Pain – Healing It Without Feeling It
Elizabeth Weinstein, M.D., M.S.
Mariel Harris, M.D., J.D.
Medical Director Supportive Oncology
Seidman Cancer Center
UH Case Medical Center
Medical Director for Senior Services
UH Richmond Medical Center
Geriatric Medicine, Hospice & Palliative Care
UH Center for Geriatric Medicine
Rajesh Chandra, M.D.
Division Chief
General Internal Medicine & Geriatrics
UH Case Medical Center
David Cogan, M.D.
Senior Medical Director
UHMP
Hildy Pearl, MS, RD, LD
Clinical Systems Liaison
UH Case Medical Center
Kim F. Bixenstine, Esq.
Vice President and Deputy General Counsel
University Hospitals
Todd M. Zeiger, M.D.
UH Sharon Center Family Medicine
Regional Medical Director
UH Sharon and Medina Health Center
Helen C. Foley, MSN, RN
Adult Oncology CNS
Seidman Cancer Center
UH Case Medical Center
Robin Rowell, RN, CNP
VP, Institute and Medical/Surgical Clinical Operations
UH Case Medical Center
Debbie Horan, RN, BSN
Clinical Systems Liaison
UH Case Medical Center
Pain – Healing it Without Feeling it
According to the Institute of Medicine, the number
of Americans who suffer from Chronic Pain is
estimated to be:
1.
2.
3.
4.
25 million
45 million
75 million
100 million
0%
A
October 27, 2012
University Hospitals
0%
B
0%
C
0%
D
Objectives
• Understand the basic principles of pain
management
• Understand the barriers to and myths of pain
management
• Understand regulations regarding
prescribing/dispensing pain medications
• Understand hospital specific resources for
pain management
October 27, 2012
University Hospitals
Case presentation
• CC: Fell off bicycle
• HPI: 55yo WM competing in 4 day fundraising
bicycle ride who fell off bicycle and now presenting
with 10/10, constant, sharp, localized left hip pain.
Patient has chronic tingling in hands and legs which
is overshadowed by current pain.
• PMH: OA- shoulders, spine, hips - s/p injections,
wears soft cervical collar to sleep; Carpal Tunnel
syndrome- wears wrist splints to sleep
• NKDA
October 27, 2012
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Case presentation
• Meds:
– Pregabalin 100mg po TID x 2 years
– Duloxetine 60mg po daily
– Oxycontin 40mg po BID x 2years
– Sennosides/ docusate 2 tabs po qhs
– Cyclobenzaprine 5mg po qhs prn
• FamHx: Non-contributory
• SocHx: interventional radiologist, swims and/or
bicycle rides 6 days a week; married to PM&R MD;
no known addiction history
October 27, 2012
University Hospitals
Case presentation
• ROS: as per HPI, otherwise negative
• PE: Afebrile, HR- 120, RR- 18, BP- 140/ 75
– Remarkable for externally rotated and
shortened L LE with pain on hip flexion
• Labs: BMP, CBC, INR, LFTs within normal limits
• Imaging: Left sided intertrochanteric hip fracture
• Plan in ED:
– Ortho consultation
– Pain control
– Admit
October 27, 2012
University Hospitals
Question 1
You recognize patient is not opiate naïve. You need to
give him something for pain. He is NPO for possible
surgery. A reasonable first dose would be:
A) Morphine 5mg IV
B) Hydromorphone 2mg IV
C) Oxycodone 5mg po
D) Ketorolac 30mg IV
Patient’s Home Meds:
Pregabalin 100mg po TID x 2 years
Duloxetine 60mg po daily
Oxycontin 40mg po BID x 2years
Sennosides/ docusate 2 tabs po qhs
Cyclobenzaprine 5mg po qhs prn
0%
1
October 27, 2012
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0%
2
0%
3
0%
4
Best response: A
A) Morphine 5mg IV
B) Hydromorphone 2mg IV
C) Oxycodone 5mg po
D) Ketorolac 30mg IV
• Route of choice
• Drug of choice
• Dose of choice
– Acute on chronic pain- chronic
pain meds are now baseline/
background
– Convention in terms of
reasonable breakthrough dose5-15% of daily long-acting
– Must calculate equianalgesic
doses
October 27, 2012
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Equianalgesic Dosing
OPIOID
Morphine
PARENTERAL
(mg)
10
Oxycodone
Hydromorphone
(Dilaudid)
October 27, 2012
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ORAL (mg)
30
20-30
1.5
7.5
Question 2
He is admitted with plans for surgery the next day. You
need to control his pain overnight. The most reasonable
option is:
A) Morphine 5mg IV q4h prn
B) Continue Oxycontin and
Pregabalin and add
Morphine 5mg IV q4h prn
C) Continue Oxycontin and
Pregabalin and add
Morphine PCA
0%
1
October 27, 2012
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0%
2
0%
3
Practical aspects of
choosing prn pain meds
Best response: C
•
•
•
A) Morphine 5mg IV q4h prn
B) Continue Oxycontin and
Pregabalin and add Morphine
5mg IV q4h prn
C) Continue Oxycontin and
Pregabalin and add
Morphine PCA
• Is patient going to be able to
ask?
