Chief Complaint: Total Body Dolor Plan: Pain Management

1. Chief Complaint: Total Body Dolor Plan: Pain Management PART 1

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

3. Objective Learn some key facts about pain management Identify practical approach to pain management Learn how to perform simple opioid conversion Learn to manage pain in patients with liver or renal diseases

4. Overview of Pain Management Standards • Patient knows best; only the patient can describe characteristics and rate the severity of his or her pain! • Pharmacological therapies • Uses non-pharmacological therapies whenever appropriate • Provide education and counseling • Use adjuvants for specific pain (ex. bone, neuropathic)

5. Mind-Body therapy Heat/Cold therapy Massage Acupuncture Tai-chi PT/OT Transcutaneous Electrical Nerve stimulator (TENS) Pain Treatment Options – Non-pharmacologic approach

6. Pain Treatment Options – Pharmacologic approach • Non-opioids • Capsaicin • Acetaminophen • NSAIDs • Steroid

7. Pain Treatment Options – Pharmacologic approach (cont) • Adjuvants • TCA: commonly used for neuropathic pain • Gapabentin: FDA-approved for partial seizures and postherpetic neuralgia but is also used for a wide variety of neuropathic pain syndromes, including postoperative pain • Lidocaine patch: FDA-approved for postherpetic neuralgia but are used for a wide variety of local pain syndromes

8. Side-effects GI Renal: reduce GFR Increase fluid retention, HTN Increase risk of confusion Platelet dysfunction Alternative treatments Consider nonacetylated salicylates or COX-2 selective (Diclofenac, Meloxicam), celecoxib plus PPi Consider topical therapy (Capsasin) Consider Naproxen or Tylenol or topical therapy Consider non-pharmacologic therapy Consider Acetaminophen NSAIDs

9. Corticosteroid • Indication: • reduce compression due to edema causing structural stretching-> visceral pain • Anti-inflammation; Trigger point injection (must rule out septic joint first). • Stimulate appetite • Need to weigh benefits vs. risks • Dexamethasone produces the least amount of mineralocorticoid effect, with the highest amount of anti-inflammatory effects

10. Summary • Only the patient can describe characteristics and rate the severity of his or her pain. • Always consider using non-pharmalogical approach when appropriate. • All non-opioids medication have ceiling effects. • Do not combine multiple NSAIDs. Use alternative treatments to minimize potential side-effects. • Consider adjuvants for specific pains such as bone pain or neuropathic.

11. Chief Complaint: Total Body Dolor Plan: Pain Management PART 2

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

13. Pain Management Option- Opioids

14. Chronic Pain Opioid Conversions Total Amounts Convert Cross-Tolerance? Choose appropriate PO PRN’s/breakthrough pain Bowel regimen

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

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

17. Let’s practice • Step 1: IV PO conversion • 8.8 mg IV Dilaudid to PO morphine • 8.8 x 20 = 176 mg PO Morphine • Step 2: Cross tolerance? • YES! Reduce by 15% • PO Morphine = 150mg • Step 3: Schedule PO Dosing frequency • MS CONTIN = BID Dosing. 150mg in BID dosing • 150/2 = 75mg MS Contin BID • Step 3: calculate breakthrough dosing • = minimum of 30-50% total daily requirement • 150 * 0.50 = 75mg / day • 75mg divided into q4h dosing = • 75 / 6 = ~12 mg q4h PRN • Step 4: don’t forget bowel regimen or you will have a very unhappy patient at your follow up appointment

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

19. Back to the initial case • The patient’s ankle pain was controlled with acetaminophen and lidocaine patches. For the neuropathic pain in his upper extremities, tramadol was started at 25 mg oral every 12 hours and increased to 50 mg oral every eight hours (below the maximum of 200 mg a day). The tramadol did not result in adequate pain relief, so gabapentin 100 mg at bedtime was initiated, then increased to twice daily over three days with some relief. • A geriatric consult was obtained to help educate him regarding addiction to opioids, as well as to explore goals of care, but he continued to insist on the use of a non-narcotic regimen for his pain.

20. Summary • Pain management is a comprehensive, patient-centered process including pharmacological agent, psychosocial counseling, and non-pharmacological treatments when appropriate. • Always start with the lowest dose, least side-effect agents and reassess frequently with patient’s input. • Use conversion chart for IV to po, and this transition should be done as soon as possible. • When in doubt, always ask for help from the experts.

21. References • Barakzoy AS, Moss AH. Efficacy of the World Health Organization analgesic ladder to treat pain in end-stage renal disease. J Am Soc Nephrol. 2006;17(11):3198-3203. • Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage. 2004;28(5):497-504. • Broadbent A, Khor K, Heaney A. Palliation and chronic renal failure: opioid and other palliative medications—dosage guidelines. Progress in Palliative Care. 2003;11(4):183-190(8). • Johnson SJ. Opioid safety in patients with renal or hepatic dysfunction. Pain Treatment Topics website. Available at: http://pain-topics.org/pdf/Opioids-Renal-Hepatic-Dysfunction.pdf. Accessed Dec. 7, 2013 • Ashburn MA, Lipman AG, et al. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. American Pain Society: 5th Edition. 2003