PART 1PART 1

Chief Complaint: Total Body Chief Complaint: Total Body Dolor Dolor

Plan: Pain Management Plan: Pain Management

A 70-year-old male with ESRD on hemodialysis A 70-year-old male with ESRD on hemodialysis presents with methicillin-resistant Staphylococcus presents with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and ankle pain after a aureus (MRSA) bacteremia and ankle pain after a fall. An MRI of his ankle is negative, and he is fall. An MRI of his ankle is negative, and he is started on acetaminophen and lidocaine patches, started on acetaminophen and lidocaine patches, which result in adequate pain relief of the ankle. which result in adequate pain relief of the ankle. He later develops significant neuropathic pain in He later develops significant neuropathic pain in both arms, and a CT scan of the cervical spine both arms, and a CT scan of the cervical spine reveals a cervical abscess and osteomyelitis. The reveals a cervical abscess and osteomyelitis. The patient desires pain relief but adamantly refuses patient desires pain relief but adamantly refuses narcotics, stating: “I don’t want to get addicted.” narcotics, stating: “I don’t want to get addicted.” How can his pain be managed? How can his pain be managed?

Learn some key facts about pain Learn some key facts about pain managementmanagement

Identify practical approach to pain Identify practical approach to pain managementmanagement

Learn how to perform simple opioid Learn how to perform simple opioid conversionconversion

Learn to manage pain in patients Learn to manage pain in patients with liver or renal diseaseswith liver or renal diseases

Overview of Pain Management Overview of Pain Management StandardsStandards

Patient knows best; Patient knows best; only the patient can describe characteristics only the patient can describe characteristics and rate the severity of his or her painand rate the severity of his or her pain!!

Pharmacological therapiesPharmacological therapies

Uses non-pharmacological Uses non-pharmacological therapies whenever appropriate therapies whenever appropriate

Provide education and counselingProvide education and counseling

Use adjuvants for specific pain (ex. bone, neuropathic)Use adjuvants for specific pain (ex. bone, neuropathic)

Pain Treatment Options – Pain Treatment Options – Non-pharmacologic Non-pharmacologic

approachapproach Mind-Body therapyMind-Body therapy

Heat/Cold therapyHeat/Cold therapy

MassageMassage

AcupunctureAcupuncture

Tai-chiTai-chi

PT/OTPT/OT

Transcutaneous Transcutaneous Electrical Nerve Electrical Nerve stimulator (TENS)stimulator (TENS)

Pain Treatment Options – Pain Treatment Options – Pharmacologic approachPharmacologic approach

Non-opioidsNon-opioids CapsaicinCapsaicin AcetaminophenAcetaminophen NSAIDsNSAIDs SteroidSteroid

Pain Treatment Options – Pain Treatment Options – Pharmacologic approach Pharmacologic approach

(cont)(cont) AdjuvantsAdjuvants

TCA: commonly used for neuropathic painTCA: commonly used for neuropathic pain Gapabentin: FDA-approved for partial Gapabentin: FDA-approved for partial

seizures and postherpetic neuralgia but is seizures and postherpetic neuralgia but is also used for a wide variety of also used for a wide variety of neuropathic pain syndromes, including neuropathic pain syndromes, including postoperative painpostoperative pain

Lidocaine patch: FDA-approved for Lidocaine patch: FDA-approved for postherpetic neuralgia but are used for a postherpetic neuralgia but are used for a wide variety of local pain syndromeswide variety of local pain syndromes

NSAIDs NSAIDs

Side-effectsSide-effects GIGI

Renal: reduce GFRRenal: reduce GFR

Increase fluid retention, Increase fluid retention, HTNHTN

Increase risk of confusionIncrease risk of confusion

Platelet dysfunctionPlatelet dysfunction

Alternative treatmentsAlternative treatments Consider nonacetylated Consider nonacetylated

salicylates or COX-2 selective salicylates or COX-2 selective (Diclofenac, Meloxicam), (Diclofenac, Meloxicam), celecoxib plus PPicelecoxib plus PPi

Consider topical therapy Consider topical therapy (Capsasin)(Capsasin)

Consider Naproxen or Tylenol Consider Naproxen or Tylenol or topical therapyor topical therapy

Consider non-pharmacologic Consider non-pharmacologic therapytherapy

Consider AcetaminophenConsider Acetaminophen

CorticosteroidCorticosteroid

Indication: Indication: reduce compression due to edema causing reduce compression due to edema causing

structural stretching-> visceral painstructural stretching-> visceral pain Anti-inflammation; Trigger point injection (must Anti-inflammation; Trigger point injection (must

rule out septic joint first).rule out septic joint first). Stimulate appetiteStimulate appetite