• Will patient ask?
• Is RN going to be able to
get to patient in a timely
manner?
• Do we need to do some
dose finding?
• Pharmocokinetics
October 27, 2012
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Practical aspects of
choosing to use a PCA
Best response: C
•
•
•
A) Morphine 5mg IV q4h
prn
B) Continue Oxycontin and
Pregabalin and add
Morphine 5mg IV q4h prn
C) Continue Oxycontin
and Pregabalin and add
Morphine PCA
• Is patient going to be able to safely use
PCA? (not delirious, using opiates
appropriately)
• Do we need to do some dose finding?
• We use less opiate with PCA than
without
• Continuous aspect of PCA- is equivalent
to long-acting opiate
• How to do PCA dosing - continuous,
patient push and RN bolus
October 27, 2012
University Hospitals
Best response: C
•
•
•
A) Morphine 5mg IV q4h
prn
B) Continue Oxycontin and
Pregabalin and add
Morphine 5mg IV q4h prn
C) Continue Oxycontin
and Pregabalin and add
Morphine PCA
• Takes more medicine to get
pain under control than to keep
it under control
• Delirium in hip fractures more
often from pain than opiates*
* Relationship between Pain and Opioid Analgesics on the
Development of Delirium Following Hip Fracture.
Morrison et. al, Journal of Gerontology : Medical Sciences 2003,
Vol. 58A, No. 1, 76-81.
October 27, 2012
University Hospitals
Question 3
Patient is now post-op. Continues to use PCA. He has
fallen asleep. Nurse is concerned that his cell phone
rings and he sleeps right through it. The nurse notifies
you of this. You should:
A) Give all the Narcan you
can find on the floor
B) Discontinue all opiates
C) Hold opiates and restart
at lower dose
D) Assess patient and
develop a ddx for the
patient’s sedation
0%
A
October 27, 2012
University Hospitals
0%
0%
B
C
0%
D
Best responses: C & D
A) Give all the Narcan you can
find on the floor
B) Discontinue all opiates
C) Hold opiates and restart
at lower dose
D) Assess patient and
develop a ddx for the
patient’s sedation
• There is no set amount of opiate
associated with sedation,
respiratory arrest/ death
• You get sedation first- safety of
PCA with no continuous dosing
(see graph)
• RR drops slowly- not abrupt
cessation of breathing
• Catching up on sleep
October 27, 2012
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Safety mechanism of PCAs with
NO CONTINUOUS DOSE
Serum
Concentration
Respiratory Depression
Sedation
Time
October 27, 2012
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Best responses: C & D
A) Give all the Narcan you can
find on the floor
B) Discontinue all opiates
C) Hold opiates and restart
at lower dose
D) Assess patient and
develop a ddx for the
patient’s sedation
October 27, 2012
University Hospitals
• Don’t want to get behind on pain
which will happen if holding
long-acting med --- liken this to
other scheduled meds (e.g. beta
blockers)
• Abbey Pain Scale or other for
assessing pain in noncommunicative patient
Assessing Pain in Patients Who Can’t Communicate Abbey Pain Scale
October 27, 2012
University Hospitals
Question 4
Hospital day 3
Patient’s pain is well controlled. He is doing well with PT and is going
to be discharged home with home PT. He has had no BM since
admission. What do we need to think of before he goes home?
