Post on 02-Jan-2016
ED Pain Management (and the Drug-seeking Patient)
Grant Innes, MD
Pain hurts!Pain hurts!
ObjectivesObjectives
Acute pain vs. chronic pain Acute pain vs. chronic pain
Chronic pain vs. addictionChronic pain vs. addiction
Impact of pain biology on patient Impact of pain biology on patient behaviour and response to therapy behaviour and response to therapy
Basic concepts in pain Rx for EDBasic concepts in pain Rx for ED patients who may be opioid dependentpatients who may be opioid dependent
Pain management may be the most Pain management may be the most important thing we do, but . . .important thing we do, but . . .
It is a secondary consideration for It is a secondary consideration for most physicians,most physicians,
We under-treat pain.We under-treat pain.
We underutilize potent analgesicsWe underutilize potent analgesics
Trust me! I’m a doctor.Trust me! I’m a doctor.
Medical school time devoted to Medical school time devoted to rare metabolic disorders . . . rare metabolic disorders . . .
400 hours400 hours
Time devoted to studying pain and Time devoted to studying pain and pain management . . . pain management . . . 1 hour1 hour
Textbook of Surgical AnalgesiaTextbook of Surgical Analgesia
Chapter 1. Parenteral analgesiaChapter 1. Parenteral analgesiaDemerol 50-75 mg IM q4h prnDemerol 50-75 mg IM q4h prn
Chapter 2. Oral AnalgesiaChapter 2. Oral AnalgesiaTylenol #3, I-II tabs po q4h prnTylenol #3, I-II tabs po q4h prn
Case 1Case 1 An unkempt 32 year-old man presents with An unkempt 32 year-old man presents with
a severe toothache. His chart shows he was a severe toothache. His chart shows he was seen 2 days earlier and given a Rx for 20 seen 2 days earlier and given a Rx for 20 Tylenol #3 tabs, which he says were Tylenol #3 tabs, which he says were ineffective. Your next step is:ineffective. Your next step is:
A. Call securityA. Call security B. Suggest OTC Tylenol, then call securityB. Suggest OTC Tylenol, then call security C. Prescribe an unusual NSAID (“Idarac”)C. Prescribe an unusual NSAID (“Idarac”) D. Give him 4 “T3” to goD. Give him 4 “T3” to go E. None of the aboveE. None of the above
***
Treatment – Case 1Treatment – Case 1
Infra-orbital nerve blockInfra-orbital nerve block MarcaineMarcaine Xylocaine with epiXylocaine with epi
Ibuprofen to start before the pain recurrsIbuprofen to start before the pain recurrs
Tylenol to start when the pain recurrsTylenol to start when the pain recurrs
OxycodoneOxycodone
Treating Acute Pain:Treating Acute Pain:The The Modified Modified WHO Pain LadderWHO Pain Ladder
Step 1: AcetaminophenStep 1: Acetaminophen
Step 2: NSAID (ibuprofen)Step 2: NSAID (ibuprofen)
Step 3: Syndrome-specific agentStep 3: Syndrome-specific agent ““muscle relaxant” for back painmuscle relaxant” for back pain Dopamine antagonist for migraineDopamine antagonist for migraine
Step 4: OpioidStep 4: Opioid Pretend opioid (codeine)Pretend opioid (codeine) Real opioid (morphine, hydronorphone)Real opioid (morphine, hydronorphone)
Acute Pain Physiology Acute Pain Physiology (in 2 slides)(in 2 slides)
Mechanical, thermal or chemical stimuli (with Mechanical, thermal or chemical stimuli (with tissue injury) lead to local inflammatory tissue injury) lead to local inflammatory mediator releasemediator release
Pain impulses transmitted to spinal cordPain impulses transmitted to spinal cord
At DRG: neuropeptides mediate sensitizationAt DRG: neuropeptides mediate sensitization pain threshold decreases, andpain threshold decreases, and central response to pain increasescentral response to pain increases
Antidromic conduction/recruitmentAntidromic conduction/recruitment
To DRG
Neurogenic inflammationNeurogenic inflammation
Antidromic conduction and inflammatory Antidromic conduction and inflammatory mediator releasemediator release
Secondary hyperalgesia; recruitmentSecondary hyperalgesia; recruitment
Pain is a vicious cycle. Preempt itPain is a vicious cycle. Preempt it
Acute pain: More biochemical than neuralAcute pain: More biochemical than neural
Migraine: An Inflammatory SyndromeMigraine: An Inflammatory Syndrome
Noxious triggers activate trigeminal nociceptors
Trigeminal brainstem sensory complex receives input from 7,9,10,12
Antidromic trigeminal activation leads to release of vasoactive neuropeptides!
