas, MSN, RN, Nancy Yelton, MSN, RN

Abstract


The primary goal of this single-group study was to determine the safety of a standard opioid titration order sheet to manage pain in ambulatory cancer patients. Secondary goals were to examine opioid toxicity and efficacy of this pain protocol.
Twenty-seven patients who required fixed-dose opioids and who had uncontrolled pain were enrolled. All patients had their initial opioid dose titrated by the study physician using the opioid titration order sheet. Data were obtained by the study nurse during a weekly telephone interview and used to determine if pain was controlled. After initial titration, a trained study nurse titrated opioid doses based upon the standing order sheet. At each contact, patients were assessed for adverse effects, pain intensity, and analgesics used.
Patients who completed the four-week trial (n = 17) did not differ from patients who did not complete the trial. No adverse effects were observed in 39 opioid titrations com-pleted by the study nurse. Opioid toxicities, worst pain, usual pain, and pain-related distress declined from baseline to week four. Patients who were adherent to their prescribed medications reported significantly lower pain intensity and distress (ps < 0.06).
The opioid titration order sheet, used by a trained nurse, is safe to use in ambulatory cancer patients who have moderate to severe pain. Common opioid toxicities were reduced. The protocol also demonstrated initial efficacy in improving worst and usual pain and pain-related distress. Further research to establish efficacy of theprotocol is recommended.


Keywords


cancer pain, standing orders, opioid titration

Full Text:

PDF

References


Portenoy RK: Cancer pain: Epidemiology and syndromes. Cancer. 1989; 63(11 Suppl): 2298-2307.

Zeppetella G, O’Dorhery CA, Collins S: Prevalence and char-acteristics of breakthrough pain in cancer patients admitted to a hospice. JPain Symptom Manage. 2000; 20(2): 87-92.

Wells N, Hepworth J, Murphy BA, et al.: Improving cancer pain management through patient and family education. J Pain Symptom Manage. 2003; 25(4): 344-356.

Marks RM, Sachar EJ: Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med. 1973; 78(2): 173-181.

McCaffery M, Ferrell B: Nurses’ knowledge of pain assessment and management: How much progress have we made? J Pain Symptom Manage. 1997; 14(3): 175-188.

Field MJ, Cassel CK (eds.): Approaching Death: Improving Care at the End of Life. Washington DC: National Academy Press, 1997.

Weissman DE, Dahl JL: Update on the cancer pain role model education program. J Pain Symptom Manage. 1995; 10(4): 292297.

Janjan NA, Martin CG, Payne R, et al.: Teaching cancer pain management: Durability of educational effects of a role model program. Cancer. 1996; 77(5): 996-1001.

Oneschuk DFR, Hanson J, Bruera E: Assessment and knowledge in palliative care in second year family medicine residents. J Pain Symptom Manage. 1997; 14(5): 265-273.

Smith WR: Evidence for the effectiveness of techniques to change physician behavior. Chest. 2000; 118 (2 Suppl): 8S-17S.

Smith JL (unpublished data), 1997.

Anderson KO, Mendoza TR, Valeroo N, et al.: Minority cancer patients and their providers: Pain management attitudes and practice. Cancer. 2000; 88(8): 1929-1938.

Grimshaw JM, Sheran L, Thomas R, et al: Changing provider behavior: An overview systematic reviews of interventions. Med Care. 2001; 39(8 Suppl 2): E-2-E-45.

Folstein MF, Folstein S, McHugh PR: “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975; 12(3): 189-198.

Daut RL, Cleeland CS, Flanery RC: Development of the Wisconsin Brief Pain Questionnaire to assess pain in cancer and other diseases. Pain. 1983; 17(2): 197-210.

Cleeland CS. Assessment of pain in cancer: measurement issues. In: Foley KM, Bonica JJ, Ventafridda V (eds.): Advances in Pain Research and Therapy, Vol. 16. New York: Raven Press, 1990: 47-55.

Price D, McGrath PA, Rafii A, et al.: The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain. 1983; 17(1): 45-56.

Price DD, Harkins SW, Baker C: Sensory-affective relationships among different types of clinical and experimental pain. Pain. 1987; 28(3): 297-307.

Ward SE, Carlson-Dakes K, Hughes SH, et al.: The impact on quality of life of patient-related barriers to pain management. Res Nurs Health. 1998; 21(5): 405-413.

Serlin RC, Mendoza TR, Nakamura Y, et al.: When is cancer pain mild, moderate, or severe? Grading pain severity by its interference with function. Pain. 1995; 61(2): 277-284.

de Wit R, van Dam F, Hanneman M, et al.: Evaluation of the use of a pain diary in chronic cancer pain patients at home. Pain. 1999; 79(1): 89-99.

Maunsell E, Allard P, Dorval M, et al.: A brief pain diary for ambulatory patients with cancer: Acceptability and validity. Cancer. 2000; 88(10): 2387-2397.

Portenoy RK, Thaler HT, Kornblith AB, et al.: The Memorial Symptom Assessment Scale: An instrument for the evaluation of symptom prevalence, characteristics, and distress. Eur J Cancer. 1994; 30A(9): 1326-1336.

Rhodes VA, Watson PM: Symptom distress—The concept: Past and present. Semin Oncol Nurs. 1987; 3(4): 242-247.

Cleeland CS, Mendoza TR, Wang XS, et al.: Assessing symptom distress in cancer patients: the M.D. Anderson Symptom Inventory. Cancer. 2000; 89(7): 1634-1646.

Wells N, Murphy B, Wujcik D, et al.: Pain-related distress and pain interference in ambulatory patients with cancer pain. Oncol Nurs Forum. 2003; 30(6): 977-986.

Du Pen SL, Du Pen AR, Palissar N, et al.: Implementing guidelines for cancer pain management: Results of a randomized controlled clinical trial. J Clin Oncol. 1999; 17(1): 361-370.

Miaskowski C, Dodd MJ, West C, et al.: Lack of adherence with the analgesic regimen: A significant barrier to effective cancer pain management. J Clin Oncol. 2001; 19(23): 4275-4279.

Agency for Health Care Policy Research: Cancer Guidelines. Clinical Practice Guidelines. Publication No. 94-0592. Vol. 9, 1994.

World Health Organization: Cancer Pain Relief. Geneva, Switzerland, 1986.




DOI: https://doi.org/10.5055/jom.2005.0011

Refbacks

  • There are currently no refbacks.