A) Which intern is responsible for
d/c summary
B) What his opiate dose will be
C) What adjuvants he should be
on
D) What resources are available to
him and you as you continue
to manage his pain
E) Who do we need to give a
handoff to
F) Fixing his constipation
G) All of the above
October 27, 2012
University Hospitals
0%
0%
A
B
0%
0%
0%
0%
0%
C
D
E
F
G
Opiate dosing
Best response:
G
A) Which intern is responsible
for d/c summary
B) What his opiate dose will be
C) What adjuvants he should
be on
D) What resources are
available to him and you as
you continue to manage his
pain
E) Who do we need to give a
handoff to
F) Fixing his constipation
G) all of the above
October 27, 2012
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– Long-acting is 50-75% of
total daily Oral Morphine
Equivalent
• varies for incident pain,
expected changes to pain
– Short-acting dose
• Convention in terms of
reasonable breakthrough
dose - 5-15% of daily longacting
Basic Principles of Opiate Prescribing
• Make it simple: oral route, one drug
• Prescribe an adequate dose
• Do the math! Use equianalgesic conversion table
• Use a correct dosing interval
• Prescribe around-the-clock (long-acting opiate) - when
warranted
• Provide a breakthrough dose (short-acting opiate)
• Treat common opiate side effects
• Use appropriate adjuvants
October 27, 2012
University Hospitals
Do the math!
• Calculate 24 hour oral morphine equivalent (OME)
• Consider adequacy of pain control
– Calculate - expected total oral morphine equivalent
– Increase current 24 hr OME by 25-50% for moderate pain control
– Increase current 24 hr OME by 50-100% for poor pain control
• Determine the opiate that will be given
• Use equianalgesic conversion table
• Correct for incomplete cross-tolerance when rotating to
different opiate
– Reduce dose by 25 – 50 %
• Calculate short and long-acting doses
October 27, 2012
University Hospitals
Equianalgesic Dosing
OPIOID
Morphine
PARENTERAL
(mg)
10
Oxycodone
Oxymorphone
Hydromorphone
(Dilaudid)
Fentanyl
Hydrocodone
October 27, 2012
University Hospitals
ORAL (mg)
30
20-30
1
10
1.5
7.5
0.1
30
Best response:
G
A) Which intern is responsible
for d/c summary
B) What his opiate dose will be
C) what adjuvants he should
be on
D) What resources are
available to him and you as
you continue to manage his
pain
E) Who do we need to give a
handoff to
F) Fixing his constipation
G) all of the above
October 27, 2012
University Hospitals
ADJUVANTS
– Inflammation/ post-op NSAIDS/ steroids
– Neuropathic –
TCA, anti-epileptics, SNRI,
anesthetics
– Complementary therapies heat/ice, massage, physical
therapy, acupuncture etc.
Best response: G
A) Which intern is responsible
for d/c summary
B) What his opiate dose will be
C) What adjuvants he should
be on
D) What resources are
available to him and you as
you continue to manage his
pain
E) Who do we need to give a
handoff to
F) Fixing his constipation
G) all of the above
October 27, 2012
University Hospitals
– Talk to Team assuming
care - re: course and plan
for meds and what is
being written for at d/c
Guidelines for Dictating Pain Management History
• Describe pain syndromes patient suffered
• For each complaint, describe:
– Type of pain and severity reported
– Provoking factors
– Relieving factors
– Procedures completed/ attempted and result
– Medications tried, what worked and at what dose
– Medications tried that were ineffective
– Medications with adverse reactions, how treated (remember to
distinguish intolerance, such as nausea or sedation, from true
allergy)
October 27, 2012
University Hospitals
Guidelines for Dictating Pain Management History
Detailed description of
– Discussion with patient and family on how to manage
analgesics after discharge
– Prescriptions given, including # of pills of each Rx and
whether any refills were authorized
– What doctor or doctors will be responsible for follow-up
– If appropriate, what OARRS or pharmacy investigation was
done
– If appropriate, what REMS information was given to patient
and whether a contract was or should be made for use of
long-acting opiates in chronic non-cancer pain syndromes
October 27, 2012
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Definition of Terms
Misuse
• Use of a medication (for a medical purpose) other than as directed or as
indicated, whether willful or unintentional, and whether harm results or
not
Abuse
• Any use of an illegal drug
• The intentional self administration of a medication for a nonmedical
purpose such as altering one’s state of consciousness, eg, getting high
Addiction
• A primary, chronic, neurobiological disease, with genetic, psychosocial,
and environmental factors influencing its development and
manifestations
• Behavioral characteristics include one or more of the following:
impaired control over drug use, compulsive use, continued use despite
harm, craving
Pseudoaddiction
October 27, 2012
• Syndrome of abnormal behavior resulting from undertreatment of pain
that is misidentified by the clinician as inappropriate drug-seeking
behavior
• Behavior ceases when adequate pain relief is provided
• Not a diagnosis; rather, a description of the clinical intention
University Hospitals
Katz NP, et al. Clin J Pain. 2007;23:648-660.