OpioidsOpioidsCodeine (Tylenol #3):- Moderately effective- GI upset (low abuse potential)
Meperidine:- Poorly absorbed. Shorter acting. AEs.
Potent oral opioids:- Less GI upset- Effective but more euphoria/CNS effects- Potential for abuse
Multimodal AnalgesiaMultimodal Analgesia
AcetaminophenAcetaminophen
NSAIDs or COX-2NSAIDs or COX-2
OpioidsOpioids
““Muscle relaxants”Muscle relaxants” CyclobenzeprineCyclobenzeprine MethocarbamolMethocarbamol
AntidepressantsAntidepressants
Sedative-hypnoticsSedative-hypnotics
Regional blocksRegional blocks
AnticonvulsantsAnticonvulsants
Dopamine antagonistsDopamine antagonists
Antimigraine drugsAntimigraine drugs
Heat and UltrasoundHeat and Ultrasound
MassageMassage
AcupunctureAcupuncture
Alternative remediesAlternative remedies
Case 2: A young female, disabled by chronic leg pain (compartment syndrome), presents with a painful arm. When you pass by the bed, she moans and clutches her arm. She is on methadone for chronic pain and has told the nurse she will need 250 mg of Demerol because she has a “high pain threshold”. She is febrile and has a markedly swollen arm with multiple recent needle tracks. When you touch the skin lightly, she screams and pulls her arm away
Q. The best treatment is:IV antibiotics + acetaminophen and ibuprofenAntibiotics + additional methadoneAntibiotics + high-dose titrated IV morphineAntibiotics + 4 “Tylenol #3 to go”
Vancouver, BC - 1.2 million peopleVancouver, BC - 1.2 million people
Canada’s richest postal code
Canada’s poorest postal code
St. Paul’s Hospital
HIGH Prevalence of Opioid HIGH Prevalence of Opioid Addiction and DependencyAddiction and Dependency
Features of the CaseFeatures of the CaseShe moans and clutches her arm—as you pass
Drug-seeking behavior: She is communicating with you
She is febrile with a +++ swollen arm. This is an acute exacerbation—not her steady state
She says she needs 250 mg of Demerol Tolerance
When you touch the skin lightly, she screams and pulls her arm away
Allodynia
Q. The best treatment is:Q. The best treatment is:IV antibiotics + acetaminophen + ibuprofenIV antibiotics + acetaminophen + ibuprofenAntibiotics + additional methadoneAntibiotics + additional methadoneAntibiotics + high-dose titrated IV morphinAntibiotics + high-dose titrated IV morphineeAntibiotics + 4 “Tylenol #3 to go”Antibiotics + 4 “Tylenol #3 to go”
A. For opioid dependent patients with unequivocal A. For opioid dependent patients with unequivocal and uncontrolled painand uncontrolled pain, treat the pain aggressively, treat the pain aggressively
Substance abuse disorder (Addiction)Substance abuse disorder (Addiction)
A complex neurochemical A complex neurochemical disorder that: disorder that:
causes behaviour patterns that are causes behaviour patterns that are misunderstood and aggravating to ED staffmisunderstood and aggravating to ED staff
makes it difficult for addicts to make makes it difficult for addicts to make constructive and rational decisionsconstructive and rational decisions
Substance abuse disorderSubstance abuse disorder
Cognitive, behavioural and physiological symptoms Cognitive, behavioural and physiological symptoms
Substance use despite significant related problems. Substance use despite significant related problems.
