Microsoft PowerPoint - PC5-lee-painmanagementcases-narrated-fmr20f-09082020Seung J. Lee MD MBA University of Maryland
School of Medicine Department of Anesthesiology
Division of Pain Medicine
Disclaimer
Dr. Seung J. Lee, MD, MBA does not have any financial conflict to disclose for this presentation
This presentation is intended to provide educational information related to pain management strategies by case presentations
The speaker is not promoting any particular services or products
Objectives
Following the presentation, the participants should be able to:
1. Recognize red flags of low back pain 2. Formulate a multi-modal analgesia plan 3. Differentiate between CRPS 1 and CRPS 2 4. Set proper expectations for opioid therapy
PAIN CASE #1
History of Present Illness
J.H. is a 50-year-old man with low back pain worsened by activity – Pain stays mostly on his back – No weakness, incontinence or numbness – Pain started after two weeks ago and has been intermittently
severe since then – He isn’t sleeping well, and his appetite is poor
Previously, he has taken oxycodone for this pain and is asking you to prescribe some today
Pain Assessment
What else would you like to know?
How is it impairing his functioning? What else has he tried? Who prescribe oxycodone? Red Flag Findings
Rule out serious underlying illness
Recent Trauma?
Fever? Signs/symptoms of cancer of the prostate/bowel/lung?
You want to be sure he doesn’t have a primary spinal tumor, infection or metastatic lesion
RED FLAGS?
Physical Exam
Appears to be in discomfort when rising from a chair
Straight leg raise negative
No neurologic deficits
Wren, Anava et al (2019) Tompkins, D., Hobelmann, J., & Compton, P. (2017).
Recommendations
Reassurance: most back pain will resolve Advise return to normal activities with gentle exercise
NSAIDS Referral to Physical Therapy
Gentle Exercise
• Swimming and walking are good options
• Tai Chi and qigong are other possibilities. They may be particularly good choices to help manage stress
The patient is unhappy with the recommendations
Already taking NSAIDs and Tylenol OTC
The patient is reluctant to do PT due to the pain
YOUR PATIENT INSISTS THAT YOU “GET RID OF ALL THIS PAIN.” HOW WOULD YOU
RESPOND TO THIS STATEMENT?
YOUR PATIENT INSISTS THAT YOU “GET RID OF ALL THIS PAIN.” HOW WOULD YOU
RESPOND TO THIS STATEMENT?
Focus on function, not pain elimination
You would like to redirect the patient away from a goal of total elimination of pain, towards a focus on functioning
Find out what he cannot do now because of his pain and make that to be the goal of treatment.
I STILL NEED SOMETHING DONE TODAY!!
What else can we offer the patient today? Imaging studies? Acupuncture? Referrals to surgeon/pain center? Opioids? Muscle relaxants?
MRI of LS
North American Spine Society – Do not recommend advanced
imaging (e.g., magnetic resonance imaging) of the spine within the first six weeks in patients with nonspecific acute low back pain in the absence of red flags.
Acupuncture
YES
Has been shown to be effective in the treatment of back pain
The acupuncturist can also address stress/anxiety/depression
Opioids: oxycodone 1-2 tabs every 4 hours • NO • Short-term effectiveness for pain relief and functioning, but
long-term effectiveness and safety are unclear • Do conservative therapy first
Muscle Relaxants
YES
More effective pain relief and global efficacy in acute nonspecific low back pain when compared with placebo
Cyclobenzaprine 5 mg three times per day as needed for two weeks
Avoid benzodiazepines
AFTER 2 MONTHS OF PT, THE PATIENT CONTINUES TO HAVE
PAIN. HE HAS BEEN EVALUATED BY TWO NEUROSURGEONS
Surgical evaluation
Neurosurgery 2nd opinion recommended trial of continuing physical therapy
Why do the 2 neurosurgeons disagree?
