Pain Management

Pain is inevitable. Suffering is optional.

Andrew Parchman

Objectives

Review Evaluation of Pain Review Classes of Pain medications General Approach to Pain Management Cases Prescriptions Drug Schedules

Acute Vs Chronic Pain

History and Physical - how did it start - describe the pain - intensity - aggravating/alleviating factors - how does it effect life - physical findings autonomic response

Types of Pain

Chest Neuropathic gabapentin, pregabalin Cancer - opiates Abdominal - NSAIDS Pelvic - NSAIDS Musculoskeletal - NSAIDS Drug Seeking Behavior

Acetaminophen

Mechanism unknown Route - PO, PR Onset - variable, half life = 2-3 h Side effects - hepatotoxicity, AIN/tubular necrosis Contraindications RelativeEtOH use, liver disease (max daily dose reduction), renal disease (prolonged use) History 1894, 35% current pain med market, more ER visits for OD than all other pain meds.

Salicylates

Mechanism - COX inhibition Route - PO, PR Side effects - GI disturbance, bleeding Contraindications Relative - ASA/NSAID induced asthma, peri-op CABG, GI bleed, Renal dysfunction, liver disease.

Absolute - small children with fevers, hypersensitivity

NSAIDS

Mechanism - COX inhibitors, lipoxygenase inhibitors Route - PO, PR, IV, IM Side effects- platelet inhibition, PUD, dyspepsia, CNS dysfunction, headache, renal dysfunction Contraindications Relative - ASA/NSAID induced asthma, peri-op CABG, GI bleed, Renal dysfunction, liver disease.

NSAIDS

Opiates

Mechanismvariations on opioid receptor agonists, mixed agonist RoutePO, PR, IV, IV-PCA, IM, transdermal, transmucosal, epidural/intrathecal Side effectssedation, respiratory depression, n/v, constipation, itching Contraindications RelativeCOPD, hypotension, impaired renal function, impaired liver function, elderly patients AbsoluteHypersensitivity, paralytic ileus, respiratory depression

Opiate MOA

Central Mu

respiratory depression analgesia euphoria miosis

Peripheral Mu
cough suppression constipation

Topicals/Local

Mechanismlocal receptor effect Routetopical Side effectslocal reaction, accidental IV injection, burning, erythema, hives, seizures, respiratory arrest, asthma Contraindications

Relativeliver dysfxn, renal dysfxn, heart block

Adjuvants/Other classes

Gabapentin/Pregabalin, anticonvulsants - neuropathic pain Tricyclics - neuropathic and chronic pain Caffeine - useful as an adjuvant with NSAIDS Things we shouldnt use acutely

Benzodiazepines: no role for acute pain relief unless due to muscle spasm Antihistamines, dextroamphetamine, steroids, intrathecal clonidine

General Approach

If on chronic pain meds continue them Mild pain APAP, ibuprofen Mild Moderate Scheduled NSAID +/- T3 or opiate Mod-Severe IV toradol + opiate Prn Meds Scheduled vs Prn in uncontrolled pain

Cases

Case 1

35 yo male with history of HTN and DM presents after straining his back in a kickball game. History and physical are negative for red flags. How would you treat this patients pain? What are the red flags for back pain?

Musculoskeletal Pain

Treat back strain with NSAIDS, not narcotics

Ibuprofen 400-600mg qid Naproxen 220-500mg bid Watch for side effects Consider muscle relaxant based on severity

Red Flags: cancer, fevers/recent infection, major trauma, incontinence, focal deficits, saddle anesthesia.

Case 2

AP is a 27 yo aa female with sickle cell who is complaining of 10/10 pain in her arms, legs, and back which is typical of a pain crisis.
What questions should you ask? How do you treat this patients pain?

Case 2

She is not on long acting pain meds at home. She has been taking 2 percocets every 4 hours with no relief. In the ED she was given 10mg morphine with no relief. What do you do now?

Sickle Cell Pain

Sickle Cell Pain

Pain Management - Narcotic boluses IVPB only - No IV access give po, IM, or Subcutaneous - continue chronic long acting meds - initially give morphine 5-10mg IV and repeat q1hr prn until improvement, or dialudid 1-2mg IV q 2hr until pain improves. - start PCA with same medication - may give breakthrough equal to one hour demand as needed - consider NSAIDS if no contraindication - increase PCA by 25% prn

Patient Controlled Analgesia

Basal: ____ Bolus: ____ Lock Out: ___ Max: _____

Patient Controlled Analgesia

Morphine Basal: 0 Bolus: 1mg Lock Out: 5 min Max: 10mg/hr

History Button

Patient Controlled Analgesia

Dilaudid Basal: 0 Bolus: 0.4mg Lock Out: 6 min Max: 2mg

History Button

Case 2

On the fourth day of admission the patients pain is controlled and you want to stop the PCA. Over the last 24 hours she has taken 50mg of morphine IV. How do you switch this patient to a po regimen?