At least three of the following: At least three of the following: Tolerance; Tolerance; Withdrawal; Withdrawal; Larger amounts and longer time periods than intended; Larger amounts and longer time periods than intended; Persistent desire or unsuccessful attempts to control use; Persistent desire or unsuccessful attempts to control use; Disproportionate time and effort to obtain the substance; Disproportionate time and effort to obtain the substance; Impact on social, occupational, or recreational activities Impact on social, occupational, or recreational activities Continued use despite health, social or economic problemsContinued use despite health, social or economic problems
Case 3: A middle-age woman presents with chronic upper back pain that is worse since a recent fall. Her oxycodone is not working and she hasn’t slept for 3 days. She feels she cannot manage at home and may need hospitalization.
PMH: depression and fibromyalgia.
Meds: Diclofenac (50 mg tid) and oxycodone (80 mg/day).
Exam: She lies motionless in bed with her eyes closed. She is in no evident pain and appears depressed. She winces in pain when her skin is touched over the upper back, but there are no objective findings.
Your treatment options might include:
A. NSAIDs B. IV opioids C. Oral hydromorphone
D. Antidepressants E. Other
Features of the caseFeatures of the case
She lies motionless in bed with her eyes closed. A complex neurochemical disorder causing behaviour
patterns that are misunderstood and aggravating to ED staff
She is in no evident pain Chronic pain does not look like acute pain
She appears depressed. Depression travels with chronic pain
She winces in pain when her skin is touched lightly over the upper back
Allodynia
Chronic painChronic painDefinitionDefinition: Lasts longer than expected: Lasts longer than expected
Ongoing pain increases the expression of CNS pain Ongoing pain increases the expression of CNS pain receptors that influence pain experiencereceptors that influence pain experience Allodynia and hyperalgesiaAllodynia and hyperalgesia
• A chronic disease with exacerbations + remissionsA chronic disease with exacerbations + remissions
At steady state with their analgesics, unless change At steady state with their analgesics, unless change in disease status: may need dose increase w flareupin disease status: may need dose increase w flareup
Inflammation is a minor concern in chronic pain Inflammation is a minor concern in chronic pain and an insignificant concern in neuropathic pain and an insignificant concern in neuropathic pain
Chronic Pain doesn’t “look like” acute painChronic Pain doesn’t “look like” acute pain
Acute painAcute pain: : protective activation of the ANSprotective activation of the ANS Pallor, anxiety, tachy, diaphoresis, restless Pallor, anxiety, tachy, diaphoresis, restless
Chronic painChronic pain: : Not inflammatoryNot inflammatory Minimal ANS activationMinimal ANS activation DepressionDepression
Directed combination therapy for chronic painDirected combination therapy for chronic pain
Simple analgesicsSimple analgesics
NSAID if an acute component or chronic NSAID if an acute component or chronic inflammatory state—not in neuropathic pain. inflammatory state—not in neuropathic pain.
Opioids often necessary but rarely sufficient as a Opioids often necessary but rarely sufficient as a single agentsingle agent Consider opioid rotation (different opioid receptor Consider opioid rotation (different opioid receptor
subtypes respond to different drugs)subtypes respond to different drugs) For rapid analgesia, titrate short-acting agentsFor rapid analgesia, titrate short-acting agents If addictive tendency, consider longer acting or SR If addictive tendency, consider longer acting or SR
agents, with less euphoric effects and less intense W/Dagents, with less euphoric effects and less intense W/D
Treat related symptoms (e.g. anxiety, insomnia, Treat related symptoms (e.g. anxiety, insomnia, depression) with specific agentsdepression) with specific agents
Other “Analgesic” OptionsOther “Analgesic” Options
Dopamine antagonists and antimigraine drugs for HADopamine antagonists and antimigraine drugs for HA
““Muscle relaxants” Muscle relaxants” (e.g. cyclobenzeprine, methocarbamol)(e.g. cyclobenzeprine, methocarbamol)
Antidepressants Antidepressants (e.g. Amitryptiline, Trazodone)(e.g. Amitryptiline, Trazodone)
Anticonvulsants for neuropathic painAnticonvulsants for neuropathic pain
Sedative-hypnotics for anxietySedative-hypnotics for anxiety
Regional blocks Regional blocks
Physical modalities (heat, US, massage, acupuncture)Physical modalities (heat, US, massage, acupuncture)
Alternative remediesAlternative remedies
DefinitionsDefinitionsToleranceTolerance: Adaptation with diminished drug efficacy. : Adaptation with diminished drug efficacy.
