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Pain Management

Pain Management. Stephanie Kim PGY-3 Intern Bootcamp, July 2014. “My arm hurts.”. OUTLINE. Types of pain Tylenol NSAIDs Opioids Conversions PCAs Special situations Anticonvulsants Antidepressants. NEUROPATHIC PAIN. caused by damage within nervous system

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Pain Management

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  1. Pain Management • Stephanie Kim PGY-3 • Intern Bootcamp, July 2014 “My arm hurts.”

  2. OUTLINE • Types of pain • Tylenol • NSAIDs • Opioids • Conversions • PCAs • Special situations • Anticonvulsants • Antidepressants

  3. NEUROPATHIC PAIN • caused by damage within nervous system • eg. DM neuropathy, postherpetic neuralgia, stroke

  4. NEUROPATHIC PAIN: TREATMENT • 1st line: • Anticonvulsants: pregabalin, gabapentin • SNRIs: duloxetine, venlafaxine • TCAs: amitriptyline, nortriptyline (better SE profile) • 2nd line: • weak opioids • opioids • Others: topical anesthetics (lidocaine patch)

  5. NOCICEPTIVE PAIN • caused by stimuli threatening tissue damage • eg. musculoskeletal, inflammation, mechanical/compressive

  6. NOCICEPTIVE PAIN: TREATMENT • Mild-Mod: • topical: lidocaine, capsaicin • inflammatory w/out RFs: NSAIDs + PPI • non-inflammatory or RFs for NSAIDs: tylenol • Severe/Refractory: • TCAs or SNRIs • Opioids

  7. ACETAMINOPHEN • Initial Dose: 325-650mg q4-6h • Max: 4gm/day if short-term; 3gm/day in general • Considerations: • if increased risk of hepatotoxicity: 2gm/day max dose • don’t forget about IV tylenol, we can give 1gm q6h x 4

  8. NSAIDs • General considerations: • synergy with opioids • AVOID in • renal insufficiency CrCl <60, increased age • heart failure, resistant hypertension • hepatic failure, cirrhosis • PUD, GIB • h/o platelet dysfunction, on aspirin • on anticoagulation • CAUTION with steroids

  9. IBUPROFEN • Initial Dose: 400mg q4-6h • Max: • 3200mg qd if acute • 2400mg qd if chronic • Considerations: • 200mg to 400mg comparable with 650mg tylenol

  10. NAPROXEN • Dose: • naproxen base 200-500mg q12h • naproxen sodium 220-550mg q12h • Max: • base: 1250mg qd acute, 1000mg qd chronic • sodium: 1375mg qd acute, 1100mg qd chronic • Considerations: • naproxen sodium has more rapid onset than naproxen base • naproxen may have less CV toxicity than other NSAIDs • if rheumatologic d/o, 1500mg qd max

  11. IV KETOROLAC • Initial dose: • if >65yo and >50kg: 15-30mg q6h • if >65yo or <50kg: 15mg q6h • Max: • if >65yo and >50kg: 120mg qd x 5 days • if <65yo or <50kg: 60mg qd x 5 days • Considerations: • used for short-term acute pain control • increased risk of gastropathy after 5 days • PO ketorolac has no advantage over other PO NSAIDs • not indication for chronic pain control

  12. OPIOIDS • Properties of receptors • Mu1: supraspinal analgesia, bradycardia, sedation • Mu2: respiratory depression, euphoria, dependence • Delta: spinal analgesia, respiratory depression • Kappa: spinal analgesia, respiratory depression, sedation

  13. OPIOIDS • General considerations: • in back pain, opioids vs placebo – no diff in pain scores • in neuropathic pain, opioids are 2nd line • Assessing risk: • HIGH RISK: personal or family history of EtOH/drugs • HIGH RISK: psych d/o • Things that mitigate risk: • poor performance status • restricted prognosis

  14. PRINCIPLES OF USE • WHO Ladder: a stepwise approach • Mild pain: Tylenol, NSAID, +/- adjuvant • Moderate: Codeine/tramadol, +/- nonopioid, +/- adj • Severe: Opioid, +/- nonopioid, +/- adj • If chronic, may need a fixed dose schedule for opioids • 50-75% long-acting, rest short-acting • DON’T FORGET A BOWEL REGIMEN

  15. SIDE EFFECTS • N/V 2/2 activation of chemoreceptor trigger zone in medulla • delayed gastric emptying, constipation • hyperalgesia • narcotic bowel (hyperalgesia of gut – severe chronic abd pain) • sedation • respiratory depression

  16. TRAMADOL • weak Mu agonist, reuptake inhibitor of NE and SE • Dose: 50-100mg q4-6h • Max: 300mg qd • Considerations: • not recommended in renal insufficiency • SE: seizure, worsening depression, SI

  17. MORPHINE IMMEDIATE RELEASE • Initial Dose: • 2-5mg IV q2-4h • 2-10mg SQ q3-4h • 15-30mg PO q3-4h EXTENDED RELEASE / MSCONTIN • Initial dose: • 15mg PO q8-12h AVOID IN RENAL FAILURE!

