Acute Pain ManagementAcute Pain Management

Jeff Adams MDJeff Adams MD

Pain Management is a Three-Pain Management is a Three-way Streetway Street

Hopefully this functions better than a highway Hopefully this functions better than a highway constructed the same way.constructed the same way.

patient patient physician physician nurse nurse

PAINPAIN

This only works if there is sharing of knowledge This only works if there is sharing of knowledge and questioning by all parties.and questioning by all parties.

Which of the following is a Which of the following is a false requirement of JCfalse requirement of JC

1.1. Pain is assessed in all patientsPain is assessed in all patients

2.2. Discharge must provide for continued Discharge must provide for continued care of paincare of pain

3.3. Patients are educated about pain as part Patients are educated about pain as part of treatmentof treatment

4.4. Patients receiving pain medications are Patients receiving pain medications are monitored post-proceduremonitored post-procedure

5.5. None of the above are falseNone of the above are false

Why the concern about pain Why the concern about pain management?management? JCAHO Joint commission on JCAHO Joint commission on

accreditation of healthcare accreditation of healthcare organizationsorganizations::

Patients have the right to appropriate Patients have the right to appropriate assessment and management of pain. assessment and management of pain.

Pain is assessed in all patients. Pain is assessed in all patients. Policies and procedures support safe Policies and procedures support safe

medication prescription or ordering.medication prescription or ordering.

Why the concern about pain Why the concern about pain management?management?

The patient is monitored during the The patient is monitored during the post-procedure period. post-procedure period.

Patients are educated about pain and Patients are educated about pain and managing pain as part of treatment, as managing pain as part of treatment, as appropriate. appropriate.

The discharge process provides for The discharge process provides for continuing care based upon the continuing care based upon the patient's assessed needs at the time of patient's assessed needs at the time of discharge.discharge.

Which of the following is the Which of the following is the best tool to access a child’s level best tool to access a child’s level of pain?of pain?

1.1. Assessment by physicianAssessment by physician

2.2. Assessment by nurseAssessment by nurse

3.3. Assessment by parentAssessment by parent

4.4. Self reporting using a numeric scaleSelf reporting using a numeric scale

5.5. Self reporting using a face scaleSelf reporting using a face scale

The 5th vital signThe 5th vital signEvaluatingEvaluating

Assume patient self-reporting is the Assume patient self-reporting is the best method to assess painbest method to assess pain

Numeric scale works well in adults if no Numeric scale works well in adults if no cognitive dysfunctioncognitive dysfunction

In children, parents are better at In children, parents are better at accurately rating pain then the accurately rating pain then the physician. Faces scale or poker chip physician. Faces scale or poker chip tool work well.tool work well.

The 5th vital signThe 5th vital signEvaluatingEvaluating

Revaluate pain levelsRevaluate pain levels Have system in place for patient to contact Have system in place for patient to contact

care provider if pain not well controlledcare provider if pain not well controlled Minorities, are less likely than Caucasians Minorities, are less likely than Caucasians

to be treated with analgesics in the ED. to be treated with analgesics in the ED. the elderly and children also receive the elderly and children also receive suboptimal treatment.suboptimal treatment.

Which of the following types of pain is Which of the following types of pain is most typically in a elderly patient with most typically in a elderly patient with ischemic bowel, notable for classically ischemic bowel, notable for classically presenting with pain disproportionate presenting with pain disproportionate to clinical findings?to clinical findings?

1.1. Neuropathic painNeuropathic pain

2.2. Somatic nociceptiveSomatic nociceptive

3.3. Viseral nociceptiveViseral nociceptive

4.4. Homeopathic painHomeopathic pain

5.5. Allopathic painAllopathic pain

Types of painTypes of pain

Patients may have a combination of typesPatients may have a combination of types NociceptiveNociceptive

2 types somatic and visceral2 types somatic and visceral NeuropathicNeuropathic

NociceptiveNociceptive

Tissue damage occursTissue damage occurs Histamine, serotonin, bradykinen, Histamine, serotonin, bradykinen,

substance P, prostaglandins are releasedsubstance P, prostaglandins are released Trigger the nerveTrigger the nerve Reduce future stimuli needed to Reduce future stimuli needed to

depolarize the nervedepolarize the nerve

NeuropathicNeuropathic

Results form damage to the nerve, not Results form damage to the nerve, not stimulationstimulation

