Pain Management Top 10 Resident Pitfalls- 2019

1. Pain ManagementTop 10 Resident Pitfalls- 2019 Theresa Kristopaitis, MD Professor of Medicine, Division of Hospital Medicine

2. Pain ManagementTop 10 Resident pitfalls 10. Norco PRN for everyone!

4. “CDC Guidelines for Prescribing Opiates for Chronic Pain” • Current EPIDEMIC of prescription opioid overdose and deaths • As many as 1 in 4 people receiving prescription opioids long term in primary care setting struggles with addiction • 2016 Guidelines developed for • Primary care providers • Treating patients with chronic pain • Does not include patients undergoing active cancer txand end of life care

5. Guideline Summary-Chronic Pain • Nonpharmacologic and NONOPIOID pharmacologic tx preferred for chronic pain • Consider opioid therapy only if expected benefits for pain AND function outweigh risks

6. Guideline Summary – ACUTE Pain Long-term Opioid Use Often Begins With Tx Of Acute Pain • When opioids are used for ACUTE pain • Prescribe • Lowest effective dose • Immediate release formulation • Quantity no greater than expected duration of pain severe enough to require opiates • 3 days or less often sufficient • More than 7 days rarely needed

8. IF you are going to prescribe opioids… Now embedded when ordering in EPIC

9. Pain ManagementTop 10 Resident pitfalls 9. Percocet – that’s like lortab, right? They both have hydromorphone? 10. Norco PRN for everyone!

10. Pain Management • Know your analgesics

11. WHO 3 step ladder • Step 1 • Acetaminophen • Nonsteroidals • Aspirin

12. Who 3 step ladder • Step 2 • Codeine +acetaminophen • T#2, T #3, T#4 • Hydrocodone + acetaminophen • Norco • Vicodin • Lortab • Oxycodone + acetaminophen • Percocet • Tramadol • Ultram

13. Who 3 Step Ladder • Step 3 • Morphine • Hydromorphone • Dilaudid • Oxycodone • Methadone • Fentanyl

14. Pain ManagementTop 10 Resident Pitfalls 8. Equianalgesic table? Does your i-phone have that? 9. Percocet – that’s like lortab, right? 10. Norco PRN for everyone!

15. Pain Management • Have an opioid conversion chart with you with which you are familiar

16. Equianalgesic Dose

17. Pain ManagementTop 10 Resident Pitfalls 7. Uh Yeah, 2mg of IV dilaudid sounds good 8. Equianalgesic table? Does your i-phone have that? 9. Percocet – that’s like lortab, right? 10. Norco PRN for everyone!

18. Pain Management --Respect potency of opioid analgesics --Know starting doses

19. Pain Management • Always start with short-acting opioids

20. Starting doses of opioids • Factors • Age • Weight • Comorbidities • Prior experience with analgesics • Frequency, severity of pain

21. List the following from analgesics from least to most potent • Tramadol • Hydromorphone • Oxycodone • Hydrocodone • Codeine • Morphine

22. Least to most potent • Codeine • Tramadol • Morphine = Hydrocodone • Oxycodone • Hydromorphone

23. Effective ORAL Starting Doses • Codeine 30 mg • Tramadol 25-50 mg • Morphine = Hydrocodone 5 mg • Oxycodone 3 mg • Hydromorphone 1 mg

24. Effective IV Starting Doses of Opioids • Morphine 1mg • Hydromorphone0.15mg 6.66

25. Pain ManagementTop 10 Resident pitfalls 6. 2mg of IV morphine didn’t work? Go ahead and change it to 2mg IV dilaudid. 7.Uh Yeah, 2 of IV dilaudid sounds good 8. Equianalgesic table? Does your i-phone have that? 9. Percocet – that’s like lortab, right? 10. Norco PRN for everyone!

26. Pain Management • Describe the principles of opioid dose escalation

27. Dose Escalation • Recommended frequency of dose escalation -depends on peak effect time and the half- life of the drug

28. Escalation • IV opioids  every 15-30 minutes • Short-acting PO single-agent  every 2 hours • ?what about combination products? • Sustained release oral opioids ->every 24 hours • Transdermal fentanyl no more frequently than every 72 hours

29. Common Formula • For ongoing moderate to severe painincrease opioid doses by 50-100% • For ongoing mild to moderate pain increase by 25-50%

30. Rotation to another opioid is not the first choice • So long as • a dose-response effect is being seen • patient is tolerating the regimen

31. Math Time • 2mg of IV morphine didn’t work? Go ahead and change it to 2mg IV dilaudid. • Hydromorphone 2mg IV is the equivalent of what dose of morphine? • Does that follow the rule of dose escalation?

32. 2mg IV hydromorphine x 10mg IV morphine = 1.5mg IV hydromorphone 13mg IV morphine !!!!! 2mg IV morphine to 13mg IV morphine = 200%+ increase

33. 2mg IV morphine administered and 30 minutes later patient still in pain • For ongoing moderate to severe pain increase opioid doses by 50-100% • For ongoing mild to moderate pain increase by 25-50%

34. Family arrives and says STOP – morphine made him crazy – we want something else!! • 2mg IV morphine x 1.5mg IV hydromorphone 10mg IV morphine 0.3mg IV hydromorphone

35. Public Service Announcement ORDERING PAIN MEDICATIONS and AVOIDING “OPIOID STACKING” • PRN pain medications require an associated  pain severity scale to assist nursing administration.                         mild pain, (pain score 1-3)                         moderate pain (pain score 4-6)                         severe pain (pain score 7-10) • If medications are ordered for different pain levels then dosing intervals should be the same for all of these meds to avoid medication stacking ie: ibuprofen 600mg every 6 hours for mild pain                               hydrocodone/acetaminophen 5mg/325mg every 6hours for moderate pain                               hydrocodone/acetaminophen 10mg/325 mg every 6hours for severe pain • Additional medications can be given between these intervals, and the prn indication should be documented as "breakthrough pain."  The physician team should be contacted to enter orders specifically for "breakthrough pain."

