Appropriate morphine administration by paramedics: a review of the literature

Pain Management

Pain is defined by the International Association for the Study of Pain (IASP) as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’ (Australian and New Zealand College of Anaesthetists and Faculty of Medicine (ANZCA), 2005). Pain is an individual, multifactorial experience influenced by culture, previous pain events, beliefs, mood and ability to cope (ANZCA, 2005). It may be an indicator of tissue damage but may also be present in the absence of an identifiable cause. It is estimated that close to one-third of the population of the industrialised world suffers from some type of chronic pain (Loesser, 1999). The National Health and Medical Research Council (NHMRC) (2005) acknowledges that rough estimates suggest the financial cost of pain may be as high as $10 billion per annum; therefore, pain should be considered a pervasive and costly health care problem (NHMRC, 2005). Pain management is a leading reason why patients seek medical care in developed countries and the adequate management of pain is considered an important issue in both primary care and pre-hospital medicine (Zagari et al, 1996; Loesser, 1999). While paramedics spend a significant amount of time with patients who have pain, adequate treatment of pain continues to be a major pre-hospital health concern (Lord and Parsell, 2003; Gallagher, 2004; Williams et al, 2012). Ambulance management of pain consists of both independent and collaborative paramedical actions but efficient pain management is dependent on expert knowledge and attitude of the person administering the pain relief.

Recent pain management guidelines and evidence-based studies recommended the use of opioids in the management of pain (ANZCA, 2005; Birnbaum et al, 2007). Morphine is a class of drug that is identified as an opiate-based drug due to its compound being derived predominantly from the opium poppy plant. Morphine has been regarded as the treatment of choice in most Australian Ambulance Services for about 25 years (Bendll et al, 2012). It is ideal for relief of severe pain because it can be administered both intramuscularly and intravenously. The intravenous route is usually considered the optimal route for drug administration due to its rapid effectiveness, ease of titration and favourable risk-to-benefit ratio (Borland et al, 2002; Center for Addiction and Mental Health, 2013). There are numerous recommended drug therapy protocols doses in Australian Ambulance Services, with initial dosage ranging from 0.05–0.15 mg/kg. As seen in Table 1, some guidelines recommend a single dose of 10 mg, whereas other protocols recommend a maximum dose of 10 mg with small aliquots delivered over a predetermined time period.

Barriers to pain management

Despite pain management being a key performance indicator within ambulance services, experts agree that many barriers hinder the delivery of adequate pain management to patients with pain (Gilson and Joranson, 2003. The questions include: what causes paramedics to under-treat pain and what underlying factors could influence paramedics’ decisions to use opioid analgaesics for patients with pain?

It has been identified in some cohorts that education influences behavior and ultimately improves patient outcome (Kennedy et al, 2004). The ability to impact behaviour through education interventions and clinical practice guidelines is unlikely to be effective until the factors that impact on a clinician's decision about whether or not to implement knowledge are better understood (Kennedy et al, 2004). To date, ‘no study has comprehensively examined the multifactorial influences that affect the gap between knowledge and behavior in any clinical model’ (Kennedy et al, 2004: 387). This paucity of evidence is particularly apparent in the pre-hospital environment.

Research into pre-hospital analgaesia administration has been minimal until relatively recently despite reports that the problem is common and often poorly managed (Lord, 2004; Woolard, 2006; Rickard et al, 2007). Authors over the last 10 years continue to suggest that pain management is inadequate in the pre-hospital setting (Fullerton-Gleason et al, 2002; Jones and Machen, 2003). The problem potentially originates from a combination of poor education and poor assessment (Fullerton-Gleason et al, 2002; Lord and Parsell, 2003). To fully understand pain management a firm knowledge is required of pain management processes, physiology and overall appropriate management (Bendall et al, 2012).

Obstacles to narcotic administration include inadequate education and training, concerns of patients’ addiction, potential for abuse or misuse, side effects, and fear of scrutiny (Weinstein et al, 2000; Morley-Forster et al, 2003; Gallagher, 2004). Experts believe that knowledge gaps, fear of patient addiction, deficient pain assessment skills, fear of scrutiny and timidity in administering may lead to opioids phobia and a prejudice against the use of opioids analgaesics (Glajchen, 2001).

Attitudes toward morphine and its role in treating pain may affect paramedics’ decision to administer this type of analgaesic for pain management (Lord, 2004). In addition to their own attitudes, paramedics may consider the beliefs of other individuals and groups such as supervisors, doctors, nurses and peers (Williams et al, 2012) in their decision-making to administer this type of opioid analgaesic. Yet if ambulance clinical leaders such as the highly trained Mobile Intensive Care Paramedics (MICA), Intensive Care Paramedics (ICP) and senior doctors lead from the frontline and set good examples in pain management the culture of learning and practice may improve in pain management (Bennetts et al, 2012). Further, the level of control paramedics have in their administration decisions may be influenced by external factors such as drug therapy protocols, clinical procedure guidelines such as intravenous cannulation (Bendall et al, 2012), or education (Lord, 2003). As a result, it is suspected that the aforementioned factors play some role in the formation of paramedics’ intentions to administer or not administer morphine for patients with pain.

Within the pre-hospital environment paramedics still identify the age of the patient as a hurdle to morphine administration with children reportedly less likely to receive morphine analgaesia (Bendall et al, 2012; Williams et al, 2012). Limitations in the paramedics’ ability to cannulate and accurately gauge the child's pain score are identified barriers to adequate pain relief in children (Lord et al, 2009). Just as age is an issue for paramedics in effectively administering morphine for pain relief, another demographic factor is evidently a barrier to pain management. Gender has been highlighted as a barrier to effective pain management with female patients less likely to receive pain relief (lord et al, 2009).

