Transcript Inpatient Pain Management - Health Sciences Center for Knowledge

Inpatient Pain Management:
Challenges and Solutions for the
Modern Era
James R Knight, M.D.
Assistant Clinical Professor
Division of Hospital Medicine
The Ohio State University Medical Center
[email protected]
Outline/Objectives
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Define and describe pain
Describe inpatient pain management
strategies
Describe the scope of the problem of
prescription opioid use, misuse, and abuse
Discuss strategies for patient encounters
heavily influenced by these issues
Pain - Defined
• Nociceptors or free nerve endings release
neurotransmitters; a complex series of
signal transduction results in the thalamus
redistributing this information to the
hypothalamus, pons, and somatosensory
cortex.
• Because pain is a universally understood
signal of disease, it is a common
presenting symptom for patients.
http://en.wikipedia.org/wiki/Pain#Theory_today
Harrison's 17th Edition, 81.
Pain - Described
• Pain has a duality: sensation and emotion.
• Higher intensity pain can be accompanied
by anxiety and a desire to escape a
situation.
• Acute pain is accompanied by behavioral
arousal and a stress response (Increased
BP, HR, pupil diameter, plasma cortisol
levels).
Harrison's 17th Edition, 81.
Sensitization
• Intense, repeated, or prolonged stimuli are
applied to damaged or inflamed tissues
resulting in a DECREASED threshold for
activating afferent nociceptive receptors.
• This is particularly important in deep joints
and hollow viscera, areas of the body that
don't typically have sensitivity to
mechanical stimulation in the abscense of
inflammation.
Harrison's 17th Edition, 81.
Central Modulation
• There are brain “circuits” that modulate
pain.
– A soldier in battle may not even take notice of
significant injury.
– The expectation of pain from venipuncture
can be so overwhelming as to stimulate pain.
– This is activated by prolonged
pain and fear.
– Opioids are the most effective
way to modulate this circuit.
Harrison's 17th Edition, 83.
Medical Inpatient Pain
• 43% of medical inpatients experience pain
• 12% report unbearable pain.
• ED and post-surgical literature indicates that
healthcare providers generally underestimate
pain.
• Guidelines for inpatient pain management on
medical inpatients are virtually nonexistent.
– The current literature includes Surgical,
cancer, and sickle cell inpatients.
Dix et al. British Journal of Anaesthesia 2004;92:235-7.
Luger et al. Academy of Emergency Medicine 2003; 10:627-32.
Pain Assessment
• Bias can be introduced by either party.
• Stoic patients may be more likely to suffer with
pain.
• Providers may view pain as a weakness.
– Or may be prone to perceive “seeking” behavior
• Location, Quality, Duration, Severity, Timing,
context, modifying factors
• Also, patient attitudes towards opioids or
analgesics and history of substance abuse
Scales
• Visual analog scale – 10cm scale, patient makes
a mark on the scale.
• Verbal numeric scale – 1-10 scale traditionally
taught, but a 1-5 scale is proven to provide
improved patient differentiation.
• Facial Pain Scales – a series of 710 faces ranging from grimacing
to neutral (ideal for children).
• Multidimensional Pain Inventories
McQuay et al. BMJ 1997; 314:1531-5.
The Problem with Scales and
Protocol Driven Responses
• The scales are only minimally validated in
medical inpatients
• Vila et al. at USF evaluated ADRs after
initiating the 2001 JCAHO requirement
requiring pain assessment.
– They coordinated a system whereby high pain
scores received increased opioid analgesia.
– Patient satisfaction and adverse drug events
both had a statistically significant increase.
Vila, et al. Anesth Analg 2005;101:474-80.
Pain Management in the
Hospitalized Patient
•
WHO Analgesic ladder (1986)
– Designed for cancer pain
– Never validated in hosptialized medical
patients
1. non-opioids for mild pain
2. opioids for mild-mod pain, +/- non-opioids
and adjuvants
3. Opioids for mod-sev pain +/- non-opioids
and adjuvants
McQuay et al. BMJ 1997; 314:1531-5.
Morphine
What’s wrong with morphine?
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Nothing!
