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DISCLOSURE

DISCLOSURE. MEMBER OF MEDICAL ADVISORY BOARD PFIZER-LYRICA(PREGABILIN). ASSESSMENT AND MANAGEMENT OF REFRACTORY POST-OP PAIN. R.HEWKO MD FRCPC. SIGNIFICANCE. PATIENT PERSISTANT DISTRESS INABILITY TO MOBILIZE PROLONGED HOSPITALIZATION

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DISCLOSURE

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  1. DISCLOSURE • MEMBER OF MEDICAL ADVISORY BOARD PFIZER-LYRICA(PREGABILIN)

  2. ASSESSMENT AND MANAGEMENT OF REFRACTORY POST-OP PAIN R.HEWKO MD FRCPC

  3. SIGNIFICANCE • PATIENT PERSISTANT DISTRESS INABILITY TO MOBILIZE PROLONGED HOSPITALIZATION POTENTIAL FOR IATROGENISIS EVOLUTION OF CHRONIC PAIN • SYSTEM RESOURCE UTILIZATION • PHYSICIAN ETHICAL OBLIGATION MEDICAL/LEGAL CONSEQUENCES

  4. DIFFERENTIAL DIAGNOSIS • EVOLVING PROCESS • NARCOTIC DEPENDANCY • NARCOTIC TOLERANCE • “LOW PAIN TOLERANCE” • NEUROPATHIC PAIN • MALINGERING

  5. EVOLVING PROCESS • AT RISK complex trauma patients long bone #’s-compartment syndrome • ASSESSMENT Hx- quality, pattern of pain Further investigation

  6. NARCOTIC DEPENDENCY VS NARCOTIC TOLERANCE • NARCOTIC TOLERANCE DEFN. PHYSIOLOGICAL STATE RESULTING IN INCREASED DOSE OF NARCOTIC TO OBTAIN SIGNIFICANT EFFECT. ABRUPT DISCONTINUATION MAY RESULT IN PHYSICAL WITHDRAWAL SYMPTOMS • NARCOTIC DEPENDANCYDEFN. INNAPPROPTIATE / EXCESSIVE USE OF NARCOTIC FOR NON-MEDICALLY INDICATED REASONS MAY OR MAY NOT BE ASSOCIATED WITH WITHDRAWAL WITH ABRUPT DISCONTINUATION

  7. ASSSESSMENT OF DEPENDENCY • AGENT(S) • AMOUNT • DURATION • LAST USE • PREVIOUS WITHDRAWAL • WITHDRAWAL MANAGEMENT

  8. PAIN MANAGEMENT • EQUIVALENCY MORPHINE / HEROIN-ALMOST EQUAL IN MOLECULAR WEIGHT / POTENCY PURITY OF HEROIN – 15 TO 85 % • RELIABILITY ALCOHOLICS REPORT HOW LITTLE THEY DRINK HEROIN ADDICTS REPORT HOW MUCH THEY USE • IATROGENISIS SIG. POTENTIAL FOR OVERDOSE

  9. RX OPTIONS • AGENTS -MORPHINE DEMEROL- MORPHINE ALLERGY? METHADONE -ONLY IF DOCUMENTED USE OR FOR STABILIZATION - MAINTAIN IF POSSIBLE - 1mg methadone= 4-10mg morphine • OPTIONS-CONTINUOUS INFUSION PRN PO/SC/IM/IV CONTIN

  10. MANAGEMENT • ESTABLISH TOLERANCE IV BOLUS 2-4 MG DOSES ASSESS FOR RESPONSE-DEGREE OF ANALGESIA / LOC • TITRATION AGGRESSIVE PRNS 10-20 MG SC/IM OR 20-30 MG PO Q3H 1-5 MG IV BOLUS QIH CONTINUOUS INFUSION-RANGE 4-10 MG TITRATE TRANSITION TO CONTIN WITH PRNS • EQUIVALENCY PARENTERAL TO ORAL -1 mg PARENTERAL TO 2 ORAL

  11. NARCOTIC TOLERANCE • BASE – REG.DOSE PLUS “REG” PRNS CONTIN OR CONT. INFUSION - maintain methadone/fentanyl patch • PRNS - 1 ½ TO 2 X STANDARD • KETAMINE / EPIDURALS • TITRATE BASE – Anticipate escalating base requirement.