The surgical treatment of chronic back pain with no neurological dysfunction is controversial
Patients should always get several neurosurgical opinions before undergoing surgery in this circumstance
Work up
Lumbar MRI reveals multiple bulging disks and a central disk herniation at L5-S1
His MRI makes it clear that surgery is indicated? Herniated discs do not
necessarily need to be surgically treated, – Particularly if there are
no neurologic deficits – Especially for axial pain
only
MRI results correspond poorly with pain
People with markedly abnormal MRIs can have no pain and people with normal MRIs can have pain
However, in this case, if the patient has lumbar radiculopathy symptoms, then the MRI may be correlating with his symptoms
Still continues to have pain after 4 months Consider referring him to a multidisciplinary pain
management center
Case Scenario
22-year-old female come to the ER with Right ankle pain – Multiple admission in past – History of drug abuse
Urine toxicology -positive for opioid (heroine) and cocaine
– Urine pregnancy test Negative
H&P
H&P Physical examination
HR 120, BP 140/89 Obvious right ankle deformity Otherwise exams were within normal limit Ortho consult done. Imaging study ordered.
What would be good pain medications for this patient in ER?
– Toradol 30 mg IV q6h – IV/PO Opioid therapy – Tylenol – Gabapentin – Methadone – Ketamine – Lidoderm patch
Acute Post-Operative Pain
Wren, Anava & Ross, Alexandra & D’Souza, Genevieve & Almgren, Christina & Feinstein, Amanda & Marshall, Amanda & Golianu, Brenda. (2019)
Pain Treatment Plan Maintain baseline opioid, after
verification(?) with caution
Consider multi-modal analgesia
Gabapentinoids
– basal rate
Treatment - PCA
Opioid Use and Transition
24-hour Use – Day 1: 38 mg – Day 2: 34 mg – Day 3: 20 mg
Day 4: Transition to Oral Oxycodone 10- 20 mg every 4 hours as needed
The Patient Comes To Your Office, Asking To Continue Her Discharge
Medications Oral Oxycodone 10 - 20 mg every 4 hours as
needed Gabapentin 300 mg three times per day
Naproxen 500 mg twice per day
Who is responsible for the opioid medications?
Surgical Team
Pain Management Team
Primary Care Physician
The patient states that she needs her medication today. She is afraid of going
through withdrawal from opioid. She was told by the surgical team to come and get the
medication from the primary care physician.
Too high dose of opioid?
The patient is taking 20mg four times per day Oxycodone 80 mg = 120 mg of morphine
CDC Guideline Recommendation 5 Clinicians should avoid using dosage to ≥90 MME/day
Guideline’s scope NOT INTENDED FOR
active cancer treatment Patients experiencing acute sickle cell crises Patients experiencing post-surgical pain
Intended for primary care clinicians treating chronic pain for patients 18 and older
So what now? Should you give opioid medications to
the patient?
It is up to the individual providers and situations Considerations
– Expectation Management – Safety of providing opioid medications with the patient
Family member’s involvement
– Naloxone Rx – One-month Rx of oxycodone – Refer to addiction program – Opioid Titration
Expectation Management CDC Recommendation 2 Clinicians should establish
treatment goals with all patients
Clinicians should consider how opioid therapy will be discontinued if benefits do not outweigh risks
(recommendation category: A, evidence type: 4)
Safety of providing opioid medications to the patient
Family member’s involvement
CDC Recommendation 8 – Intra-nasal Naloxone Is an opioid antagonist that can
reverse severe respiratory depression
Considering offering naloxone when factors that increase risk for opioid overdose
– history of overdose – history of substance use
disorder – higher opioid dosages (≥50
MME/day) – concurrent benzodiazepine use
times per day?
For patients with opioid use disorder
Clinicians should offer or arrange evidence-based treatment (usually medication- assisted treatment with buprenorphine or methadone in combination with behavioral therapies)
Opioid Titration CDC Recommendation 7
Rapid Taper
– reducing weekly dosage by 10%–50% of the original dosage
– Ultrarapid detoxification under anesthesia is associated with substantial risks, including death, and should not be used
Slow Taper
Experts noted that tapers slower than 10% per week (e.g., 10% per month) also might be appropriate and better tolerated than more rapid tapers
SIX MONTH AFTER THE OPERATION, THE PATIENT HAS SIGNIFICANT ANKLE PAIN.
Why does she still have pain? What would be next steps?
The patient complains of
• Allodynia • Hyperalgia • Edema • Abnormal hair growth • Abnormal skin color changes • Abnormal skin temperature (> or < 1 C) • Limited range of movement • Motor neglect
CRPS Criteria
Complex Regional Pain Syndromes
Pain and sensory changes disproportionate to the injury in magnitude or duration
Only difference between types is the cause. Type II is known previously as Causalgia.