Need to weigh benefits vs. risksNeed to weigh benefits vs. risks Dexamethasone produces the least amount Dexamethasone produces the least amount

of mineralocorticoid effect, with the highest of mineralocorticoid effect, with the highest amount of anti-inflammatory effectsamount of anti-inflammatory effects

SummarySummary Only the patient can describe characteristics Only the patient can describe characteristics

and rate the severity of his or her pain.and rate the severity of his or her pain. Always consider using non-pharmalogical Always consider using non-pharmalogical

approach when appropriate.approach when appropriate. All non-opioids medication have ceiling All non-opioids medication have ceiling

effects. effects. Do not combine multiple NSAIDs. Use Do not combine multiple NSAIDs. Use

alternative treatments to minimize potential alternative treatments to minimize potential side-effects.side-effects.

Consider adjuvants for specific pains such as Consider adjuvants for specific pains such as bone pain or neuropathic.bone pain or neuropathic.

Chief Complaint: Total Body Chief Complaint: Total Body Dolor Dolor

Plan: Pain ManagementPlan: Pain ManagementPART 2PART 2

Clinical CaseClinical Case

A 70-year-old male with ESRD on hemodialysis A 70-year-old male with ESRD on hemodialysis presents with methicillin-resistant presents with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and Staphylococcus aureus (MRSA) bacteremia and ankle pain after a fall. An MRI of his ankle is ankle pain after a fall. An MRI of his ankle is negative, and he is started on acetaminophen negative, and he is started on acetaminophen and lidocaine patches, which result in adequate and lidocaine patches, which result in adequate pain relief of the ankle. He later develops pain relief of the ankle. He later develops significant neuropathic pain in both arms, and a significant neuropathic pain in both arms, and a CT scan of the cervical spine reveals a cervical CT scan of the cervical spine reveals a cervical abscess and osteomyelitis. The patient desires abscess and osteomyelitis. The patient desires pain relief but adamantly refuses narcotics, pain relief but adamantly refuses narcotics, stating: “I don’t want to get addicted.” How can stating: “I don’t want to get addicted.” How can his pain be managed? his pain be managed?

Pain Management Option- Pain Management Option- OpioidsOpioids

1)1) Total AmountsTotal Amounts

2)2) ConvertConvert

3)3) Cross-Tolerance? Cross-Tolerance?

4)4) Choose appropriate POChoose appropriate PO

5)5) PRN’s/breakthrough painPRN’s/breakthrough pain

6)6) Bowel regimenBowel regimen

Principles of Analgesic Use in the Treatement of Acute Pain and Cancer Principles of Analgesic Use in the Treatement of Acute Pain and Cancer Pain, 5Pain, 5thth Ed, American Pain Society. 2003 Ed, American Pain Society. 2003

Let’s practiceLet’s practice

78 YO F with no PMH was admitted 78 YO F with no PMH was admitted to the hospital for newly diagnosed to the hospital for newly diagnosed pancreatic cancer. The patient has pancreatic cancer. The patient has been requiring large amounts of been requiring large amounts of Dilaudid (hydromorphone) IV during Dilaudid (hydromorphone) IV during (totaling 8.1mg / 24 hrs). The (totaling 8.1mg / 24 hrs). The patient is ready for discharge. What patient is ready for discharge. What oral regimen should you send her oral regimen should you send her home on?home on?

Let’s practiceLet’s practice Step 1: IV Step 1: IV PO conversionPO conversion

8.8 mg IV Dilaudid to PO morphine8.8 mg IV Dilaudid to PO morphine 8.8 x 20 = 176 mg PO Morphine8.8 x 20 = 176 mg PO Morphine

Step 2: Cross tolerance?Step 2: Cross tolerance? YES! Reduce by 15%YES! Reduce by 15%

PO Morphine = 150mgPO Morphine = 150mg Step 3: Schedule PO Dosing frequency Step 3: Schedule PO Dosing frequency

MS CONTIN = BID Dosing. 150mg in BID dosing MS CONTIN = BID Dosing. 150mg in BID dosing 150/2 = 75mg MS Contin BID150/2 = 75mg MS Contin BID

Step 3: calculate breakthrough dosing Step 3: calculate breakthrough dosing = minimum of 30-50% total daily requirement = minimum of 30-50% total daily requirement

150 * 0.50 = 75mg / day150 * 0.50 = 75mg / day 75mg divided into q4h dosing = 75mg divided into q4h dosing =