Proven historical profile
Renally excreted
More likely to cause histamine release
– Which may be associated with vasodilatation,
flushing, hypotension as well as itching
– Usually controlled with oral diphenhydramine
IV Morphine Equivalence
• 10 mg of IV morphine is the equivalent of:
– 30mg PO morphine
– 1.5mg IV/IM hydromorphone
– 7.5mg oral hydromorphone
– 10-12.5mg oxycodone
– 15mg PO hydrocodone
Online Opioid Converters
• Johns Hopkins
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–
http://www.hopweb.org
Registration is free!
The Problems with Hydromorphone
and Fentanyl
• Hydromorphone’s primary metabolite has
greater neuroexcitatory potential than that
of morphine (potential for allodynia,
myoclonus, seizures).
• Fentanyl has a very short half life (~1-1.5
hrs) in lower doses that could be safely
used for pain.
The Problems with
Hydromorphone, continued...
• Hydromorphone may have more euphoria
associated with it.
• It's easy to give significantly higher doses
of hydromorphone simply because it is
dosed in small amounts.
–
i.e. a dose increase from 1 mg to 2 mg is
a dose increase from 6.7 to 13.3 IV
morphine equivalents.
Tramadol
• Centrally acting weak mu opioid receptor
agonist
• Also blocks reuptake of serotonin and
norepinephrine (not fully reversible with
naloxone)
• Useful in neuropathic pain
• Not a controlled substance
• Seizure risk (common on those misusing it)
• Risk of serotonin syndrome with SSRIs or
TCAs
Adjuvants
• TCAs (amitriptyline, nortriptyline, etc.)
• Antiepileptics (gabapentin,
carbamazepine, topamax, etc.)
• Glucocorticoids
• Local anaesthetics (lidocaine, capsaicin)
• Benzodiazepines
Other Adjuvants
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Remove the cause (surgery/splint)
Epidural anaesthesia
Local anaesthetic
Nerve blocks
Physiotherapy
Manipulation
Transcutaneous Electrical Nerve Stimulation (TENS)
Acupuncture
Ice
Relaxation
Psycoprophylaxis
hypnosis
Inpatient Acute Pain Management
in the Chronic Pain Patient
• Acute pain needs to be treated.
• Continue home oral opioid regimen or
parenteral equivalent.
– Additional pain requirements due to acute
cause of pain may be an increase of 25-50%
or more from the maintenance opioid regimen.
• If abuse is a concern, avoid
hydromorphone or fentanyl.
Opioid Use
• Americans make up 4.6% of the world’s
population yet use 80% of the global
opioid supply, 99% of the global
hydrocodone supply, and 2/3 of the world’s
illegal drugs.
• Patients on long-term opioid use have
been shown to increase the overall cost of
healthcare, disability, rates of surgery, and
late opioid use.
Manchikanti and Singh Pain Physician 2008; Opioid Special Issue: 11:S63-S88.
Opioid Abuse
• Use and abuse of prescription narcotic analgesia
has increased markedly since 1990.
• In 1997, the American Society of
Anaesthesiologists, the American Academy of
Pain Medicine, and the American Pain Society
all advocated for expanded opioid use in the
management of chronic pain when other
treatments are inadequate after careful patient
evaluation and counseling.
Anaesthesiology, 1997; 87:995-1004
Increased Use mg/person 19972006
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Morphine
Methadone
Oxycodone
Hydrocodone
Fentanyl
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184%
1129%
899%
231%
450%
Manchikanti and Singh Pain Physician 2008; Opioid Special Issue: 11:S63-S88.
Increased Deaths
• Unintentional Drug poisoning deaths have
increased by 68% from 1999-2004, the
majority related to opioids.
• West Virginia was the worst, with an
increase of 550%.
• A study of 2006 WV opioid poisoning
deaths showed some interesting data.
Hall, et al. JAMA, 2008; 300(22): 2613-2620.
WV deaths, 2006
• 33% women, 67% men
Percentage of Deaths by age range
8%
15%
18-24 yrs
25-34 yrs
35-44 yrs
45-54 yrs
>/=55 yrs
29%
23%
25%
Hall, et al. JAMA, 2008; 300(22): 2613-2620.
Other WV 2006 Death Data
• 35% Married, 33% Never Married, 29%
Divorced, 3% Widowed
• 25% with <12th grade education, 43% high
school grads, 15% with any college
• Women more likely to exhibit “doctor shopping”
(5 different physician scripts for opioids in the
last year) 31% vs. 17% for men
• 63% of the decedants had prescription
substances in their blood that were not
prescribed to them.