Pain management education and continuing education

Insufficient education (Lord, 2004) and training of health professionals in pain management (Otis and Fudin, 2008) are identified barriers to opioid administration. Medical educators find that improved clinical knowledge about pain management can be positively influenced through effective and high-quality education (Weinstein et al, 2000). However, although educators recognise the need for improved training in pain management, it is not seen as a priority in medical education programmes (Benedetti et al, 2001). This is reflected in a CME pain management programme offered to an Australian ambulance service where the education package was completed within just four hours more importantly there are no ongoing mandatory programmes for pain management.

French et al (2013) identified that initial education programmes and ongoing clinical education programmes reviewing neuroanatomy, assessment, judgement and management of pain practices are important for effective outcomes in the reduction of pain in patients and limiting ongoing complications associated with poor pain management (French et al, 2013). However, education programmes may not always be successful in improving knowledge, attitudes or behaviour of health professionals providing adequate pain management; this is true especially if there are no follow-up continuing education programmes (ANZCA, 2005).

French et al (2013) implemented a continuing education programme looking predominantly at pain management by paramedics. The three-hour continuing medical education (CME) programme showed significant improvements in behaviour of paramedics towards pain management. There was a 17.5% increase in an understanding of pain, paramedic perception of patient's complaints of pain increased by 4.2% and management of patients improved by 21% (French et al, 2013). The authors noted that: ‘Paramedics not only improved their baseline field management of pain but we discovered through this study that further continuing education is effective’ (French et al, 2013: 101). Although this was only a three hour session, the improvements in knowledge and performance of pain management was significant and it should be recognised that improvements in paramedics’ declarative knowledge and improvements in their clinical judgment and practice based on CME can be of benefit to patient outcomes Jones and Machen, 2003).

Knowledge and management of patients suffering pain is improved through continuing education with efficient pre-hospital pain management guidelines and effective clinical application being a multifaceted approach between paramedics and their educators (French et al, 2006). Through appropriate attitudes and effective education strategies, paramedics should be utilising effective clinical judgement to consider the underlying cause for the patient's pain and commencing non pharmacological management strategies such as psychological support and physical methods of pain relief. These strategies have been identified as effective tools and therapies and are paramount in pain management strategies (French et al, 2006).

A number of other studies have shown the benefits of education and/or guidelines on improved prescribing patterns both in general terms and specifically for Non Steroidal Anti-Inflammatory Drugs (NSAID’s), paracetamol and pethidine (ANZCA, 2005). For a successful pain management programme to be installed into ambulance services an effective and successful programme must be introduced not only by ambulance services but through baccalaureate programmes in tertiary education. Just as important is the follow up of clinical practices by paramedics through a quality assurance programme that includes continuing education (Lord and Parsell, 2003; Hennes and Kim, 2006; French et al, 2013).

Rickard et al (2007) used a randomised, controlled, open-label study to compare the use of intranasal fentanyl (INF) (n=127) to intravenous morphine (IVM) (n=100) for pre-hospital analgaesia. All paramedics received education at the commencement of the study. While INF was found to be an effective alternative to IVM for use in the pre-hospital setting, it was the paramedics’ attitudes towards the change that was of interest to the researcher more so than the education undertaken (Rickard et al, 2007).

Despite the literature showing improvements in pain management, knowledge and application, there is still little published research on continuing medical education programmes for paramedic development and up-skilling (Bissell et al, 1999; Hinings et al, 2003; Squires, 2004; Ball, 2005; Price et al, 2005; Woolard, 2006; Birnbaum et al, 2007. In-service education programmes for paramedics have shown to improve patient care outcomes (Snider et al, 2004; Birnbaum et al, 2007) and greatly enhance the impact of knowledge and skills on the overall quality of care (Kouroubali and Tsiknakis, 2007; French et al, 2013).

Due to the lack of CME programmes into pre-hospital pain management, the author reviewed other CME programmes on offer to paramedics to review their outcomes on overall patient care. A study into aspirin administration rates in Oregon Emergency Medical Technician (EMT) services showed that two simple consecutive educational sessions increased the rate of aspirin administration from 15.1% to 37% for patients with Acute Coronary Syndrome (ACS) (Snider et al, 2004). The researchers found that while there was resistance to the 30 minute lecture, knowledge increased and an improvement in aspirin administration occurred (Snider et al, 2004). The research identified that knowledge was a precursor for the improvement of education and in turn improved the clinical management of patients suffering from ACS. The two brief educational interventions, a protocol change and a lecture, lead to modest increases in aspirin administration rates (Snider et al, 2004).

One qualitative study explored paramedics’ attitudes towards the administration of pre-hospital thrombolysis (PHT) (Price et al, 2005). In-depth interviews with 20 paramedics were recorded, transcribed and analysed for emergent themes using the constant comparative method. Although there were positive attitudes towards PHT because of its benefits to patients, the associated risks, aspects of pay and working conditions and certain organisational factors undermined the intention of some paramedics to administer thrombolysis (Price et al, 2005). Positive attitudes to PHT had also been fostered by the PHT training. Because the course had been delivered by a team that included nurses and doctors from the hospital (who showed trust, respect and confidence in the paramedic's skills), the paramedics had improved confidence about their ability to deliver PHT (Price et al, 2005). In this study not only did an education programme improve patient outcomes through PHT, but through the delivery of education by other health professionals there was an influence on the paramedic's decision to perform PHT without concerns over close scrutiny by other health professionals.

To date there are numerous studies into the measurement strategies for pain scoring as well as barriers into pain management, but there are no comprehensive studies into continuing pain management education programmes and direct constructs affecting the behavior of paramedics related to the administration of morphine.