75 / 6 = ~12 mg q4h PRN 75 / 6 = ~12 mg q4h PRN Step 4: don’t forget bowel regimen or you will have a very Step 4: don’t forget bowel regimen or you will have a very

unhappy patient at your follow up appointmentunhappy patient at your follow up appointment

Back to the initial caseBack to the initial case

A 70-year-old male with ESRD on A 70-year-old male with ESRD on hemodialysis presents with MRSA hemodialysis presents with MRSA bacteremia and ankle pain after a fall now bacteremia and ankle pain after a fall now found to have significant neuropathic pain found to have significant neuropathic pain in both arms with evidence of cervical in both arms with evidence of cervical abscess and osteomyelitis on C-spine CT. abscess and osteomyelitis on C-spine CT. The patient desires pain relief but The patient desires pain relief but adamantly refuses narcotics, stating: “I adamantly refuses narcotics, stating: “I don’t want to get addicted.” How can his don’t want to get addicted.” How can his pain be managed? pain be managed?

Back to the initial caseBack to the initial case The patient’s ankle pain was controlled with The patient’s ankle pain was controlled with

acetaminophen and lidocaine patches. For the acetaminophen and lidocaine patches. For the neuropathic pain in his upper extremities, neuropathic pain in his upper extremities, tramadol was started at 25 mg oral every 12 hours tramadol was started at 25 mg oral every 12 hours and increased to 50 mg oral every eight hours and increased to 50 mg oral every eight hours (below the maximum of 200 mg a day). The (below the maximum of 200 mg a day). The tramadol did not result in adequate pain relief, so tramadol did not result in adequate pain relief, so gabapentin 100 mg at bedtime was initiated, then gabapentin 100 mg at bedtime was initiated, then increased to twice daily over three days with some increased to twice daily over three days with some relief.relief.

A geriatric consult was obtained to help educate A geriatric consult was obtained to help educate him regarding addiction to opioids, as well as to him regarding addiction to opioids, as well as to explore goals of care, but he continued to insist on explore goals of care, but he continued to insist on the use of a non-narcotic regimen for his pain.the use of a non-narcotic regimen for his pain.

SummarySummary Pain management is a comprehensive, Pain management is a comprehensive,

patient-centered process including patient-centered process including pharmacological agent, psychosocial pharmacological agent, psychosocial counseling, and non-pharmacological counseling, and non-pharmacological treatments when appropriate.treatments when appropriate.

Always start with the lowest dose, least side-Always start with the lowest dose, least side-effect agents and reassess frequently with effect agents and reassess frequently with patient’s input.patient’s input.

Use conversion chart for IV to po, and this Use conversion chart for IV to po, and this transition should be done as soon as possible.transition should be done as soon as possible.

When in doubt, always ask for help from the When in doubt, always ask for help from the experts.experts.

ReferencesReferences Barakzoy AS, Moss AH. Efficacy of the World Health Organization Barakzoy AS, Moss AH. Efficacy of the World Health Organization

analgesic ladder to treat pain in end-stage renal disease. J Am Soc analgesic ladder to treat pain in end-stage renal disease. J Am Soc Nephrol. 2006;17(11):3198-3203.Nephrol. 2006;17(11):3198-3203.

Dean M. Opioids in renal failure and dialysis patients. J Pain Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage. 2004;28(5):497-504.Symptom Manage. 2004;28(5):497-504.

Broadbent A, Khor K, Heaney A. Palliation and chronic renal Broadbent A, Khor K, Heaney A. Palliation and chronic renal failure: opioid and other palliative medications—dosage guidelines. failure: opioid and other palliative medications—dosage guidelines. Progress in Palliative Care. 2003;11(4):183-190(8).Progress in Palliative Care. 2003;11(4):183-190(8).

Johnson SJ. Opioid safety in patients with renal or hepatic Johnson SJ. Opioid safety in patients with renal or hepatic dysfunction. Pain Treatment Topics website. Available at: dysfunction. Pain Treatment Topics website. Available at: http://pain-topics.org/pdf/Opioids-Renal-Hepatic-Dysfunction.pdf. http://pain-topics.org/pdf/Opioids-Renal-Hepatic-Dysfunction.pdf. Accessed Dec. 7, 2013Accessed Dec. 7, 2013

Ashburn MA, Lipman AG, Ashburn MA, Lipman AG, et al.et al. Principles of Analgesic Use in the Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. American Pain Society: Treatment of Acute Pain and Cancer Pain. American Pain Society: 5th Edition. 20035th Edition. 2003