“My arm hurts.”
Pain Management
Stephanie Kim PGY-3
Intern Bootcamp, July 2014
OUTLINE
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Types of pain
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Tylenol
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NSAIDs
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Opioids
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Conversions
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PCAs
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Special situations
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Anticonvulsants
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Antidepressants
NEUROPATHIC PAIN
•caused
•eg.
by damage within nervous system
DM neuropathy, postherpetic neuralgia,
stroke
NEUROPATHIC PAIN:
TREATMENT
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•
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1st line:
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Anticonvulsants: pregabalin, gabapentin
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SNRIs: duloxetine, venlafaxine
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TCAs: amitriptyline, nortriptyline (better SE profile)
2nd line:
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weak opioids
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opioids
Others: topical anesthetics (lidocaine patch)
NOCICEPTIVE PAIN
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caused by stimuli threatening tissue damage
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eg. musculoskeletal, inflammation,
mechanical/compressive
NOCICEPTIVE PAIN:
TREATMENT
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Mild-Mod:
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topical: lidocaine, capsaicin
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inflammatory w/out RFs: NSAIDs + PPI
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non-inflammatory or RFs for NSAIDs: tylenol
Severe/Refractory:
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TCAs or SNRIs
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Opioids
ACETAMINOPHEN
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Initial Dose: 325-650mg q4-6h
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Max: 4gm/day if short-term; 3gm/day in general
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Considerations:
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if increased risk of hepatotoxicity: 2gm/day max dose
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don’t forget about IV tylenol, we can give 1gm q6h x 4
NSAIDs
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General considerations:
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synergy with opioids
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AVOID in
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•
•
•
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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
IBUPROFEN
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Initial Dose: 400mg q4-6h
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Max:
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3200mg qd if acute
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2400mg qd if chronic
Considerations:
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200mg to 400mg comparable with 650mg tylenol
NAPROXEN
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•
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Dose:
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naproxen base 200-500mg q12h
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naproxen sodium 220-550mg q12h
Max:
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base: 1250mg qd acute, 1000mg qd chronic
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sodium: 1375mg qd acute, 1100mg qd chronic
Considerations:
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naproxen sodium has more rapid onset than naproxen base
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naproxen may have less CV toxicity than other NSAIDs
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if rheumatologic d/o, 1500mg qd max
IV KETOROLAC
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•
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Initial dose:
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if >65yo and >50kg: 15-30mg q6h
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if >65yo or <50kg: 15mg q6h
Max:
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if >65yo and >50kg: 120mg qd x 5 days
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if <65yo or <50kg: 60mg qd x 5 days
Considerations:
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used for short-term acute pain control
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increased risk of gastropathy after 5 days
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PO ketorolac has no advantage over other PO NSAIDs
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not indication for chronic pain control
OPIOIDS
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Properties of receptors
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Mu1: supraspinal analgesia, bradycardia, sedation
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Mu2: respiratory depression, euphoria, dependence
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Delta: spinal analgesia, respiratory depression
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Kappa: spinal analgesia, respiratory depression, sedation
OPIOIDS
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•
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General considerations:
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in back pain, opioids vs placebo – no diff in pain scores
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in neuropathic pain, opioids are 2nd line
Assessing risk:
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HIGH RISK: personal or family history of EtOH/drugs
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HIGH RISK: psych d/o
Things that mitigate risk:
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poor performance status
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restricted prognosis
PRINCIPLES OF USE
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WHO Ladder: a stepwise approach
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Mild pain: Tylenol, NSAID, +/- adjuvant
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Moderate: Codeine/tramadol, +/- nonopioid, +/- adj
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Severe: Opioid, +/- nonopioid, +/- adj
If chronic, may need a fixed dose schedule for opioids
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50-75% long-acting, rest short-acting
DON’T FORGET A BOWEL REGIMEN
SIDE EFFECTS
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N/V 2/2 activation of chemoreceptor trigger zone in medulla
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delayed gastric emptying, constipation
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hyperalgesia
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narcotic bowel (hyperalgesia of gut – severe chronic abd pain)
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sedation
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respiratory depression
TRAMADOL
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weak Mu agonist, reuptake inhibitor of NE and SE
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Dose: 50-100mg q4-6h
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Max: 300mg qd
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Considerations:
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not recommended in renal insufficiency
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SE: seizure, worsening depression, SI
MORPHINE
IMMEDIATE RELEASE
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Initial Dose:
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2-5mg IV q2-4h
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2-10mg SQ q3-4h
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15-30mg PO q3-4h
EXTENDED RELEASE / MSCONTIN
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Initial dose:
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15mg PO q8-12h
AVOID IN RENAL FAILURE!