CRPS
management Sympathetic Blocks Spinal Cord Stimulator Intrathecal pump
CRPS Treatments
PT PT
Mirror Therapy
Lesser Used agents – IV immunoglobulin – Calcitonin – Bisphosphonate – Low dose oral naltrexone? – Subanesthetic ketamine
METHADONE
Methadone Advantages Potency
– May control pain even when large doses of other opioids failed
Infrequent dosing – is intrinsically long acting
Works for neuropathic pain Usable in renal failure Low cost
Methadone Disadvantages
Can cause potentially dangerous over-sedation
Difficult equal-analgesic conversion Can only increase dose every 5 days Don’t use if QT is prolonged – can cause Torsades
Methadone: Conversion
Schuster, Michael, Oliver Bayer, Florian Heid, and Rita Laufenberg- Feldmann. 2018. “
Methadone – big picture
• Very effective and good for mixed somatic & neuropathic pain
• Builds up so can cause over-sedation (potentially fatal) days after you increased the dose
• Challenging to manage at first – be sure to get help from an experienced colleague when first using methadone
Lumbar Sympathetic Block
vicious sympathetic hyperactive feedback, these blocks along with physical therapy and medication help restore normal limb function
Spinal Cord Stimulation
Spinal cord stimulator (SCS) is a device, which delivers low voltage electrical stimulation to the spinal cord
Replace the sensation of pain with a tingling sensation
CHRONIC PAIN CASE #3
Case 3
A 27-year-old woman who underwent emergency C-section in 2014 under general anesthesia after failed neuraxial block, who developed a non-healing wound infected with Pseudomonas
Workup revealed that she had a previously undiagnosed immunodeficiency disorder diagnosed as common variable immune deficiency IgG for which she receives IVIG therapy every 3 weeks
Case 3
The patient states she has had multiple revision surgeries and multiple admissions for abdominal infection over the past 5 years
She recently had a motor vehicle accident on New Year's Eve and then admitted to University of Maryland Medical Center on January 2nd and discharged January 8th. Her prior admission was about 5 weeks ago
Case 3
PAST MEDICAL HISTORY: Consists of chronic abdominal wound infection; status post emergency C-section in 2014; common variable immune deficiency, IgG, receiving IVIG therapy every 3 weeks; asthma; hypertension; anxiety; depression; endometriosis
Case 3
SIGNIFICANT OPERATIVE HISTORY: Multiple I and D's from October 9th to present of the abdominal wound; C-section; appendectomy, September 2002; cholecystectomy; PICC insertion with removal on 01/07/2020
Case 3
CURRENT MEDICATIONS:
Ambien 10 mg once ciprofloxacin 750 mg Colace 100 mg doxycycline 100 mg hydrochlorothiazide 12.5 mg ibuprofen 800 mg IVIG injection
lisinopril 20 mg multivitamin ondansetron 4 mg oxycodone immediate release
15 mg QID OxyContin ER 40 mg 2 times
daily Tylenol 1000 mg Xanax 1 mg TID RRN
Case 3
PDMP Review from December 2019 to beginning of January 2020
OxyContin 40 mg 21 tablets Percocet 5/325 110 tablets OxyIR 15 118 tablets OxyIR 5 mg 130 tablets 155 tablets of 1 mg Xanax 70 tablets of 0.5 mg Xanax
Case 3
The patient was informed of our University practice and our multimodal nature of it. Due to patient's opioid prescription history, the patient was informed that we would not be able to continue any opioid medication at this time
The patient was informed of our some of interventional therapeutic options. The patient is going to IVIG treatment; however, the patient still has an open wound. Therefore, the patient may be a candidate about 6 months after the infection has healed
CHRONIC PAIN CASE #4
Case 4
Patient is 58-year-old who presents to clinic complaining of lower back pain which radiates into his right groin
The pain is in the lower back, it is shooting, feels like being stabbed with a hot poker, it is also sharp and it shoots his groin. Denies any burning sensation. Endorses cramping in his right leg. Denies numbness, tingling, and weakness
Case 4
Currently the patient is not receiving any medications, so the patient is using intravenous heroin to help with this pain, using every few days
Both the patient and the patient's family expressed frustration about getting the health care and the medical management for the patient since the opioid medication worked for the patient. The patient states that due to the inadequate treatment of pain, the patient must utilize street drugs
Case 4
PAST MEDICAL HISTORY: Hepatitis C, per the family he has end-stage liver disease. Patient also has bronchitis, chronic obstructive pulmonary disease, spinal stenosis
ALLERGIES: Skelaxin, recently in the hospital it gave him some delirium
MRIs, which showed diskitis and osteomyelitis with phlegmon formation, right psoas. Per record review, ESR and biopsy were negative for the active infection at this time
Case 4
So what would you do for this patient? What is the opioid risk? Is the patient appropriate for opioid medications?
