Transcript Chronic Pain in the ED

Chronic Pain in the ED
Martin Huecker
Hugh Shoff
Summary
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Case
Pathophysiology of Pain
Acute vs Chronic
Epidemiology
Treatment
Barriers / Challenges
Guidelines
Future considerations
Case
• 35 year old white male with chronic neck pain
related to degenerative disc disease
• Surgery 3 years ago, has been on Oxycontin 40
bid with hydromorphone po tid for
breakthrough pain
• Presents in 10/10 pain, has run out of his
home medications
• Visiting family in your town
Pathophysiology
• Nociceptive versus
• Nociceptive: Noxious stimulus
• Neuropathic: altered CNS signal processing
Acute vs Chronic Pain
• Acute pain has “identifiable pathologic
condition” and warns the individual of injury
or illness.
• Acute becomes chronic when the pain pattern
persists after the insult has resolved.
• Transition is complex with obvious physiologic
and psychosocial aspects.
• Likely related to treatment efforts in the acute
phase
Chronic Pain
• “Continues beyond the usual recovery period for an
injury or illness … continuous or come and go”
– American Chronic Pain Association
• “adversely affects the function or well-being of the
patient, attributable to any non-malignant etiology”
– American Society of Anesthesiologists
• “pain and disability far out of proportion to the
peripheral stimulus.”
• Schofferman
Chronic Pain
• Either:
– Not related to tissue injury, or
– Tissue injury not expected to resolve, past the
time of normal resolution, expected to progress
Recurrent Pain
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Subset of Chronic Pain
Is not constant in nature, waxes and wanes
Back pain, migraines, sickle cell, IBD
Treatment approach different – treat like
acute pain with goal of preventing future
episodes
Chronic pain of malignancy
• Similar to acute pain due to ongoing
nociceptive stimulus
• Similar to chronic pain due to duration and
psychobehavioral components
Chronic Pain Patients
• 1. Exacerbation of chronic pain
• 2. Untreated chronic pain / gap in treatment
(our case)
• 3. Acute pain in the patient already being
treated for chronic pain
Epidemiology
• 42-78% of ED visits are for painful conditions
• Of these, as much as 40% have underlying
chronic pain conditions
• Opioid abuse is the fastest-growing drug
abuse problem in the United States
• Opioid overdose deaths:
– 1999: 4030
-- 2008: 14,800
• 2nd highest injury death after MVA, greater
than cocaine and heroin combined
More Statistics
• 710mg per person  enough to supply every
american with 5mg hydrocodone Q4H
• EM 3rd highest specialists in number of opioid
prescriptions in 10-30 year olds
• Deaths from overdose have led to statewide
opioid prescribing guidelines
• Recommended by the 2011 Prescription Drug
Abuse Prevention Plan from the White House
Office of National Drug Control Policy
Chronic Pain
• 24 million adults with chronic pain visit the ED
annually
• 12 million visits due to acute exacerbations of
chronic pain syndromes
• 11% to 20% of ED patients have chronic pain
• 89% of Americans have pain once a month
• 15% severe pain monthly
• >65yo, 55% have pain daily
Definitions
• Allodynia: pain from a stimulus that is not
normally painful
• Hyperalgesia: Pain out of proportion to a
noxious stimulus
Neuropathic Pain
• Due to nerve injury
• Most of the neuropathic pain syndromes are
included in the Complex Regional Pain
Syndrome
Complex Regional Pain Syndrome
• CRPS
• Type 1: No nerve injury
• Type 2: Known nerve injury
Treatment
• Pain subjective, therefore determination of
success and failure can be difficult
• Pharmacologic Therapies
• Nonpharmacologic
Pharmacologic
• NSAIDs
– Nonselective COX, COX-2 inhib
• Acetaminophen
• Opioids
– Agonists, agonist-antagonists
• Nonanalgesics
• Local Anesthesia
NSAIDs
• No abuse potential
• GI and Renal side effects may be prohibitive
• Valuable augmentation to opioids
Acetaminophen
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Safe in less than 3 grams per day dosing
No GI side effects
No renal injury concern
Hepatotoxic
Opioids
• Role well established in ACUTE pain
• Analgesic effect AND altered emotional response to
pain
• Controversial in Chronic pain
• Concerns: respiratory suppression, dependence,
diversion
• Can be used in acute exacerbations of chronic pain
• Should be prescribed for chronic conditions in
concert with pain management physician with pain
contract
Nonanalgesics
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Skeletal Muscle Relaxants
Anti-depressants
Anticonvulsants
NMDA receptor antagonists
Non-Pharmacologic
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Transcutaneous Electrical Nerve Stimulation
Physical Therapy
Hypnosis
Acupuncture
System Barriers / Challenges
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Time Limitations
Limited Priority
Frequent Flyers
Insurance
No PCP
Physician Barriers
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Annoyance
Fear of addiction / bad intentions
Belief in pathology
Diversion
Reluctance to prescribe
Exaggeration / Manipulation
Futility
Pseudoaddiction
• Patient behaviors occurring when pain is
undertreated
• Intense focus on obtaining analgesics
