Albert Einstein in Montefiore is singlehandedly, repeatedly pushing literature regarding appropriate titration of pain control in the Emergency Department. They have several previously published papers describing their hydromorphone 1 + 1 protocol, describing its safety and efficacy. This paper is their prospective, randomized version demonstrating its safety and superiority to “usual practice”. You could implement their protocol tomorrow and have better narcotic pain control in your ED. It clearly works.
But the real issue this line of research uncovers is not that they’ve discovered a magic protocol. What we’re missing by taking the simple interpretation is more that our pain control in the ED is flawed. If you look at the morphine equivalents their patients received in this article, they’re preposterous. I am a huge proponent of 0.1mg/kg for morphine – even in adults – and their mean dose in the “usual care” arm was 6mg morphine equivalents, and their mean additional dose was 3mg. 0.1mg/kg is a starting dose for morphine that gives less than 50% of patients adequate pain relief – which is where the second part of their protocol comes in. Scheduled reassessment for pain and a standing order for additional medication is another area where “usual care” will obviously fall behind, simply because of the uncontrollable chaos of the ED.
So, my take home from this article is that protocolized, standing orders for narcotic analgesia in appropriately selected patients is safe and effective, and, you can use their protocol or develop your own.