Morphine Proposals

Two days off. I did some EMS project work. I put together three proposed protocol changes along with the backing science. One involves asthma -- making SoluMedrol a standing order and adding Magnesium for severe asthma, also on standing order. The other two both involved Morphine, and are an excellent example of how research is changing the way we practice (although I am not certain the committee will go along with my suggestion). I am proposing to make morphine for undifferentiated abdominal pain a standing order at a "judicious" dose of .05mg/kg before having to call medical control. The dose for fractures and burns is .1/mg/kg. I am also proposing that morphine for chest pain be taken off standing order and returned to a medical control option because of recent research suggesting that not only may morphine may not help patients with Acute Coronary Syndrome, it may contribute to their deaths.

Here's an excerpt from my proposal:

Proposed Protocol Change # 1:
Morphine for Undifferentiated Abdominal Pain

The Change:

In the Pain algorithm under Other Pain, change the heading to “Abdominal Pain (possible kidney stone, sickle cell anemia or undifferentiated pain)” and include the following:

If patient is hemodynamically stable: Administer .05 mg/kg Morphine Sulfate (MS) SIVP to a max of 5mg.

Establish Medical Control

Possible Physican Orders:

Additional MS

Also, add the following footnote:

“This change is due to recent research that shows morphine does not hinder abdominal pain assessment, and may in fact improve diagnoisis. Thus paramedics may give “a judicious dose” of morphine (.05 mg/kg) on standing order to patients with non-traumatic abdominal pain. Additional needed morphine may be requested upon contact with medical control.”

Background:

Withholding morphine for abdominal pain in the belief that it might mask pain, delay diagnosis and contribute to mortality has been a long-standing practice in medicine despite the lack of any research supporting such a practice. As medicine has turned to evidence-based practice and with a concern toward alieviateing patient pain, as well as the presence of increased laboratory and imaging tools, there has been a paradigm shift on this issue.

“The judicious use of analgesics in the setting of acute abdominal pain is appropriate.”
-Cope’s Early Diagnosis of the Acute Abdomen
2000 Edition

“Administration of narcotics to patients with abdominal pain to facilitate the diagnostic evaluation is safe, humane, and in some cases, improves diagnostic accuracy. Incremental doses of an intraneneous narcotic agent can eliminate pain but not palpation tenderness. Analgesics decrease patient anxiety and cause relaxation of their abdominal muscles, thus potentially improving the information obtained from the physical examination. There is evidence that pain treatment does not obscure abdominal findings, or cause increased morbidity or mortality.”
-Clinical Policy: Critical Issues for the Initial Evaluation and Management of Patients Presenting With the Chief Complaint of NonTraumatic Acute Abdominal Pain
American College of Emergency Physicians, 2000

“It should be recognized that no study establishing negative outcomes (of giving MS to patients prior to surgical exam) of any sort has been published. Humane treatment of suffering should therefore be the only argument required to treat abdominal pain.”
-Pain Management and Sedation: Emergency Department Management
McGraw Hill, 2006

Studies- (Full Abstracts and Additional Related Studies attached in Science Document)

1. Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective, randomized trial.
J Am Coll Surg. 2003 Jan;196(1):18-31, Thomas SH, Silen W, Cheema F, Reisner A, Aman S, Goldstein JN, Kumar AM, Stair TO.

CONCLUSIONS: Results of this study support a practice of early provision of analgesia to patients with undifferentiated abdominal pain. Copyright 2003 by the American College of Surgeons

2. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med. 1996 Dec;3(12):1086-92. Pace S, Burke TF.

CONCLUSIONS: When compared with saline placebo, the administration of MS to patients with acute abdominal pain effectively relieved pain and did not alter the ability of physicians to accurately evaluate and treat patients.

3. Intravenous Morphine in Emergency Department Patients with Acute Abdominal Pain Does Not Alter Disposition Decision, Acad Emerg Med Volume 12, Number 5_suppl_1 18-19, David Esses, Polly Bijur, Conroy Lee, Michael Lahn and E. John Gallagher

Conclusions: The decisions to admit or discharge patients with acute abdominal pain were comparable, regardless of the administration of morphine.


Proposed Protocol Change #3: Make Morphine Medical Control Option in ACS

While Morphine as been a tradition of ACS care (evidence MONA), recent research suggests it may increase mortality. While not removing it entirely from the protocol, I suggest it now require a medical control option.

Am Heart J. 2005 Jun;149(6):1043-9.

Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative.
Meine TJ, Roe MT, Chen AY, Patel MR, Washam JB, Ohman EM, Peacock WF, Pollack CV Jr, Gibler WB, Peterson ED; CRUSADE Investigators.

BACKGROUND: Although intravenous morphine is commonly used for the treatment of chest pain in patients presenting with non-ST-segment elevation acute coronary syndromes (NSTE ACS), its safety has not been evaluated. The CRUSADE Initiative is a nonrandomized, retrospective, observational registry enrolling patients with NSTE ACS to evaluate acute medications and interventions, inhospital outcomes, and discharge treatments. METHODS: The study population comprised patients presenting with NSTE ACS at 443 hospitals across the United States from January 2001 through June 2003 (n = 57,039). Outcomes were evaluated in patients receiving morphine versus not and between patients treated with morphine versus intravenous nitroglycerin. RESULTS: A total of 17,003 patients (29.8%) received morphine within 24 hours of presentation. Patients treated with any morphine had a higher adjusted risk of death (odds ratio [OR] 1.48, 95% CI 1.33-1.64) than patients not treated with morphine. Relative to those receiving nitroglycerin, patients treated with morphine also had a higher adjusted likelihood of death (OR 1.50, 95% CI 1.26-1.78). Utilizing a propensity score matching method, the use of morphine was associated with increased inhospital mortality (OR 1.41, 95% CI 1.26-1.57). The increased risk of death in patients receiving morphine persisted across all measured subgroups. CONCLUSIONS: Use of morphine either alone or in combination with nitroglycerin for patients presenting with NSTE ACS was associated with higher mortality even after risk adjustment and matching on propensity score for treatment. This analysis raises concerns regarding the safety of using morphine in patients with NSTE ACS and emphasizes the need for a randomized trial.

As I said, we'll see if the committee goes along with me. I expect that in five years what I am proposing will be standard everywhere. But the reaction now may be. We don't want to ruffle the surgeon's feathers, even if most of them agree with giving pain meds prior to their exam, and since MONA is still in the 2005 ECG Guidelines, who are we to change it. My arguements will be EMS doesn't always have to be the tail. We can be the dog. And as far as surgeons who are concerned that morphine may take away their ability to conduct an exam, as I read in a book in the medical store bookstore(Having already bought one $60 pain management book) one word to them NARCAN. Let them explain to the patient that they need to put them back in excruciating pain in order to try to figue out what is wrong with them.