Physical dependencyPhysical dependency:: cessation causes withdrawal sx cessation causes withdrawal sx
AddictionAddiction:: maladaptive behavior including: maladaptive behavior including: loss of loss of controlcontrol, , compulsive substance usecompulsive substance use, preoccupation with , preoccupation with using a substance despite negative consequences. using a substance despite negative consequences.
PseudoaddictionPseudoaddiction:: a behavioral response to inadequate a behavioral response to inadequate pain control (perceived as drug seeking). Aberrant pain control (perceived as drug seeking). Aberrant behavior ceases with appropriate pain management*.behavior ceases with appropriate pain management*.
Note: Tolerance and dependency do not indicate addiction
Differential Diagnosis: Differential Diagnosis: Chronic pain vs. addictionChronic pain vs. addiction
Overlap between chronic pain and addiction.
Some chronic pain patients are addicted.
No objective test to differentiate
Non-addicts often display drug seeking behavior
Hi likelihood of diagnostic error
Important Findings—or not??Important Findings—or not??Dress and grooming?Dress and grooming?Appearance and vital signs?Appearance and vital signs?A lost prescription; out of meds; A lost prescription; out of meds; Asks for drugs and doses by nameAsks for drugs and doses by nameA tale of woe: many causes of painA tale of woe: many causes of pain Different opioids - different doctorsDifferent opioids - different doctors Stable employment, family, and functionStable employment, family, and functionNoncompliant with Rx planNoncompliant with Rx plan
Is it real, or . . .Is it real, or . . .Using my best judgment, how patients with real pain
will I refuse to treat? (assuming 80% sensitivity, 80% specificity and 5% prevalence of drug-seekers).
TruthTruth
JudgmentJudgment
AddictAddict PainPain
AddictAddict 4040 190190 230230
PainPain 1010 760760 770770
5050 950950 10001000
PPV=17.4%
NPV=98.5%
Pts with pain of uncertain validityPts with pain of uncertain validityWhen in doubt . . . Treat the pain!
Pain is what the patient says it is -- usually
Old records and Pharmanet
Frequent flyer (DMP) program: DMP committee develops an ED care protocol defining a
consistent approach to subsequent ED visits. Plan is consistent with the pt’s overall care plan, and is
printed automatically at triage each time the pt comes to ED. Pts with no primary care provider are referred to one Pts likely to benefit from other expertise (e.g. psychiatry,
chronic pain service) are referred during their next ED visit
SummarySummaryAcute pain concepts:Acute pain concepts:
Neurogenic inflammationNeurogenic inflammation Multimodal analgesiaMultimodal analgesia
Chronic pain conceptsChronic pain concepts Cognitive/behavioural changes. DepressionCognitive/behavioural changes. Depression Loss of autonomic activation.Loss of autonomic activation. Hyperalgesia and allodyniaHyperalgesia and allodynia Directed combination therapyDirected combination therapy
Tolerance and dependency = addictionTolerance and dependency = addiction
Pain is (usually) what the patient says it isPain is (usually) what the patient says it is
Speaker EvaluationsSpeaker EvaluationsPain Management and the Drug-Seeking Patient (Innes)
How would you rate this presentation?A. Excellent!! This was the finest educational experience I’ve
ever had—by far!
B. Superb! The speaker was incredible. This information will change my practice dramatically for the better.
C. Outstanding! It scares me how I was practicing medicine before I saw this presentation
D. Fair. Please report me to the FBI for fraudulent billing practices
Opioid Equianalgesic DataOpioid Equianalgesic Data
OpioidOpioid Parenteral (mg) Parenteral (mg) Oral (mg)Oral (mg)
MorphineMorphine 1010 30* 30*
HydromorphoneHydromorphone 1.51.5 7.5 7.5
OxycodoneOxycodone ------ 20 20
CodeineCodeine 130130 200 200
FentanylFentanyl 0.1^0.1^ --- ---
MethadoneMethadone ------ 3-5 3-5
The Causes of Drug-SeekingThe Causes of Drug-Seeking
Commerce: To acquire drugs to sellCommerce: To acquire drugs to sellMisuse: Using drugs for euphoric effectMisuse: Using drugs for euphoric effectInadequately treated acute painInadequately treated acute painInadequately treated chronic painInadequately treated chronic pain