– Patient can appear to be “drug-seeking”
• Unlike “drug-seeking,” resolves with adequate
treatment / relief of pain
Drug-Seeking Behavior
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Exaggeration of pain
Very susceptible to bias
Patient deserves benefit of doubt
Multidisciplinary approach
Prescription monitoring programs
Opioid Prescription
• Guidelines
• Monitoring Systems
Example Chronic Pain Treatment
Guidelines
• Definitive management is NOT the EP’s role
• Rescue, Referral
• Treat pain aggressively, promptly,
appropriately
• Thorough physical exam
• Expect exaggerated avoidance, emotion,
allodynia, nondermatomal distribution,
autonomic manifestations
Example Chronic Pain Treatment
Guidelines
• Look for fear, worry, “catastrophizing,”
suppression, distraction, depression
• Multimodal treatment
• Avoid prolonged immobolization, return to
work early
• Multimodal pain clinic
• Minimize stress, depression
ACEP: Drug Monitoring Programs
• 41 states, 7 more in the process
• Level C
• Programs MAY identify patients at high risk of
diversion and doctor shopping
• No proven decrease in mortality or abuse
Monitoring Programs
• Since 1930s
• Computerized in 1990s
• 2002 Harold Rogers Prescription Drug
Monitoring Program, US DOJ
• 2005 National All Schedules Prescription
Electronic Reporting Act
• State-based, limited interstate communication
thus far
Monitoring Programs
• Useful tool in recognizing and intervening
upon patients involved in substance abuse
• Emergency Physicians received little training
• Maintain therapeutic stance
– Beneficence, Nonmaleficence
• Avoid despair and hostility
KASPER
• Kentucky All Schedule Prescription Electronic
Reporting System
• KASPER is a reporting system designed to be:
– A source of information for practitioners and
pharmacists.
– An investigative tool for law enforcement.
KASPER
• Access to KASPER:
– Prescribers for medical treatment of a current or prospective
patient,
– Dispensers for pharmaceutical treatment for a current patient,
– Law enforcement officers for a bona fide drug-related
investigation,
– Commonwealth's attorneys and assistant Commonwealth's
attorneys, county attorneys and assistant county attorneys,
– Licensure boards for an investigation of a licensee,
– Medicaid for utilization review on a recipient,
– A grand jury by subpoena, and
– A judge or probation or parole officer administering a drug
diversion or probation program.
Border State Prescription
Monitoring Programs
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Indiana PMP (INSPECT)
Illinois PMP
Ohio PMP (OARRS)
Tennessee PMP
Virginia PMP
West Virginia PMP (RXDataTrack)
House Bill One
• Legislation in state of KY, first of its kind
• Mandatory registration with KASPER
• Mandatory use of KASPER when prescribing
Schedule II, Schedule III with hydrocodone,
and specified Schedule IV medications
• Certain Exceptions include administration in
the ED, inpatient setting, cancer, end of life
care
ACEP: Low Back Pain
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Level C
No obvious benefit to opioid or non-opioid
Risk of opioid
Therefore physician should attempt nonopioid except in severe or refractory pain
• No more than three to seven days of
medication
ACEP: New-onset acute pain:
Schedule II vs III
• Level B
– For “short-term relief of acute MSK pain”
physicians may prescribe either
• Level C
– “Inadequate” evidence of any superiority of
Schedule II over Schedule III
ACEP: Opioids In Acute Exac of
Noncancer Chronic Pain
• Level C:
• Physicians should avoid prescribing of opioids
for patients with acute exacerbations of
chronic non-cancer pain
• Lowest possible dose and duration
• Honor pain contracts
Future
• Patient satisfaction as a metric?
• HCAHPS survey and reimbursement
• Additional state or federal legislation similar
to House Bill 1
• Additional state opioid prescribing guidelines
similar to those in Washington, New York, etc
References
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Miner, JR, Paris, PM, Yealy, DM. (2009). Pain Management. In Rosen’s Emergency Medicine – Concepts and
Clinical Practice (7th Edition, pp. 2410-2428). Mosby
Hansen, GR. Management of Chronic Pain in the Acute Care Setting. Emerg Med Clin N Am. 23 2005;307338.
Cantrill, SV, et al. Clinical Policy: Critical Issues in the Prescribing of Opioids for Ault Patients in the
Emergency Department. Ann Emerg Med. 2012;60:499-525
Baker, K. Chronic Pain Syndromes in the Emergency Department: Identifying Guidelines for Management.
Emergency Medicine Australasia. 2005;17:57-64
Todd, KH. Pain and Prescription Monitoring Programs in the Emergency Department. Ann Emerg Med.
2010;56:24-26
Todd, KH, et al. Chronic or Recurrent Pain in the Emergency Department: National Telephone Survey of
Patient Experience Western Journal of Emergency Medicine. 2010;11:408-415
Wilsey, BW, et al. Chronic Pain Management in the Emergency Department: A Survey of Attitudes and
Beliefs. Pain Management 2008;9:1073-1080
KASPER Kentucky All Schedule Prescription Electronic Reporting System.
http://www.chfs.ky.gov/os/oig/KASPER.htm
Kentucky House Bill 1. http://www.kbml.ky.gov/NR/rdonlyres/DFFF4843-1343-4468-9574C9BE26CE48CF/0/HouseBill1.pdf