Equianalgesic Doses for Opiates

Converting IV to PO

Morphine IV to PO conversion is 13
So equianalgesic dose is 150mg morphine po Give - 2/3 dose in long acting form MS contin (30mg bid or q8 hours) Make short acting 5-15% on long acting po (10mg po prn) Use good judgement (dont give more po than on PCA) Taper as appropriate.

Case 3

Youre on Weisman and get a call at 0300 for a sickle cell patient on the Ratnoff team who is complaining of 10/10 pain. VS are 94/50, 120, 88% on 2L.
What questions should you ask? How do you treat this patients pain? When do you need to go evaluate a patient with pain?

Acute Chest Syndrome

Case 4

JJ is a 64 yo vet with prostate cancer with bone mets whos admitted for pain control. At home he had been taking one percocet every four hours like clockwork. He never took more than one because it made him feel sick. - How should you manage JJs pain?

Case 3
1.

2.
3. 4.

Add up current 24 hour opiate use Divide into 2 long acting doses Provide Breakthrough doses Bowel Regimen

Case 3

1 percocet q4 hours = 30mg oxycodone/day Start 10-15mg oxycontin bid for long acting pain control Oxycodone or percocet for breakthrough pain Increase long acting based on breakthrough use and side effects

Case 3

JJ hospital day #5. You get paged and the nurse tells you that the patient is difficult to arouse. Vitals are BP 106/60, HR 100, RR 8, 88% on 2L.
What questions should you ask? What do you look for on physical exam? What is the treatment?

Narcotics

Overdose - Depressed mental status - Decreased RR - Decreased TV - Decreased BS - Miotic pupils

Withdrawal - appetite suppression - nausea and vomiting - Mydriasis - goosebumps - diarrhea/abd pain - Tachycardia - hot flushes/sweating - irritability - insomnia - violent yawning - depressive moods

Case #5

35 yo female with endometriosis presents to the ED with a cc of pelvic pain. She appears to be in so much distress that she is given 2mg of dilaudid IV push x 2.
How much morphine is 4mg of dilaudid IV equivalent to? What is an appropriate starting dilaudid dose? What else could you treat this patients pain with?

Equianalgesic Doses for Opiates

Case 6

69 yo male with Stage IV metastatic non-small cell lung cancer to the bilateral lungs, bone, brain, liver, and adrenal glands. After your discussion with the patient and his family he has elected for comfort measures. Currently the nurse says that the patient appears very uncomfortable, tachypneic, and hypoxic. Vitals are HR 114, BP 90/50, 90% on 2L, and 8/10 pain. The patient is no longer taking po, and has altered mental status. You think that the patient is actively dying. What options do you have to keep the patient comfortable?

End of Life

Principle of Double Effect Morphine drip Oral, transdermal, PR Palliative Care Consult Service

Prescriptions
Date: Name: Street: City: State: Zip: Telephone:

Superscription

Recipe = Take Thou

Inscription
Subscription Signatura

Med/Dose

Disp#: Instructions for Pharmacist Sig: Write or Label = instructions for patient
Quantity, route, frequency, and reason
Refill _________ Times DEA Number _____________ Suffix Number ____________ 11100 Euclid Avenue Cleveland, Ohio 44106 Phone (216)844-1000 _________________________________ M.D. Signature _________________________________ Print Name/ Pager # _________________________________ UH Dr. Number

Drug Schedules

Schedule I No medical use (heroin, marijuana, LSD, peyote, etc.) Schedule II High abuse potential (opium, morphine, codeine, hydromorphone, methadone, oxycodone, cocaine, amphetamine, PCP) Schedule III less abuse potential than II (certain narcotic analgesic drugs, and other drugs such as barbiturates and GHB) Schedule IV less abuse potential than III schedule (barbital, phenobarbital, chloral hydrate, diazepam) Schedule V least abuse potential. (Dextromethorphan, Loperamide)

Drug Schedules

Refills for Schedule II drugs are not permitted. Refills for Schedule III, IV, and V drugs are permitted.
5 refills max Script expires in 6 months

No refills over the phone or for someone elses patient

Date: 7/10/09 Name: Hill, Billy Joe Street: 623 Trailor Ridge City: Brecksville State: Oh Zip: Telephone:

0xycodone 10mg (ten) Disp#: 30 (thirty) Sig: Take one tab p.o. q6hours for pain control.
_________________________________ M.D. Signature

Refill NONE Times DEA Number AU-2222222 Suffix Number z-123 11100 Euclid Avenue Cleveland, Ohio 44106 Phone (216)844-1000

Parchman / 37619
_________________________________ Print Name/ Pager #

11111
_________________________________ UH Dr. Number

12345678910
_________________________________ NPI

Final Case

Mr. Hill is a 50 yo vet with a broken leg who you see in the urgent care at the VA. You send him to the VA pharmacy with the above script for oxycodone. He returns to the UCC one hour later and appears to be in terrible pain and very angry. Why is he angry, and how do you ameliorate the situation?

Questions?

However long the night, the dawn will break.