Hall, et al. JAMA, 2008; 300(22): 2613-2620.
Misuse and Abuse
Euphoria
• The degree of euphoria produced by
a given medication is likely related
to ability to cross the blood brain
barrier.
• Euphoria may be related to relative
mu receptor subtype stimulation.
• Euphoria tolerance may be related
to overdose potential.
White and Irvine, Addiction, 1999; 94(7), 961-972.
circle=oxycodone 10, 20, 40 mg
square=hydrocodone 15, 30, 45 mg
triangle=hydromorphone 10, 17.5, 25 mg
Dose
Walsh et al. / Drug and Alcohol Dependence 98 (2008) 191–202.
Tolerance
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Tolerance is a need for increased amounts
of substance to achieve intoxication or
desired effect OR diminished effect with
continued use of the same amount of the
substance
Abuse
Any one of the following
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DSM IV
Substance use interferes with work, school,
or home.
Use despite physical hazard
Recurrent substance related legal problems
Use despite recurrent social/interpersonal
problems
Dependence
3 of the following in a 12 month period
 Tolerance
 Withdrawal
 Use for longer periods of time or higher
amounts than intended
 Persistent desire to cut down
DSM IV
Dependence, cont'd
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DSM IV
Significant time spent obtaining, using,
and recovering from the substance
Decreased social/work activities
secondary to the substance
Continued use despite physical or
psychological problem worsened by the
substance
Addicts and Prescription Opioids
• In a Toronto study from 2003, 82% of patients
presenting for enrollment in methadone maintenance
programs admitted prescription opioid use.
• 61% of those using prescription opioids reported
obtaining them from a physician.
• 24% used prescription opioids only.
• 35% used heroin first and then prescription opioids.
• 24% used prescription opioids first and heroin later.
• The majority of patients using prescription opioids
starting to use them for pain control (86% of those
only using prescription opioids and 62% of those who
started with prescription opioids).
Brands, et al. Drug and Alcohol Depedence, 2004, 73:199-207.
Informed Patients
Opioid abuse has entered the digital age.
Numerous forums are related to usage
patterns for prescription opioids.
forum.opiophile.org
www.bluelight.ru
A Sampling of Forum Thread
Titles
“Finding a quack doctor...”
“IF YOU HAD YER(sic) OWN RX PAD...”
“Opiate Dosage Converter Program”
“Surviving Acetaminophen (Tylenol)
Poisoning”
“State Prescription Drug Monitoring
Programs”
“Cant(sic) feel 20mg dilaudid shot, help?”
Health Care Provider
Obligations
• “HCPs are obligated to act in the best interests of
their patients.”
• “This action may include the addition of opioid
medication to the treatment plan of patients whose
symptoms include pain.”
• “It is...a medical judgment that must be made by a
HCP in the context of the provider-patient
relationship based on knowledge of the patient,
awareness of the patient's medical and psychiatric
conditions and on observation of the patient's
response to treatment.”
A consensus document from the American Academy of Pain Medicine, the American Pain Society, and the
American Society of Addiction Medicine. http://ampainsoc.org/advocacy/pdf/rights.pdf
Keeping Patients Safe
• If the gut works, use it!
– Use oral medications if the patient is able to
take oral intake.
• Safety checks for the rooms of patients
suspected of altering the route of
administration of the medication or
surreptitiously taking other home
medications
Keeping Patients Safe
• Check an OARRS report (Ohio Automated
Rx Reporting System)
– In the literature, “doctor shopping” is usually
defined as opioid prescriptions from 5 or more
physicians in a year.
http://www.ohiopmp.gov
Keeping Patients Safe
• Addicts, by definition, will be manipulative
and deceitful in efforts to obtain their
desired drug.
• Doing the “right” thing for the patient does
not always mean prescribing opioids.
• Patients should not be permitted to leave
the floor while receiving IV opioids.
Keeping Patients Safe
• Injection drug use often leads to infection.
Patients with a documented pattern of
opioid abuse or directly observed
dangerous behavior should be considered
for facility placement for prolonged
courses of IV antibiotics via PICC line.
• Keep realistic expectations. Patients with
chronic pain are never going to be “pain
free”.
Outline/Objectives




Define and describe pain
Describe inpatient pain management
strategies
Describe the scope of the problem of
prescription opioid use, misuse, and abuse
Discuss strategies for patient encounters
heavily influenced by these issues