J. D. is a 34-year-old male who was admitted to the hospital for abdominal pain to rule out peptic ulcer disease. During a diagnostic work-up, a biopsy was taken from tissue in the stomach via esophagogastroduodenoscopy (EGD). The biopsy was found positive for gastric adenocarcinoma. J. D. underwent surgical resection of the stomach under general anesthesia, but the tumor was not completely resected. Postoperatively, J. D. was prescribed morphine sulfate 1 mg intravenously (IV) via demand mode of a patient-controlled analgesia (PCA) pump with a lockout interval of 6 minutes and a 4-hour maximum limit of 30 mg.

On the first postoperative night, J. D. rated his abdominal pain as 7 on a scale of 0 to 10 (0 = no pain; 10 = worst pain ever), after receiving 8 mg (that is, eight doses of 1 mg each) of morphine for two consecutive hours.

Recognizing that the patient’s pain was not optimally controlled with near-maximum demand doses, the nurse contacted the surgeon to request an increase in opioid analgesia. The surgeon ordered the morphine to be given via the continuous mode, in addition to the demand mode. The dose for the continuous mode is ordered to be 2 mg to 3 mg/hour, and the demand bolus doses are increased to 1.5 mg every 6 minutes, with a 4 hour maximum of 40mg. Within an hour, the patient reported that his pain decreased to a level of 3 using 8 boluses. The patient is sleeping in naps, but easily arousable and oriented when awake, with a respiratory rate of 16 both during sleep and when awake. Within 2 hours the client rates his pain level “0,” receiving a continuous hourly rate of 2 mg, with two demand doses each hour.

On the third postoperative day, the surgeon orders a decrease in the continuous dose of morphine to 1 mg each hour, with a decrease in the bolus to 0.5 mg every 6 minutes as needed (PRN). The patient states that his pain at times is at “5,” usually after activity, but decreases to “0” quickly with demand doses. He continues to receive an hourly continuous infusion and occasional demand doses of morphine for another 3 days. On the sixth day after surgery, the surgeon discontinues the intravenous (IV) morphine via the PCA, and orders oxycodone 5 mg/acetaminophen 325 mg, one to two tablets every 4 hours PRN for pain. The patient is discharged home, but no prescription is written for analgesia after discharge. Discharge orders do, however, include an order for an IV antibiotic to be infused at 8:00 AM daily by a home-health nurse. Arrangements are also made for the client to see a medical oncologist 1 week after discharge for possible treatment of his grade III gastric cancer.

J. D. receives two tablets of oxycodone 5 mg/acetaminophen 325 mg (Percocet) in the hospital and is discharged home at 4:30 PM. By 9:00 PM, J. D. has severe abdominal pain. J. D.’s wife first calls the surgeon to report the client’s severe pain, and the surgeon instructs her to give two tablets of acetaminophen every 4 hours PRN. J. D. receives no relief from the acetaminophen, and his wife contacts the on-call home-health agency.

Because of his diagnosis of advanced gastric cancer, J. D. is admitted to the transitional care/hospice department of the home-health agency. Nurses in this department have intensive training in management of pain and embrace the philosophy that pain should be aggressively treated and controlled, particularly with advanced disease. Recognizing that the surgeon did not arrange for analgesia after discharge, the on-call transitional care nurse contacts the medical oncologist with whom J. D. has an appointment the following week. Although the oncologist states that he generally does not order medication when he has not yet seen the patient, he agrees to order it at this time based on the data provided by the nurse. The nurse instructs the doctor to call the hospice pharmacy, because she
knows that the pharmacist there will fill a narcotic with a telephone order from the physician. The oncologist orders morphine sulfate 20 mg/mL, the dose to be 10 to 20 mg orally (PO) PRN every 1 to 2 hours.

In the 1990s, lack of standardization and ineffective pain management prompted the federal government to develop and publish clinical practice guidelines on acute pain (1992) and cancer pain (1994). In 2001, the Joint Commission Accreditation of Health Care Organizations (JCAHO) published pain management standards, which were meant to ensure that pain was being assessed at regular intervals and managed appropriately. Despite these guidelines and standards, pain continues to be inadequately managed due to insufficient knowledge of the pharmacology of analgesics, healthcare provider misconceptions about potent narcotics, and fear of addiction. Some of the variability in management of pain seems to be related to the different philosophies of pain management in different practice areas.