Lecture created by: Lindsay Nicholson, MD University of Michigan Internal Medicine
Lecture created by: Lindsay Nicholson, MD University of Michigan Internal Medicine Resident Education Committee 2010-2011 Pain: an unpleasant feeling conveyed to the brain by sensory neurons ◦ Signals actual or potential injury to the body ◦ Also includes perception/subjective interpretation of the discomfort Location Intensity Character Emotional response Pain of any type is the most common reason patients seek medical attention This presentation will discuss management of acute pain. Chronic pain is different from acute pain. ◦ It requires comprehensive physical, functional, behavioral and psychosocial assessment and is beyond the scope of this presentation. Mr. Wilson 78-year-old man PMHx: ◦ HTN, HPL ◦ DM2 ◦ Prostate cancer w/ mets to spine and pelvis, HPI: Comes to the ED w/ 2 weeks of worsening low back pain Metastatic cancer Pathologic/compression fracture Musculoskeletal strain Bulging/herniated disk Degenerative joint disease Nephrolithiasis Pyelonephritis Psoas abcess Retroperitoneal hematoma Pulmonary: PNA, PE, etc. Cardiovascular: Aortic dissection, angina equivalent Take a thorough Hx: ◦ ◦ ◦ ◦ ◦ ◦ ◦ Location and radiation Timing, duration, onset Severity Character/description of the pain Alleviating factors Exacerbating factors Associated Sxs Perform a good PEx (with neuro exam) Plain films of the lumbar spine What would you be looking for with plain films? Cross-sectional imaging? Chronic LBP Well-controlled prior to this episode w/ APAP, ibuprofen, and occasional Vicodin Acute-on-chronic lumbar pain, non-radiating Began 2 weeks ago, getting progressively worse Dull, achy Rates 8/10 Alleviated by lying down, Vicodin Over past 2 days taking up to 8 Vicodin tab/day w/o lasting relief Exacerbated by standing, walking No numbness, tingling, weakness, bowel/bladder Sxs No inciting trauma or injury T 36.5, HR 80, BP 130/85, RR 12, SpO2 98% RA Gen: Well-appearing. NAD when lying flat, moderate distress when asked to sit and stand HEENT, CV, Pulm, Abd exams all WNL Point tenderness @ L3, no paraspinal or CVAT, no flank ecchymoses Flexion, extension, twisting all limited 2/2 pain BLE strength 5/5 and symmetric, sensation to light touch intact over BLE and perineum, patellar/Achilles reflexes 2+, rectal tone WNL Gait, heel, and toe walk WNL Metastatic cancer Pathologic/compression fracture Musculoskeletal strain Bulging/herniated disk - no radiculopathy or cord compression findings on PEx Degenerative joint disease Nephrolithiasis Pyelonephritis Psoas abcess Retroperitoneal hematoma Pulmonary: PNA, PE, etc. Cardiovascular: Aortic dissection, angina equivalent What do you want to do for Mr. Wilson? What do you need to order? Any special considerations for Mr. Wilson in the first 12 hours (e.g., overnight while on call)? Medical Tx: ◦ Goal is first to control pain, using IV meds if necessary, then transition to regimen that may be taken as outpatient (e.g., PO, transdermal) Surgical Tx: ◦ Is the pain fixable with surgery? (e.g., acute abdomen, abcess/hematoma, orthopedic issues) Monitoring response to Tx: ◦ Does pt express relief? ◦ Does pt look comfortable? ◦ Do VS support this? (e.g., no further tachycardia/hypertension/tachypnea) Subjective: ◦ Ask pt to qualify and quantify pain: ―Pain score‖ 1-10 scale Objective: ◦ VS: tachycardia, hypertension, tachypnea ◦ FLACC scale Acetaminophen (Tylenol): ◦ Dose: 325-650mg PO Q4-6H PRN or scheduled ◦ Daily max 4000mg/day (2000mg/day in cirrhotics) Keep in mind when using opiate/APAP combinations APAP also seen in many OTC cold preparations ◦ Few side effects (unless overdosed) ◦ Effective adjunct therapy to other classes of meds ◦ Effective antipyretic Beware of masking fever with scheduled dosing NSAIDS: ◦ Ibuprofen 400-800mg PO Q4-8H PRN or scheduled ◦ Naproxen 375-500mg PO BID PRN or scheduled ◦ Many others (diclofenac, etodolac, piroxicam, indomethacin, nabumetone, etc.) Gastritis, PUD Especially with long-term use: consider PPI Platelet inhibition: Don’t use if