Dysesthesias occur: burning, tingling, Dysesthesias occur: burning, tingling, stabbing, electric-likestabbing, electric-like

DM, MS, Herniated disc, AIDS, post DM, MS, Herniated disc, AIDS, post shingles, radiation, chemotherapyshingles, radiation, chemotherapy

Somatic Nociceptive PainSomatic Nociceptive Pain

Localizing pinprick, stabbingLocalizing pinprick, stabbing Travel via fast A delta fibersTravel via fast A delta fibers Cross over in the spinal cord and ascend Cross over in the spinal cord and ascend

to brain stemto brain stem

Visceral Nociceptive PainVisceral Nociceptive Pain

Dull, generalized, acheDull, generalized, ache Travel via slow c-fibersTravel via slow c-fibers Synapse in the spinal cord with other Synapse in the spinal cord with other

interneuronsinterneurons Referred pain caused by contact with Referred pain caused by contact with

somatic afferent fiberssomatic afferent fibers Travel with the autonomic nerves Travel with the autonomic nerves

creates associated symptoms such as creates associated symptoms such as N/V, hypotension, bradycardia, and N/V, hypotension, bradycardia, and sweating.sweating.

Treatment of Neuropathic PainTreatment of Neuropathic Pain

May be resistant to opioid therapyMay be resistant to opioid therapy Mainstay of therapy:Mainstay of therapy:

Anticonvulsants: may work best for Anticonvulsants: may work best for burning pain (gabapentin/Neurontin)burning pain (gabapentin/Neurontin)

Antidepressants: may work best for Antidepressants: may work best for lancinating painlancinating pain

Which of the following Which of the following medications, using comparable medications, using comparable dosages, is the most effective for dosages, is the most effective for pain management?pain management?

1.1. KetorolacKetorolac (Toradol) (Toradol)

2.2. AcetaminophenAcetaminophen

3.3. IbuprofenIbuprofen

4.4. AspirinAspirin

5.5. Celecoxib (Celebrex)Celecoxib (Celebrex)

Non-narcotic Pain MedicationsNon-narcotic Pain Medications

They all are co-analgesics and can enhance They all are co-analgesics and can enhance pain relief even if a narcotic is being used.pain relief even if a narcotic is being used.

They all may diminish bone formation, They all may diminish bone formation, healing, and remodeling.healing, and remodeling.

ASA = Acetaminophen = ~5mg oxycodone for ASA = Acetaminophen = ~5mg oxycodone for analgesiaanalgesia

1000 mg ASA < 600-800 mg of ibuprofen for 1000 mg ASA < 600-800 mg of ibuprofen for analgesiaanalgesia

~ all equal~ all equal

Non-narcotic Pain MedicationsNon-narcotic Pain Medications

Acetaminophen: 4 gram maximum / Acetaminophen: 4 gram maximum / day in a healthy individual day in a healthy individual Lortab has 500 mg APAP/tab which Lortab has 500 mg APAP/tab which

limits total number of tablets to 8/ limits total number of tablets to 8/ dayday

Ibuprofen < 1600 mg has a risk of GI Ibuprofen < 1600 mg has a risk of GI bleed equal to placebobleed equal to placebo

Non-narcotic Pain MedicationsNon-narcotic Pain Medications

Cox-2s Cox-2s traditional NSAIDs produce equal traditional NSAIDs produce equal

analgesiaanalgesia May have less GI protection then May have less GI protection then

CLASS trial suggestCLASS trial suggest Have prothrombotic activityHave prothrombotic activity

Increased risk for MIIncreased risk for MINot necessarily cost effectiveNot necessarily cost effective

A 20 year old female has had a severe A 20 year old female has had a severe sore throat(7/10) for two days. Her quick sore throat(7/10) for two days. Her quick strep test is positive. You suspect strep test is positive. You suspect Strep. and would like to treat her pain. Strep. and would like to treat her pain. Which of the following medications Which of the following medications would you select?would you select?