OXYCODONE
IMMEDIATE RELEASE
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Initial dose:
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5-15mg PO q4-6h
EXTENDED RELEASE / OXYCONTIN
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Initial Dose:
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10mg PO BID
HYDROMORPHONE
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Initial Dose:
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0.2-1mg IV q2-4h
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0.2-1mg SQ q3-4h
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2-8mg PO q3-4h
Considerations:
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high potency
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give for short-term acute pain
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when PO route is not available
FENTANYL
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Initial Dose:
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12-25mcg TD q72h
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25-50mg IV/SQ q1-2h
Considerations:
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not recommended for acute pain
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not recommended for opioid naive patients
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IV infusions used in the ICU
caution
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CODEINE
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not recommended for chronic pain
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dose-related side effects
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polymorphic metabolism, multiple drug interactions
METHADONE
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call Palliative Care
EXAMPLES
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Mild-mod pain: schedule tylenol q6h, with oxycodone 5mg prn
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Mod-sev pain:
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if opioid-naive, start short-acting prn
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eg. oxycodone 5mg q4h prn
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if chronic pain, convert 50-75% of daily use to long-acting
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eg. oxycodone ER 10mg BID, oxycodone IR 5mg q4h prn
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if acute/or no PO route, IV morphine or dilaudid prn
TITRATION
50-100% increase
25-50% increase
25% increase
Mild pain
1-3/10
Severe pain
7-10/10
Moderate pain
4-6/10
Weinstein, Pain Presentation 10/2013
CONVERSION
Drug
PO/PR (mg)
IV/SC (mg)
Morphine
30
10
Oxycodone
20
n/a
Hydromorphone
7.5
1.5
Codeine
200
120
Hydrocodone
30
n/a
Fentanyl
n/a
Methadone
Complex
Weinstein, Pain Presentation 10/2013
MORE CONVERSION
Fentanyl patch conversion
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1 mcg transdermal fentanyl = 2 mg oral morphine
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Fentanyl 25 mcg/hr patch = 50 mg oral morphine/24 hrs
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Fentanyl 100 mcq/hr patch = 200 mg oral morphine/24 hrs
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Use caution in opioid-naïve patients
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Titrate every 72 hours
Weinstein, Pain Presentation 10/2013
Starting a PCA
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Demand
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Lockout
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Basal
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Bolus prn: default in EMR
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example: dilaudid 0.2mg demand with q6min lockout
Sickle Cell Crisis
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in ED or Acute Care Clinic, pt will be given IV boluses
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check to see if there is a Care Path in Portal
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if not, and no other contradictions, start IVF and PCA
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can augment with IV toradol if no renal insufficiency
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transition to home PO regimen when pain controlled
End-of-life
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opioids prescribed for pain and dyspnea
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oxycodone and morphine oral liquid concentrate
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can give q1h prn
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morphine gtt for increased work of breathing at the end
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start at 3mg/hr, have RN titrate to RR <20
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may need to bolus until effective dose found
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be careful with renal failure
don’t forget prn ativan, haldol, zofran, glycopyrrolate
ANTICONVULSANTS
GABAPENTIN
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Dose: start a low dose 300mg qhs, uptitrate to TID
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Max: 3600mg qd in 3 divided doses
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studied in postherpetic neuralgia and DM neuropathy
PREGABALIN
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Dose: start at 75mg BID
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Max: 300mg qd in divided doses
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studied in postherpetic neuralgia and DM neuropathy
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used but less effective in central neuropathic pain, FM
Considerations: RENALLY DOSE, sedation
ANTIDEPRESSANTS
General Considerations
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analgesic effects occur earlier (1 wk)
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used at lower dose
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TCAs and SNRIs
TCA
NORTRIPTYLINE
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DOSE:10mg qd, max 75mg qd
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SE:
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anticholinergic: dry mouth, constipation, urinary retention
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CV: arrhythmias, heart block, MI
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GI: N/V, dyspepsia
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Neuro: ataxia, tremors, sedation
Avoid in:
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heart disease, conduction disturbances (prolonged QT)
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GI dysfunction
SNRI
VENLAFAXINE
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DOSE: 150-225mg qd
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Used in DM neuropathy
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Avoid in conduction abn
DULOXETINE
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DOSE: 60mg qd
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Used in DM neuropathy, FM, back pain, OA
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Avoid in hepatic or renal insufficiency
THANKS
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to Dr. Elizabeth Weinstein and Dr. Christine Koniaris
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CONGRATS on making it to Block 1b!
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EMAIL me @ stephanie.kim@uhhospitals.org