36. EXAMPLE OF PAIN MEDICATION STACKING Pain score assessment =5 Norco 5mg given Pain is reassessed in 1 hour; pain score assessment= 8 Norco 10mg given             ->Patient is not due for another pain medication; next dose can be given 6hours after initial administration. **Pain medication stacking should be avoided to prevent iatrogenic adverse reactions and complications.

37. Pain ManagementTop 10 Resident pitfalls 5. Still in pain on hospital day #2? Slap on a fentanyl patch 6. 2mg of IV morphine didn’t work? Go ahead and change it to 2mg IV dilaudid. 7. Yeah, 2 of IV dilaudid sounds good 8. Equianalgesic table? Does your i-phone have that?9. Percocet – that’s like lortab, right? 10. Norco PRN for everyone!

38. Pain Managment • Extended release/long acting (ER/LA) opioids are NOT for acute pain management • ER/LA opioids are NOT for chronic (nonmalignant) pain management • CDC Guideline - When starting opioid tx prescribe IMMEDIATE RELEASE instead of ER/LA opioids

39. Long Acting Opioids • Morphine • MS Contin, Kadian, Avinza • Oxycodone • Oxycontin • Hydromorphone • Exalgo • Fentanyl Transdermal • Duragesic

40. Long Acting Opioids • For opioid tolerant patients • Pt taking at least • 60 mg oral morphine/day • 30 mg oral oxycodone/day • 8 mg oral hydromorphone/day • or equianalgesic dose of another opioid • for one week or longer (FDA) • For management of moderate to severe pain when a continuous, around-the-clock opioid analgesic is needed for an extended period of time

41. Acute Pain in an opioid tolerant patient? • Uncontrolled pain must be controlled via short acting oral or IV opiates BEFORE the start/titration of a long acting agent

42. Pain ManagementTop 10 Resident pitfalls 4. Still in pain after 24 hours Fentanyl 25mcg/hr patch? Go ahead and increase to a 50 patch 5. Still in pain on hospital day #2? Slap on a fentanyl patch 6. 2mg of IV morphine didn’t work? Go ahead and change it to 2mg IV dilaudid. 7. Yeah, 2 of IV dilaudid sounds good 8. Equianalgesic table? Does your i-phone have that?9. Percocet – that’s like lortab, right? 10. Norco PRN for everyone!

43. What is wrong with that management decision? • Long Acting, Sustained Release Opioids are NOT for acute pain management • this includes fentanyl transdermal • Uncontrolled pain must be controlled via short acting oral or IV opiates BEFORE start/titration of long acting agent • Dose escalate transdermal fentanyl no more frequently than every 72 hours

44. More about transdermal fentanyl • Onset of action? • 18-24 hours • Patch strengths • 12, 25, 50, 75, 100mcg/hr • What dose of ORAL MORPHINE in a 24 hour period is equianalgesic to fentanyl 25mcg/hr patch? • 50mg

45. Pain ManagementTop 10 Resident pitfalls 3. A morphine PCA sounds good. Do I have to fill in all of the blanks on the order set? 4. Still in pain after 24 hours Fentanyl 25mcg/hr patch. Go ahead and increase to a 50 patch 5. Still in pain on hospital day #2? Slap on a fentanyl patch 6. 2mg of IV morphine didn’t work? Go ahead and change it to 2mg IV dilaudid. 7. Yeah, 2 of IV dilaudid sounds good 8. Equianalgesic table? Does your i-phone have that?9. Percocet – that’s like lortab, right? 10. Norco PRN for everyone!

46. PCA orders • Opioid • Concentration • Demand dose • Lockout • 4 hour limit • BASAL RATE • Loading dose

47. Pain Management • A BASAL rate in an opioid naive patient is NOT recommended

48. Pain ManagementTop 10 Resident pitfalls 2. If you don’t poop, we’ll prescribe a laxative 3. A morphine PCA sounds good. Do I have to fill in all of the blanks on the order set? 4. Still in pain after 24 hours Fentanyl 25mcg/hr patch. Go ahead and increase to a 50 patch 5. Still in pain on hospital day #2? Slap on a fentanyl patch 6. 2mg of IV morphine didn’t work? Go ahead and change it to 2mg IV dilaudid. 7. Yeah, 2 of IV dilaudid sounds good 8. Equianalgesic table? Does your i-phone have that?9. Percocet – that’s like lortab, right? 10. Norco PRN for everyone!

49. He or she who writes the opioid order writes the bowel regimen. • Stimulant laxative • senna or bisacodyl • Stimulant laxative + osmotic laxative • Milk of magnesia • Miralax • Lactulose/sorbital

50. How/why do opioids induce constipation? Opioid Receptors Reduce peristalsis: Inhibit longitudinal smooth muscle Segmentation: increase contraction of circular smooth muscle Impair absorption of fluid from bowel Impair secretions