  12. NARCOTIC INSENSITIVITY ? • PROFILE- long term use very large doses of regular narcotics - minimal response to large doses prn narcotics • MECHANISM- physiologic upregulation • MANAGEMENT - KETAMINE - NMDA ANTAGONIST -“RESET” SYSTEM

  13. LOW PAIN TOLERANCE • PAIN TOLERANCE PHYSIOLOGICAL VARIABLITY NARCOTIC TOLERANCE-endogenous endorphin suppression PSYCHOLOGICAL VARIABILITY PERSONALITY DRUG DEPENDANCY-NARCOTIC/OTHER EXPECTATIONS-COMPLETE PAIN RELIEF ALL OR NONE (0 – 1 = 10 PAIN SCALE) CHRONIC PAIN-PHYSIOLOGICAL/PSYCHOLOGICAL FACTORS • MANAGEMENT EXPECTATIONS / POLYPHARMACY

  14. REFRACTORY PAIN- PSYCHOTHERAPY • PATIENT POPULATION NARCOTIC TOLERANT/DEPENDANT LOW PAIN TOLERANCE • DISCUSSION – CLARIFY EXPECTATIONS LIMITS OF MANAGMENT LIMITS OF NARCOTICS RISKS OF XS NARCOTIC

  15. REFRACTORY PAIN - PHARMACOTHERAPY • PHARMACOTHERAPY EPIDURALS / KETAMINE ESP WITH NARCOTIC TOLERANCE • TYELENOL – STANDARD • BENZODIAZEPINES ANXIOLYTIC BUT RISK OF DISINHIBITION/INTOXICATION - RESPIRATORY COMPROMISE

  16. REFRACTORY PAIN-PHARMACOTHERAPY • NOZINAN (METHOTRIMEPRAZINE) LOW POTENCY NEUROLEPTIC MINIMAL RISK OF EPS / DYSTONIA ANXIOLYTIC ANALGESIC SEDATIVE WITHOUT RISK OF RESPIRATORY COMPROMISE POTENTIATION OF NARCOTIC • DOSING ANALGESIC 2.5-5mg Q3H PRN 5 TO 10 mg TID SEDATION 10 - 20 mg / 25 - 50 mg QHS PRN/REG

  17. NEUROPATHIC PAIN • HX / EVIDENCE NERVE INJURY overt - amputations 80% acute covert - any large incision • LIMITED RESPONSE TO NARCOTICS • QUALITY- DYSESTHESIA HYPERASTHESIA ALLODYNIA LANCINATING

  18. NEUROPATHIC PAIN - MANAGEMENT • NARCOTICS-may require pre-anesthetic doses/rapid development tolerance • GABAPENTIN / PREGABALIN Dose range- Gabapentin100mg tid to 1200mg qid - Pregabalin 75mg bid to 300mg bid • TCA’S– NORTRIPTYLINE/DESIPRAMINE Dose range 10 mg bid to 25 mg tid • BEST OPTION TCA PLUS GABAPENTIN/PREGABALIN

  19. MALINGERING • ASSESSMENT OBSERVATION-OVERT/COVERT NURSING NOTES • MANAGEMENT CONFRONTATION LIMITS EXPECTATIONS CONSEQUENCES

  20. SUMMARY • ETHICAL / MED-LEGAL OBLIGATIONS • ONGOING ASSESSMENT/ TITRATION • CLARIFY EXPECTATIONS / GOALS • MAINTAIN DIFFERENTIAL • RECOGNITION OF “LAYERS” • PHARM ADJUVANTS • NEED FOR OUT PATIENT SERVICES

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