Opioid Risk Tool
Case 4
If the patient's life expectancy is less than six 6 months, then we will pursue palliative care/hospice care for the patient
https://www.lmhpco.org/palliative-care
Case 4
If patient's life expectancy is longer, then we will use the active addiction treatment options which include involvement of an addictionologist as well as outpatient maintenance program, methadone or Suboxone
If the patient has been stable for three to six months with the stabilization of his active addiction issue, then we can consider chronic opioid therapy
CHRONIC PAIN CASE #5
Case 5
39-year-old female with a history of chronic low back pain status post laminectomy and lumbar fusion at L5-S1, sarcoidosis, fibromyalgia, bilateral lower extremity pain, and shoulder pain
The patient returns today for follow-up complaining of pain that is constant, aching and dull with a burning sensation, especially in the thoracic area of the back. She rates the pain 8/10 in intensity
Case 5
She notes improvement in her ability to perform activities of daily living because the sarcoid is now more stable and she is not coughing as much. She states that her energy levels are beginning to return to normal
Case 5
Currently, her medications consist of methadone 5 mg every eight hours and Percocet 10/325 mg up to five times a day as needed
Overall, her analgesia is the same but she is able to breathe better which makes her feel better overall. The patient denies any nausea, sedation, constipation, itching, diarrhea or vomiting related to her medications
Case 5
What is morphine equivalent per day?
Are you concerned about the dose?
What is your recommendation?
CDC Opioid Conversion Chart
A major flaw with the CDC calculator is the methadone to morphine conversion, as the conversion is neither linear nor bidirectional due to the unique and complex pharmacokinetics of methadone.
Fudin, J., Raouf, M., Wegrzyn, E. L., & Schatman, M. E. (2018). Safety concerns with the Centers for Disease Control opioid calculator. Journal of Pain Research, 11, 1–4.
Case 5
What do you think about the dose?
What is morphine equivalent per day? 60mg from methadone 15 mg per day 75 mg from oxycodone 50 mg per day
Are you concerned about the dose?
What is your recommendation?
Case 5 – Pain Psychology
SUBSTANCE ABUSE HISTORY: The patient denies any lifetime use of illicit drugs, alcoholism, or opioid abuse. She also denies any lifetime history of intravenous drug abuse
The opioid risk assessment places the patient within the low risk classification. As a result, the patient is treated with chronic opioid therapy. She would benefit from intermittent psychological review to reassess risk factors or emergence of high-risk behavior
Opioid Risk Tool
References
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49.
Oliveira, C., Maher, C., Pinto, R., Traeger, A., Lin, C., & Chenot, J. et al. (2018). Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. European Spine Journal, 27(11), 2791-2803.
Qaseem, A., Wilt, T., McLean, R., & Forciea, M. (2017). Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals Of Internal Medicine, 166(7), 514.
Perez, R., Zollinger, P., Dijkstra, P., Thomassen-Hilgersom, I., Zuurmond, W., Rosenbrand, K., & Geertzen, J. (2010). Evidence based guidelines for complex regional pain syndrome type 1. BMC Neurology, 10(1). doi:10.1186/1471-2377-10-20
Complex regional pain syndrome in adults (2nd edition). (2018). Royal College of Physicians London. Retrieved 22 February 2020, from https://www.rcplondon.ac.uk/guidelines- policy/complex-regional-pain-syndrome-adults
References
Richebé, P., Brulotte, V., & Raft, J. (2019). Pharmacological strategies in multimodal analgesia for adults scheduled for ambulatory surgery. Current Opinion In Anaesthesiology, 32(6), 720–726.
Treillet E, Laurent S, & Hadjiat Y. (2018). Practical management of opioid rotation and equianalgesia. Journal of Pain Research, 2587.
Schuster, Michael, Oliver Bayer, Florian Heid, and Rita Laufenberg-Feldmann. 2018. “Opioid Rotation in Cancer Pain Treatment: A Systematic Review.” Deutsches Aerzteblatt International 115 (9): 135–42. doi:10.3238/arztebl.2018.0135.