1.1. Acetaminophen with codeine (Tylenol #3)Acetaminophen with codeine (Tylenol #3)2.2. Propoxyphene (Darvon)Propoxyphene (Darvon)3.3. Acetaminophen with hydrocodone (Lortab, Acetaminophen with hydrocodone (Lortab,

Vicodin)Vicodin)4.4. Acetaminophen with oxycodone (Percocet)Acetaminophen with oxycodone (Percocet)5.5. OxycotinOxycotin

PropoxyphenePropoxyphene

Not superior to acetaminophen aloneNot superior to acetaminophen alone 100 mg of propoxyphene = 50 mg of 100 mg of propoxyphene = 50 mg of

codeinecodeine Toxic metabolite - norpropoxyphene that Toxic metabolite - norpropoxyphene that

can cause cardiac conduction can cause cardiac conduction abnormalities and seizures, hallucinations, abnormalities and seizures, hallucinations, confusionconfusion

Codeine vs. Hydrocodone vs. OxycodoneCodeine vs. Hydrocodone vs. Oxycodone

codeine 100 mg

hydrocodone15 mg

oxycodone10 mg

oral morphine15 mg

IV morphine5 mg

CodeineCodeine

10% of the population can not metabolize 10% of the population can not metabolize codeine to its active opioid and therefore codeine to its active opioid and therefore receive no benefitreceive no benefit

Codeine has been shown to add < 5% Codeine has been shown to add < 5% increase in analgesia with a increase in analgesia with a disproportionate increase in side-effects.disproportionate increase in side-effects.

60 mg of codeine is = to 650 mg of ASA or 60 mg of codeine is = to 650 mg of ASA or acetaminophenacetaminophen

OxycotinOxycotin

Just as effective as oxycodone, just longer Just as effective as oxycodone, just longer actingacting

Not indicated for acute pain management Not indicated for acute pain management (FDA)(FDA)

16 year old male presents with a 16 year old male presents with a knife wound to the RLQ with pain knife wound to the RLQ with pain described as 8/10. He is tender described as 8/10. He is tender with palpation around the 2 cm, with palpation around the 2 cm, closed, laceration. closed, laceration.

Physical exam is otherwise normal. Physical exam is otherwise normal. Vital signs stable BP: 125/80, P:68, Vital signs stable BP: 125/80, P:68, R: 18. The patient has an IV.R: 18. The patient has an IV.

The ED doctor is evaluating the patient, so The ED doctor is evaluating the patient, so you speak to the surgeon who will be there in you speak to the surgeon who will be there in 20 minutes. The surgeon request that you 20 minutes. The surgeon request that you order labs, a CT of the abdomen and not give order labs, a CT of the abdomen and not give any pain medications. You relay this any pain medications. You relay this information to the ED doctor. Your information to the ED doctor. Your expectation of the ED doctor would be to:expectation of the ED doctor would be to:

1.1. order the labs, call for a CT abd., and order the labs, call for a CT abd., and await the surgeonawait the surgeon

2.2. order the labs, call for a CT abd., and order the labs, call for a CT abd., and give IV narcoticsgive IV narcotics

Treating abdominal pain does not mask Treating abdominal pain does not mask physical findings. It may actually help physical findings. It may actually help localize the area of pain.localize the area of pain.

The surgeon can reverse the opioid with The surgeon can reverse the opioid with naloxone if he wishes.naloxone if he wishes.

Which of the following would be Which of the following would be your choice to managing his pain?your choice to managing his pain?

1.1. Meperidine (Demerol)Meperidine (Demerol)

2.2. Morphine Morphine

3.3. Hydromorphone (Dilaudid)Hydromorphone (Dilaudid)

4.4. FentanylFentanyl

5.5. Butorphanol (Stadol)Butorphanol (Stadol)

The best choice would be fentanyl since The best choice would be fentanyl since the patient has the potential to the patient has the potential to hemorrhage and fentanyl is least likely to hemorrhage and fentanyl is least likely to cause hypotension.cause hypotension.

The following slides will discuss fentanyl The following slides will discuss fentanyl as well as the other choices.as well as the other choices.

