Transcript Pain Treatment Options ppt.

Chief Complaint: Total Body Dolor
Plan: Pain Management
PART 1
A 70-year-old male with ESRD on hemodialysis
presents with methicillin-resistant Staphylococcus
aureus (MRSA) bacteremia and ankle pain after a fall.
An MRI of his ankle is negative, and he is started on
acetaminophen and lidocaine patches, which result in
adequate pain relief of the ankle. He later develops
significant neuropathic pain in both arms, and a CT
scan of the cervical spine reveals a cervical abscess and
osteomyelitis. The patient desires pain relief but
adamantly refuses narcotics, stating: “I don’t want to
get addicted.” How can his pain be managed?
Learn some key facts about pain management
 Identify practical approach to pain management
 Learn how to perform simple opioid conversion
 Learn to manage pain in patients with liver or
renal diseases
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Overview of Pain Management Standards
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Patient knows best; only the patient can describe characteristics
and rate the severity of his or her pain!
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Pharmacological therapies
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Uses non-pharmacological therapies whenever appropriate
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Provide education and counseling
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Use adjuvants for specific pain (ex. bone, neuropathic)
Pain Treatment Options – Nonpharmacologic approach
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Mind-Body therapy
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Tai-chi
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Heat/Cold therapy
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PT/OT
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Massage
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Transcutaneous Electrical
Nerve stimulator (TENS)
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Acupuncture
Pain Treatment Options –
Pharmacologic approach
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Non-opioids
Capsaicin
 Acetaminophen
 NSAIDs
 Steroid
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Pain Treatment Options –
Pharmacologic approach (cont)
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Adjuvants
TCA: commonly used for neuropathic pain
 Gapabentin: FDA-approved for partial seizures and
postherpetic neuralgia but is also used for a wide
variety of neuropathic pain syndromes, including
postoperative pain
 Lidocaine patch: FDA-approved for postherpetic
neuralgia but are used for a wide variety of local pain
syndromes
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NSAIDs
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Side-effects
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Alternative treatments
Consider nonacetylated salicylates
or COX-2 selective (Diclofenac,
Meloxicam), celecoxib plus PPi
Consider topical therapy (Capsasin)
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GI
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Renal: reduce GFR

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Increase fluid retention, HTN
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Consider Naproxen or Tylenol or
topical therapy
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Increase risk of confusion
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Platelet dysfunction
Consider non-pharmacologic
therapy
Consider Acetaminophen
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Corticosteroid
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Indication:
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reduce compression due to edema causing structural
stretching-> visceral pain
Anti-inflammation; Trigger point injection (must rule out
septic joint first).
Stimulate appetite
Need to weigh benefits vs. risks
Dexamethasone produces the least amount of
mineralocorticoid effect, with the highest amount of
anti-inflammatory effects
Summary
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Only the patient can describe characteristics
and rate the severity of his or her pain.
Always consider using non-pharmalogical approach
when appropriate.
All non-opioids medication have ceiling effects.
Do not combine multiple NSAIDs. Use alternative
treatments to minimize potential side-effects.
Consider adjuvants for specific pains such as bone
pain or neuropathic.
Chief Complaint: Total Body Dolor
Plan: Pain Management
PART 2
Clinical Case
A 70-year-old male with ESRD on hemodialysis presents
with methicillin-resistant Staphylococcus aureus
(MRSA) bacteremia and ankle pain after a fall. An MRI
of his ankle is negative, and he is started on
acetaminophen and lidocaine patches, which result in
adequate pain relief of the ankle. He later develops
significant neuropathic pain in both arms, and a CT
scan of the cervical spine reveals a cervical abscess and
osteomyelitis. The patient desires pain relief but
adamantly refuses narcotics, stating: “I don’t want to
get addicted.” How can his pain be managed?
Pain Management Option- Opioids
1)
2)
3)
4)
5)
6)
Total Amounts
Convert
Cross-Tolerance?
Choose appropriate PO
PRN’s/breakthrough pain
Bowel regimen
Principles of Analgesic Use in the Treatement of Acute Pain and Cancer Pain, 5th Ed, American
Pain Society. 2003
Let’s practice
78 YO F with no PMH was admitted to the
hospital for newly diagnosed pancreatic cancer.
The patient has been requiring large amounts of
Dilaudid (hydromorphone) IV during (totaling
8.1mg / 24 hrs). The patient is ready for
discharge. What oral regimen should you send
her home on?
Let’s practice
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Step 1: IV PO conversion
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8.8 mg IV Dilaudid to PO morphine
8.8 x 20 = 176 mg PO Morphine
Step 2: Cross tolerance?
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YES! Reduce by 15%
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Step 3: Schedule PO Dosing frequency
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MS CONTIN = BID Dosing. 150mg in BID dosing
150/2 = 75mg MS Contin BID
Step 3: calculate breakthrough dosing
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= minimum of 30-50% total daily requirement
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150 * 0.50 = 75mg / day
75mg divided into q4h dosing =
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PO Morphine = 150mg
75 / 6 = ~12 mg q4h PRN
Step 4: don’t forget bowel regimen or you will have a very unhappy patient at
your follow up appointment
Back to the initial case
A 70-year-old male with ESRD on hemodialysis
presents with MRSA bacteremia and ankle pain after a
fall now found to have significant neuropathic pain in
both arms with evidence of cervical abscess and
osteomyelitis on C-spine CT. The patient desires pain
relief but adamantly refuses narcotics, stating: “I don’t
want to get addicted.” How can his pain be managed?
Back to the initial case
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The patient’s ankle pain was controlled with acetaminophen and
lidocaine patches. For the neuropathic pain in his upper
extremities, tramadol was started at 25 mg oral every 12 hours
and increased to 50 mg oral every eight hours (below the
maximum of 200 mg a day). The tramadol did not result in
adequate pain relief, so gabapentin 100 mg at bedtime was
initiated, then increased to twice daily over three days with some
relief.
A geriatric consult was obtained to help educate him regarding
addiction to opioids, as well as to explore goals of care, but he
continued to insist on the use of a non-narcotic regimen for his
pain.
Summary
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Pain management is a comprehensive, patientcentered process including pharmacological agent,
psychosocial counseling, and non-pharmacological
treatments when appropriate.
Always start with the lowest dose, least side-effect
agents and reassess frequently with patient’s input.
Use conversion chart for IV to po, and this
transition should be done as soon as possible.
When in doubt, always ask for help from the
experts.
References

Barakzoy AS, Moss AH. Efficacy of the World Health Organization analgesic ladder
to treat pain in end-stage renal disease. J Am Soc Nephrol. 2006;17(11):3198-3203.

Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage.
2004;28(5):497-504.

Broadbent A, Khor K, Heaney A. Palliation and chronic renal failure: opioid and other
palliative medications—dosage guidelines. Progress in Palliative Care. 2003;11(4):183190(8).

Johnson SJ. Opioid safety in patients with renal or hepatic dysfunction. Pain
Treatment Topics website. Available at: http://pain-topics.org/pdf/Opioids-RenalHepatic-Dysfunction.pdf. Accessed Dec. 7, 2013
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Ashburn MA, Lipman AG, et al. Principles of Analgesic Use in the Treatment of
Acute Pain and Cancer Pain. American Pain Society: 5th Edition. 2003