bleeding Worsened HTN ◦ Ketorolac (Toradol) 15-30mg PO/IM/IV Q6H PRN Potent NSAID, especially effective for nephrolithiasis/ureteral colic Max use 5 days, inpatient use only Opiates ◦ Centrally-acting µ-receptor agonists Produce analgesia and respiratory depression by decreasing brainstem response to carbon dioxide and electrical stimulation Decrease gastric, biliary and pancreatic secretion, induce peripheral vasodilation and promote hypotension due to histamine release ◦ Can be very effective for management of acute pain ◦ Side effects: Respiratory depression, CNS sedation, hypotension, constipation, N/V, pruritis Use with caution! ◦ Can also be habit-forming with potential for abuse Codeine/APAP: ◦ Tylenol #3 30/300mg 1-2 tab Q4H PRN Compounded with guaifenesin (Robitussin AC) for cough suppression Nausea/vomiting are common side effects Propoxyphene/APAP (Darvocet) ◦ Removed from market (no more efficacious than APAP alone) Hydrocodone/APAP ◦ Norco: 5/325, 7.5/325, 10/325 mg 1-2 tab Q4H PRN ◦ Vicodin: 5/500, 7.5/750, 10/660 mg 1-2 tab Q4H PRN ◦ Lortab: 10/500 mg 1 tab Q4H PRN All PO, short-acting, for short-term use Oxycodone: ◦ Oxycodone 5-10mg Q4H PRN ◦ Oxycodone/APAP (Percocet) 2.5/325, 5/325, 7.5/325, 7.5/500, 10/325, 10/650 mg PO Q4-6H PRN Short-acting preparations, for short-term use ◦ Oxycodone ER (OxyContin) 10-80mg PO BID Long-acting alternative for pts intolerant to morphine Higher risk for abuse/diversion Morphine sulfate ◦ Tablets: 10, 15, 30 mg PO Q4H PRN ◦ Liquid (Roxanol): various concentrations (useful for pts with swallowing difficulties) ◦ Injection: 2-10 mg IV/SC Q4H PRN (may be used more frequently with caution) Morphine ER ◦ MS Contin 15-30mg PO BID ◦ Kadian 30-60 mg PO daily Morphine is especially useful for relieving sensation of breathlessness/air hunger in comfort care/end-of-life scenarios Hydromorphone (Dilaudid) ◦ Tablets: 1-4 mg PO Q4H PRN ◦ Injection: 0.1-0.4 mg IV Q4H PRN Note higher potency and conversion between PO/IV Fewer side effects (pruritis, nausea) than morphine or oxycodone No long-acting formulation, should only be used short-term Higher abuse/diversion potential Fentanyl ◦ Injection: 50-100 mcg Q30-60min PRN Short acting, commonly used in OR and ICU ◦ Transdermal patch (Duragesic) 12.5 – 100 mcg/hr Change every 72 hours Variable absorption depending on adiposity For use in chronic/terminal pain Caution pts against applying heat over patch – increased medication delivery can be fatal ◦ Transmucosal/buccal lozenges also available for breakthrough (terminal) pain Methadone 2.5-30mg PO BID-TID Buprenorphine (Suboxone, Subutex) 2/0.5mg PO TID ◦ Long-acting opiates effective for chronic pain, hyperalgesia, and addiction ◦ Should only be initiated/titrated under the guidance of a pain management specialist Meperidine (Demerol) ◦ Short-acting parenteral opiate analgesic ◦ Removed from UM formulary as metabolite (normeperidine) is CNS-toxic and can cause Szs ◦ Restricted to short-term use for intractable rigors and post-op shivering Gives pt some control over pain relief On average, pts use fewer milligrams/24 hours than traditional nurse-administered pain meds Indications: ◦ Severe, acute pain requiring frequent dosing of IV opiates ◦ Anticipate need >24 hours ◦ Pt able to understand and use button (only pt may push) Dosing: ◦ Morphine or Hydromorphone ◦ Demand dose depends on level of tolerance, Q6-10min ◦ +/- basal (continuous) rate ◦ Stop all other opiates ◦ See guidelines for more details Tx: Naloxone (Narcan) ◦ For suspected opiate overdose (somnolence, respiratory depression) ◦ 0.4 mg IV push every 2-3 min until response If no response after 2 doses, the Sxs are probably not due to opiate overdose ◦ Effects are short-acting, may require repeat dosing until opiate is cleared Dose with caution, especially in renal/hepatic impairment and elderly ◦ Can always give more, but can’t take away Watch carefully for CNS and respiratory depression, hypotension Do not prescribe opiates without a bowel regimen! Anticipate need for antiemetics, antipruritics ◦ Avoid diphenhydramine in elderly or those at risk for delirium ◦ Dose diphenhydramine through oral route only Docusate (Colace) 100mg PO BID ◦ Weak stool softener Senna 2 tab daily-BID ◦ Weak stimulant laxative Bisacodyl (Dulcolax) 10 mg PO or PR (suppository) PRN ◦ Stronger stimulant laxative if above fails Polyethylene glycol (Miralax) or psyllium fiber ◦ Osmotic laxatives, non-absorbed, good for daily use Lactulose, Sorbitol, Mag Citrate, Mineral Oil ◦ Stronger osmotic laxatives if above fail Enemas: tap H2O, milk and molasses, SMOG (sorbitol, mineral oil, glycerin) ◦ Avoid: Na-phosphate (lyte disturbances) and soap suds (chemical colitis) Other: ◦ Tramadol (Ultram) 50-100mg PO Q6H PRN Weak opioid that also weakly inhibits reuptake of norepinephrine and serotonin Same side effects as other opioids; potential for dependence Can lower seizure threshold with SSRIs Also risk of serotonin syndrome Topical/Local: ◦ Transdermal lidocaine patch on 12H, off 12H ◦ Capsaicin Cream Ideal for discrete pain (i.e. postherpetic neuralgia) Few side effects, potential for skin irritation Adjunct Tx for chronic pain ◦ Require sustained use for effect ◦ Antidepressants: TCAs, SSRIs, SNRIs Effective in central pain syndromes, fibromyalgia, neuropathic pain (esp. TCAs) Depression is common in chronic pain patients Counseling may also be helpful ◦ Anticonvulsants: Gabapentin, pregabalin (for neuropathic pain) Lamotrigine (for trigeminal neuralgia) Positioning Massage Physical therapy Heat Ice Orthotics (splints, slings, compressive wraps) Guided relaxation and biofeedback techniques Inpatient goals: ◦ Pain controlled on oral or transdermal meds ◦ Able to walk, eat, void, stool Always think about bowel regimen If acute pain, plan for tapering off meds once episode has passed If chronic pain, plan for follow-up If terminal pain, anticipate need for escalation ◦ Palliative care/hospice? If orthopedic/musculoskeletal pain, could pt benefit from physical therapy? Physicians VASTLY underestimate the amount of opioid diversion by their patients Some of your patients WILL be either selling their meds or will pass on to family members and friends Opioids are rarely appropriate chronic pain—you only create dependency and a new illness ◦ Terminal illness (esp. cancer pain) is a notable exception When discharging patients, the plan should be for SHORT-TERM use The street value of opioids is higher when using brand names ALWAYS prescribe using generic (e.g., hydrocodone/APAP instead of Vicodin) In the hospital, Mr. Wilson was treated with IV morphine for his L3 compression fracture with good relief of his acute pain Oncology was consulted, and felt there was no further role for chemotherapy or radiation for his metastatic prostate cancer Orthopedics was consulted, and felt there was no role for operative management in the absence of spinal cord or nerve root compression IR performed a kyphoplasty (injection of cement under fluoroscopy) to stabilize the L3 vertebral body Mr. Wilson was transitioned to long-acting PO morphine, with short-acting PO morphine for breakthrough ◦ Long-term treatment of his terminal pain Good relief of Sxs Able to walk and perform ADLs Daily BMs on a bowel regimen Discharged home! CareLink has an Acute Pain Management order set: ◦ Find under UH/CVC Acute Pain Management Find and Tx the cause of pain Many classes of pain medications are available for Tx of acute pain Prescribe opiates with caution ◦ Don’t forget the bowel regimen! ◦ GENERIC NAMES ONLY!!! ◦ Plan should be for short-term use unless terminal pain Consult guidelines and seek expert consultation for treatment of chronic pain Pain Management in the Hospitalized Patient, Med Clin NA, 2008 UMHS Analgesic Prescribing Guidelines: http://www.med.umich.edu/i/pain/Website/6 2-11-003.pdf UMHS Guidelines for Management of Chronic Non-Terminal Pain: http://www.med.umich.edu/1info/fhp/practi ceguides/pain.html Equianalgesic Dosing Card: http://www.med.umich.edu/i/pain/pdf%20fil es/paincard100405.pdf
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