FentanylFentanyl

Dosage is different (100 mcg) IV = 10 Dosage is different (100 mcg) IV = 10 mg MS IVmg MS IV

Works wellWorks well Faster onset then MS by ~5 minutesFaster onset then MS by ~5 minutes Cost: less now that it is genericCost: less now that it is generic Muscle rigidity of chest wall and Muscle rigidity of chest wall and

laryngospasm has occurred but a high laryngospasm has occurred but a high dosages.dosages.

MorphineMorphine

Morphine 6-10 mg IVMorphine 6-10 mg IV CheapCheap EffectiveEffective Titrate every 10-15 minutes with no upper Titrate every 10-15 minutes with no upper

limitlimit Causes histamine release which can Causes histamine release which can

produce hypotensionproduce hypotension

Hydromorphone (Dilaudid)Hydromorphone (Dilaudid)

1 mg IV of Hydromorphone = 6-7 mg IV of 1 mg IV of Hydromorphone = 6-7 mg IV of MSMS

Less histamine release but can still can Less histamine release but can still can cause hypotensioncause hypotension

Butorphanol (Stadol)Butorphanol (Stadol)

Agonist / antagonistAgonist / antagonist Antagonizes its own analgesia at higher Antagonizes its own analgesia at higher

dosages.dosages. Can cause opioid withdrawal Can cause opioid withdrawal Increased incidence of confusion and Increased incidence of confusion and

hallucinations compared to agonist-only hallucinations compared to agonist-only narcoticsnarcotics

Which of the following is the most Which of the following is the most accurate statement about meperidine accurate statement about meperidine (Demerol)?(Demerol)?

1.1. It can be titrated to achieve pain reliefIt can be titrated to achieve pain relief

2.2. It can be used with SSRIsIt can be used with SSRIs

3.3. It is absorbed well IMIt is absorbed well IM

4.4. It has a 4 hour duration of actionIt has a 4 hour duration of action

5.5. It is more addictive than other narcoticsIt is more addictive than other narcotics

Meperidine (Demerol)Meperidine (Demerol)

Can be used for acute painCan be used for acute pain 10 mg of MS q 4 hours = 100-150 mg 10 mg of MS q 4 hours = 100-150 mg

meperidine q 3 hoursmeperidine q 3 hours Problems with it:Problems with it: Originally developed as an atropine Originally developed as an atropine

analog and therefore has anticholinergic analog and therefore has anticholinergic side-effects (dries secretions, side-effects (dries secretions, tachycardia, etc.)tachycardia, etc.)

Short, 2-3 hour duration of actionShort, 2-3 hour duration of action

Meperidine (Demerol): More Problems:Meperidine (Demerol): More Problems:

Active metabolite normeperidine is a CNS Active metabolite normeperidine is a CNS irritant, with a half-life of 15-20 hoursirritant, with a half-life of 15-20 hours

Contraindicated for patients on MAO Contraindicated for patients on MAO inhibitors and SSRIs (serotonin syndrome)inhibitors and SSRIs (serotonin syndrome)

Meperidine is erratically absorbed when Meperidine is erratically absorbed when given IMgiven IM

A 55 year old presents with a 2 hour A 55 year old presents with a 2 hour history of sudden onset, severe, 10/10 history of sudden onset, severe, 10/10 right flank pain and has 300 RBC in his right flank pain and has 300 RBC in his urinalysis. Which of the following urinalysis. Which of the following would you recommend to manage his would you recommend to manage his pain?pain?

1.1. MorphineMorphine

2.2. Ketorolac (Toradol)Ketorolac (Toradol)

3.3. Morphine and ketorolacMorphine and ketorolac

4.4. Morphine and ibuprophenMorphine and ibuprophen

Opioids work quicker than NSAID (takes ~ Opioids work quicker than NSAID (takes ~ 20 minutes)20 minutes)

NSAIDs is at least as effective as opioids NSAIDs is at least as effective as opioids for ureteral colicfor ureteral colic Smooth muscle tension is directly Smooth muscle tension is directly

mediated by prostaglandins.mediated by prostaglandins.

Some urologist are concerned about Some urologist are concerned about NSAIDs effect on platelets.NSAIDs effect on platelets.

