Inpatient Pain Management: Challenges and Solutions for the Modern Era

1. James R Knight, M.D. Assistant Clinical Professor Division of Hospital Medicine The Ohio State University Medical Center James.Knight@osumc.edu Inpatient Pain Management: Challenges and Solutions for the Modern Era

2. 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

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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

9. 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 7-10 faces ranging from grimacing to neutral (ideal for children). • Multidimensional Pain Inventories McQuay et al. BMJ 1997; 314:1531-5.

10. 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.

11. Pain Management in the Hospitalized Patient • WHO Analgesic ladder (1986) • Designed for cancer pain • Never validated in hosptialized medical patients • non-opioids for mild pain • opioids for mild-mod pain, +/- non-opioids and adjuvants • Opioids for mod-sev pain +/- non-opioids and adjuvants

12. McQuay et al. BMJ 1997; 314:1531-5. McQuay et al. BMJ 1997; 314:1531-5. McQuay et al. BMJ 1997; 314:1531-5.

13. Morphine

14. What’s wrong with morphine? • 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

15. 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

16. Online Opioid Converters • Johns Hopkins • http://www.hopweb.org • Registration is free!

17. 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.

18. 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.

19. 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

20. Adjuvants • TCAs (amitriptyline, nortriptyline, etc.) • Antiepileptics (gabapentin, carbamazepine, topamax, etc.) • Glucocorticoids • Local anaesthetics (lidocaine, capsaicin) • Benzodiazepines

21. Other Adjuvants • Remove the cause (surgery/splint) • Epidural anaesthesia • Local anaesthetic • Nerve blocks • Physiotherapy • Manipulation • Transcutaneous Electrical Nerve Stimulation (TENS) • Acupuncture • Ice • Relaxation • Psycoprophylaxis • hypnosis

22. 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.

23. 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.

24. 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

25. 184% 1129% 899% 231% 450% Increased Use mg/person 1997-2006 • Morphine • Methadone • Oxycodone • Hydrocodone • Fentanyl Manchikanti and Singh Pain Physician 2008; Opioid Special Issue: 11:S63-S88.

26. 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.

27. WV deaths, 2006 • 33% women, 67% men Hall, et al. JAMA, 2008; 300(22): 2613-2620.

28. 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.

29. Misuse and Abuse

30. 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.

31. White and Irvine, Addiction, 1999; 94(7), 961-972.

32. 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.

33. Tolerance • 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

34. Abuse Any one of the following • Substance use interferes with work, school, or home. • Use despite physical hazard • Recurrent substance related legal problems • Use despite recurrent social/interpersonal problems DSM IV

35. 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

36. Dependence, cont'd • 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 DSM IV

37. 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.

38. 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

39. 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?”

40. 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

41. 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

42. 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.

43. http://www.ohiopmp.gov

44. 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.

45. 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”.

46. 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