Definition of Terms
Dependence
Tolerance
October 27, 2012
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A physiological state of neuro-adaptation which is characterized by
WITHDRAWAL if…The drug is stopped, the drug is decreased
abruptly, an antagonist is administered
The need to increase the dose of opioids to achieve the same level
of analgesia
Katz NP, et al. Clin J Pain. 2007;23:648-660.
FDA – REMS
(Risk Evaluation and Mitigation Strategy)
•
•
•
Are regulatory requirements on medications that have a high threshold
potential for harm
The FDA mandates that the Drug manufacturer develop a REMS
program in order to continue sale of those medications
REMS programs may include any of the 4 following components:
–
–
–
–
•
Medication Guide
Communication Plan
Elements to Assure Safe Use (ETASU)
Implementation System
ETASU requires practitioners to complete one or all of the following:
Prescriber Certification:
Register and obtain/renew by completing drug company online training
Medication Guide:
Must be provided to all inpatients as well as outpatients prior to receiving the first dose
Register the Patient
Patient informed consent:
Must be signed prior to administration of the drug
October 27, 2012
University Hospitals
FDA – REMS
(Risk Evaluation and Mitigation Strategy)
Some commonly used ETASU drugs
•
•
•
•
•
•
•
•
•
Oxycontin
(soon to be all extended
release narcotics)
Epogen/Procrit (ESA nonESRD use)
Aranesp (ESA non-ESRD use)
Avandia
Zyprexa Relprevv
Entereg
Revlimid
Lumizyme
Tikosyn
October 27, 2012
University Hospitals
FDA – REMS
ETASU REMS Drugs
 Pop-up notifications for ETASU drugs which will include all
need-to-know compliance information
Pop-Up Notifications
October 27, 2012
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WHERE TO FIND UH OPIOID GUIDELINES, ED OPIOID GUIDELINES and
PAIN MANAGEMENT AGREEMENT
October 27, 2012
University Hospitals
Pain Management Referral Resources
•
General: Fast Facts- http://www.eperc.mcw.edu/EPERC/FastFactsandConcepts
UH System Referral Resources
University Hospitals Case Medical Center
Palliative care consult service, Pager 35614
Pain consult service, Pager 35879
Seidman Cancer Center Symptom Management and
Supportive Care clinic 216-844-3951 Option 1
Roger Goomber, M.D. 216-844-7335
Salim Hayek, M.D.
216-844-3771
Ali-Amin Khalil, MD
216-844-3552
Binit Shah, M.D.
216-844-3771
Henry Vucetic, M.D. 216-844-7335
UH Ahuja Medical Center
Joshua Goldner, M.D. 216-844-3771
Patrick McIntyre, M.D. 216-844-3771
UH Richmond Medical Center
Al-Amin Khalil, M.D. 216-844-2552
Sami Moufawad, M.D. 440-786-9885
UH Bedford Medical Center
Sami Moufawad, M.D. 440-786-9885
UH Conneaut Medical Center
UH Geneva Medical Center
Arpan Desai, M.D. 440-593-0203
(Interventional only)
UH Geauga Medical Center
Henry Vucetic, M.D.
UH Conner Integrative Medicine Network
Francoise Adan, M.D. 216-285-4070
St. John Medical Center
Abdallah Kabbara
440-827-5058
Southwest General Health Center
David Sfeir, M.D.
440-816-8990
October 27, 2012
University Hospitals
216-844-7335
Thank You.
References:
American Academy of Pain – Facts and Figures on Pain
http://www.painmed.org/patientcenter/facts_on_pain.aspx
Relationship between Pain and Opioid Analgesics on the Development of Delirium Following Hip
Fracture, Morrison et al. Journal of Gerontology Medical Sciences 2003, Vol. 58A, No. 1, 76-81.
The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia,
Abbey et al. Int Journal of Palliat Nurs 2004 Jan;10(1):6-13
Definition of Terms, Katz NP, et al. Clin J Pain. 2007;23:648-660
October 27, 2012
University Hospitals