The only benefit of ketorolac is it’s parental The only benefit of ketorolac is it’s parental routeroute

Oral NSAIDs have been shown to have Oral NSAIDs have been shown to have equal onset to parental ketorolacequal onset to parental ketorolac

A 40 year old female presents with RUQ A 40 year old female presents with RUQ pain for 4 hours described as 8/10. She pain for 4 hours described as 8/10. She has a history of similar pain, after meals, has a history of similar pain, after meals, twice in the last two months. twice in the last two months.

One week ago she had an ultrasound and One week ago she had an ultrasound and was told she had gallstones. The patient was told she had gallstones. The patient has an IV.has an IV.

Which of the following pain Which of the following pain medications would you choose?medications would you choose?

1.1. Meperidine (Demerol)Meperidine (Demerol)

2.2. Morphine Morphine

3.3. Hydromorphone (Dilaudid)Hydromorphone (Dilaudid)

4.4. FentanylFentanyl

5.5. Butorphanol (Stadol)Butorphanol (Stadol)

An equianalgesic dosage of meperidine An equianalgesic dosage of meperidine has the same risk of causing biliary has the same risk of causing biliary muscle spasm as other opioids.muscle spasm as other opioids.

Which of the following pain Which of the following pain medications has a similar action to medications has a similar action to butorphanol (Stadol) ?butorphanol (Stadol) ?

1.1. HydromorphoneHydromorphone

2.2. FentanylFentanyl

3.3. HydrocodoneHydrocodone

4.4. Pentazocine (Talwin)Pentazocine (Talwin)

5.5. Oxycodone Oxycodone

6.6. Propoxyphene (Darvon)Propoxyphene (Darvon)

Pentazocine (Talwin) is an agonist / Pentazocine (Talwin) is an agonist / antagonistantagonist

Same problems as with other agonist / Same problems as with other agonist / antagonist:antagonist: Antagonizes its own analgesia at higher Antagonizes its own analgesia at higher

dosages.dosages. Can cause opioid withdrawal Can cause opioid withdrawal Can cause confusion and hallucinationsCan cause confusion and hallucinations

With an opioid IM injection, consider With an opioid IM injection, consider adding hydroxyzine (Vistaril)?adding hydroxyzine (Vistaril)?

1.1. TrueTrue

2.2. FalseFalse

3.3. Trick questionTrick question

Which of the following is an accurate Which of the following is an accurate description of tramadol (Ultram)?description of tramadol (Ultram)?

1.1. It has been shown to be consistently It has been shown to be consistently better then placebo better then placebo

2.2. It adds no additive analgesic effect when It adds no additive analgesic effect when combined with NSAIDscombined with NSAIDs

3.3. It has one mechanism of actionIt has one mechanism of action

4.4. It has an opioid-like effect yet has a low It has an opioid-like effect yet has a low abuse potentialabuse potential

Tramadol (Ultram)Tramadol (Ultram)

It has an opioid-like effect yet has a It has an opioid-like effect yet has a low abuse potentiallow abuse potential

Some studies have found it to be less Some studies have found it to be less effective than codeine and effective than codeine and hydrocodone when used in pain hydrocodone when used in pain management in acute painmanagement in acute pain

It works on different sites than It works on different sites than NSAIDs. There are studies which have NSAIDs. There are studies which have shown synergistic effects.shown synergistic effects.

Tramadol (Ultram)Tramadol (Ultram)

It has two mechanisms of action; one is It has two mechanisms of action; one is via the liver just like codeine to an active via the liver just like codeine to an active opioid, the other inhibits serotonin and opioid, the other inhibits serotonin and norepinephrine reuptake.norepinephrine reuptake.

It may be of use in neuropathic pain due It may be of use in neuropathic pain due to its inhibiting serotonin and to its inhibiting serotonin and norepinephrine reuptake.norepinephrine reuptake.

History and Exam:13 year old child with a swollen ankle secondary to a fall in gym. Ambulatory at the scene but not now. Only tenderness is inferior to the lateral malleolus. Pain 8/10. Wt: 60 Kg

What would you do at this time?What would you do at this time?

1.1. Treat pain and get a x-ray of the ankleTreat pain and get a x-ray of the ankle

2.2. Treat painTreat pain

3.3. Get a x-ray of the ankleGet a x-ray of the ankle