Pain is a common palliative or end-of-life complaint in patients seeking treatment in the prehospital environment.  It can be well controlled in up to 90% of patients using standard therapies, but remains under-recognized and under-treated in many palliative scenarios.

The objective of care is to reduce suffering associated with the experience of pain and to improve patient comfort.  The adequacy of analgesia may be assessed through a variety of mechanisms, including physiological signs of pain, verbal numerical ratings, and overall appearance (whether distressed or not).  Frequent reassessment and repeat administrations of medication are essential components of pain management.

• Establish goals of care in consultation and conversation with the patient, family, and care team
• The total daily dose is the 24-hour total of a specific drug that is taken for regular and breakthrough pain
• Breakthrough pain is a transient exacerbation of pain against a background of relatively stable and adequately controlled pain
• The breakthrough or rescue dose is an additional dose of medication used to control breakthrough pain.  It does not replace or delay the next routinely scheduled dose.  Breakthrough doses of pain medication are generally 10% of the total regular daily opioid dose.
• Paramedics should consider referring patients with pain emergencies to acute hospital care for treatment of the underlying cause.  Pain emergencies include fractures, spinal cord compression, superior vena cava obstruction, and an obstructed or perforated viscus.

• Treatment of pain is guided by use of the 0-10 pain intensity scale
• The dose of subcutaneous morphine to be administered can be calculated by converting each of the patient’s regular opioid analgesics to a total equivalent daily dose of oral morphine
  • Where the total equivalent daily dose of oral morphine is <50 mg, the patient should receive morphine 2.5 mg subcutaneously
  • Where the total equivalent daily dose of morphine of oral morphine is >50 mg, 10% of that dose will be calculated and converted to a subcutaneous dose
  • Calculated doses of morphine >10 mg should be discussed with the clinician.  The maximum subcutaneous dose of morphine is 20 mg.  Patients who do not respond to this dose should consult CliniCall and/or be transported to hospital for further management.
• Breakthrough Dosing Principles:
  • Breakthrough doses are generally 10% of the total regular daily opioid dose
  • Use immediate release opioids every hour orally or every 30 minutes subcutaneously PRN
  • Use of the same opioid for breakthrough pain doses and the regularly scheduled opioid improves the ease and clarity for determining future dose titrations
  • Reassess when 3 or more breakthrough doses used per 24 hours (see titration section)
• Titration Principles:
  • Calculate total daily dose (TDD) for the past 24 hours
    • TDD = Regular dose + all breakthrough doses (BTD)

• Regular dose q4h for the next 24 hours = past TDD/6
• Breakthrough dose (BTD) = new regular dose X 10% Increase the opioid proportionally whenever the regular dose is increased

All palliative and end-of-life patients can be considered for inclusion in the Palliative Clinical Pathway (treat and refer) approach to care.  Paramedics must complete required training prior to applying this pathway.

Analgesia

1. Alberta Health Services. AHS Medical Control Protocols. 2020. [Link] 
2. Ambulance Victoria. Clinical Practice Guidelines: Ambulance and MICA Paramedics. 2018. [Link] 
3. BC Centre for Palliative Care. B.C. Inter-Professional Palliative Symptom Management Guidelines. 2017. [Link]
4. Nova Scotia Health Authority. Nova Scotia Palliative Care Competency Framework. 2017. [Link] 
5. Pallium Canada. Learning Essentials Approach to Palliative Care. 2019. [Link] 
6. Pre-Hospital Emergency Care Council. Palliative Care by PHECC registered practitioners. 2016. [Link] 
7. University of Colorado Denver. Delirium & RASS. 2002. [Link]