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Professor of Anesthesia and Psychology, Senior Clinical Research Scholar, Dalhousie University, Medical Director, Pediatric Pain Management, IWK Health Centre, Halifax, NS, Canada, allen.finley{at}dal.ca
To the Editor:
Vila et al. (1) have appropriately questioned slavish adherence to treatment algorithms, even in the context of cancer pain management. They are also correct in suggesting that there are more factors to consider in analgesic dosing than a one-dimensional report of pain intensity and wisely advise that level of consciousness should be part of routine assessment. We would also support the use of pulse oximetry for patients receiving parenteral opioids, as is standard in many pediatric hospitals, especially during dose titration.
However, I was disappointed in the absence of a key datum in their results: the number of patients, or patient days, on opioids. Although the total number of inpatient days has almost halved between the two time periods examined, I would not be surprised if opioid use had more than doubled. The fact that satisfaction scores increased suggests a dramatic change in care, as patients may be reluctant to report low satisfaction even with poor pain management (2). With no significant difference between adverse outcomes (and apparently decreased mortality), opioid use may actually be safer since the introduction of the "NPTA".
No one has ever suggested that opioids were risk-free, but pain also has adverse consequences, including, at least in theory, concerns that are specific to oncology (3,4). It may be appropriate to examine the risks and benefits of pain management in the context of all-cause morbidity and mortality, not merely the reported incidence of respiratory depression.
References
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