  18. OXYCODONE IMMEDIATE RELEASE • Initial dose: • 5-15mg PO q4-6h EXTENDED RELEASE / OXYCONTIN • Initial Dose: • 10mg PO BID

  19. HYDROMORPHONE • Initial Dose: • 0.2-1mg IV q2-4h • 0.2-1mg SQ q3-4h • 2-8mg PO q3-4h • Considerations: • high potency • give for short-term acute pain • when PO route is not available

  20. FENTANYL • Initial Dose: • 12-25mcg TD q72h • 25-50mg IV/SQ q1-2h • Considerations: • not recommended for acute pain • not recommended for opioid naive patients • IV infusions used in the ICU

  21. caution • CODEINE • not recommended for chronic pain • dose-related side effects • polymorphic metabolism, multiple drug interactions • METHADONE • call Palliative Care

  22. EXAMPLES • Mild-mod pain: schedule tylenol q6h, with oxycodone 5mg prn • Mod-sev pain: • if opioid-naive, start short-acting prn • eg. oxycodone 5mg q4h prn • if chronic pain, convert 50-75% of daily use to long-acting • eg. oxycodone ER 10mg BID, oxycodone IR 5mg q4h prn • if acute/or no PO route, IV morphine or dilaudid prn

  23. TITRATION 50-100% increase Severe pain 7-10/10 25-50% increase Moderate pain 4-6/10 25% increase Mild pain 1-3/10 Weinstein, Pain Presentation 10/2013

  24. CONVERSION Weinstein, Pain Presentation 10/2013

  25. MORE CONVERSION • 1 mcg transdermal fentanyl = 2 mg oral morphine • Fentanyl 25 mcg/hr patch = 50 mg oral morphine/24 hrs • Fentanyl 100 mcq/hr patch = 200 mg oral morphine/24 hrs • Use caution in opioid-naïve patients • Titrate every 72 hours Fentanyl patch conversion Weinstein, Pain Presentation 10/2013

  26. Starting a PCA • Demand • Lockout • Basal • Bolus prn: default in EMR • example: dilaudid 0.2mg demand with q6min lockout

  27. Sickle Cell Crisis • in ED or Acute Care Clinic, pt will be given IV boluses • check to see if there is a Care Path in Portal • if not, and no other contradictions, start IVF and PCA • can augment with IV toradol if no renal insufficiency • transition to home PO regimen when pain controlled

  28. End-of-life • opioids prescribed for pain and dyspnea • oxycodone and morphine oral liquid concentrate • can give q1h prn • morphine gtt for increased work of breathing at the end • start at 3mg/hr, have RN titrate to RR <20 • may need to bolus until effective dose found • be careful with renal failure • don’t forget prn ativan, haldol, zofran, glycopyrrolate

  29. ANTICONVULSANTS GABAPENTIN • Dose: start a low dose 300mg qhs, uptitrate to TID • Max: 3600mg qd in 3 divided doses • studied in postherpetic neuralgia and DM neuropathy PREGABALIN • Dose: start at 75mg BID • Max: 300mg qd in divided doses • studied in postherpetic neuralgia and DM neuropathy • used but less effective in central neuropathic pain, FM • Considerations: RENALLY DOSE, sedation

  30. ANTIDEPRESSANTS General Considerations • analgesic effects occur earlier (1 wk) • used at lower dose • TCAs and SNRIs

  31. TCA NORTRIPTYLINE • DOSE:10mg qd, max 75mg qd • SE: • anticholinergic: dry mouth, constipation, urinary retention • CV: arrhythmias, heart block, MI • GI: N/V, dyspepsia • Neuro: ataxia, tremors, sedation • Avoid in: • heart disease, conduction disturbances (prolonged QT) • GI dysfunction

  32. SNRI VENLAFAXINE • DOSE: 150-225mg qd • Used in DM neuropathy • Avoid in conduction abn DULOXETINE • DOSE: 60mg qd • Used in DM neuropathy, FM, back pain, OA • Avoid in hepatic or renal insufficiency

  33. THANKS • to Dr. Elizabeth Weinstein and Dr. Christine Koniaris • CONGRATS on making it to Block 1b! • EMAIL me @ stephanie.kim@uhhospitals.org

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