Clinical Decision Making in Clinical Decision Making in Pain Management:Pain Management:

The PanelThe Panel

Andy Jagoda, MD, FACEP, Professor of Emergency Andy Jagoda, MD, FACEP, Professor of Emergency MedicineMedicineMount Sinai School of Medicine, New York, New YorkMount Sinai School of Medicine, New York, New York

Robert Asselta, RN, BSN, CEN, Paramedic, Education Robert Asselta, RN, BSN, CEN, Paramedic, Education Specialist Mount Sinai Emergency DepartmentSpecialist Mount Sinai Emergency Department

Alex Manini, MD, MS, Toxicologist and Research Director, Elmhurst Medical Center

Ron Walls, MD, Professor and Chair, Brigham and Women’s, Ron Walls, MD, Professor and Chair, Brigham and Women’s, Harvard School of Medical StudentHarvard School of Medical Student

OverviewOverview

• Scope of the problemScope of the problem• Mechanisms of painMechanisms of pain• Case studies Management optionsCase studies Management options• Future directions: Is there a need to Future directions: Is there a need to

change practicechange practice

Key PointsKey Points

• Management of pain must be placed in the context of the Management of pain must be placed in the context of the clinical presentationclinical presentation Underlying mechanism of pain impacts approach to Underlying mechanism of pain impacts approach to

managing the painmanaging the pain• Treatment should not be delayed pending a diagnosisTreatment should not be delayed pending a diagnosis• IV titration is generally the preferred approach for severe acute IV titration is generally the preferred approach for severe acute

painpain Treat early, front-load, around the clockTreat early, front-load, around the clock Acute management must be linked to the continuum of careAcute management must be linked to the continuum of care

• Opioids are not always best and NSAIDs are not benignOpioids are not always best and NSAIDs are not benign• Non-pharmacologic management and anxiolysis play an Non-pharmacologic management and anxiolysis play an

important role in the pain responseimportant role in the pain response

ACEP Pain Policy Statement March 2004•ED patients should receive expeditious pain management, avoiding delays such as those related to diagnostic testing or consultation.•Hospitals should develop unique strategies that will optimize ED pain management using both narcotic and non-narcotic medications.•ED policies and procedures should support the safe utilization and prescription writing of pain medications in the ED.•Effective physician and patient educational strategies should be developed regarding pain management, including the use of pain therapy adjuncts and how to minimize pain after disposition from the ED.•Ongoing research in the area of ED patient pain management should be conducted.

BackgroundBackground

• Pain is the most common reason people come to the EDPain is the most common reason people come to the ED Accounts for 70% of ED visitsAccounts for 70% of ED visits Children and the elderly are commonly undermedicatedChildren and the elderly are commonly undermedicated

• Varying levels of understanding of pain and its treatment Varying levels of understanding of pain and its treatment existexist Many patients come to the ED out of desperation Many patients come to the ED out of desperation

• PathwaysPathways Nociceptive: activation of primary peripheral pain Nociceptive: activation of primary peripheral pain

receptors (A-delta and C fibers)receptors (A-delta and C fibers) Neuropathic: aberrant signal processing in the Neuropathic: aberrant signal processing in the

peripheral or central nervous systemperipheral or central nervous system

Pain treatment optionsPain treatment options

• Eliminate mechanical and environmental factorsEliminate mechanical and environmental factors• Block opiate receptorsBlock opiate receptors• Block inflammatory mediatorsBlock inflammatory mediators• Block transmission to the CNS: local anestheticsBlock transmission to the CNS: local anesthetics• Modulate central 5-HT pathways Modulate central 5-HT pathways • Modulate the “close gates” at dorsal horn: TENS, Modulate the “close gates” at dorsal horn: TENS,

acupunctureacupuncture• Decrease anxiety Decrease anxiety • Maximize placebo effectMaximize placebo effect

The CasesThe Cases

• Severe dirty “road rash” Severe dirty “road rash” traumatic injuriestraumatic injuries in in 16 year old boy skateboarder who did one too 16 year old boy skateboarder who did one too many flipsmany flips

• Progressive, diffuse severe Progressive, diffuse severe abdominal painabdominal pain in in a 72 year old man a 72 year old man

• Severe sudden onset Severe sudden onset headacheheadache associated associated with vomiting in a 28 year old womanwith vomiting in a 28 year old woman

• Acute pain crisis in a 34 year old patient with Acute pain crisis in a 34 year old patient with sickle cellsickle cell disease disease

MythsMyths

• You can assess severity of pain by looking at the You can assess severity of pain by looking at the patient and the vital signspatient and the vital signs

• Fear of adverse reactionsFear of adverse reactions Rare and generally preventableRare and generally preventable

• Fear of masking critical clinical findingsFear of masking critical clinical findings Questionable and unlikely if judgement usedQuestionable and unlikely if judgement used

• Fear of inducing addictionFear of inducing addiction Rate of 1/3,000 pts in Boston studyRate of 1/3,000 pts in Boston study

• Patients will request pain medication if they need itPatients will request pain medication if they need it 70% of pts will not request Tx despite pain70% of pts will not request Tx despite pain

• IM treatment saves time and moneyIM treatment saves time and money

Who are you?Who are you?

a)a) Emergency nurseEmergency nurse

b)b) Other nurseOther nurse

c)c) PhysicianPhysician

d)d) ResidentResident

e)e) EMTEMT

f)f) Medical studentMedical student

g)g) OtherOther

Do you think EDs do a good job treating pain?Do you think EDs do a good job treating pain?

a)a) YesYes

b)b) NoNo

If If youyou present to the ED, how long is reasonable present to the ED, how long is reasonable before before youyou receive your first dose of analgesic? receive your first dose of analgesic?

a)a) 10 minutes10 minutes

b)b) 30 minutes30 minutes

c)c) 60 minutes60 minutes

d)d) 120 minutes120 minutes

Do you think there is a role for complimentary Do you think there is a role for complimentary medicine in ED practice?medicine in ED practice?

a)a) YesYes

b)b) NoNo

16 yo skate boarder; flipped going down hill and skidded 30 16 yo skate boarder; flipped going down hill and skidded 30 feet. Severe pain in face and arm with deformity of arm. feet. Severe pain in face and arm with deformity of arm.

Denies LOC, amnesia, headache, neck painDenies LOC, amnesia, headache, neck pain

EMSEMS

• The patient is in severe pain with transport time of The patient is in severe pain with transport time of 35 minutes35 minutes What are the primary prehospital concerns?What are the primary prehospital concerns? Should this patient be given analgesia during Should this patient be given analgesia during

transport?transport?

ED TriageED Triage

• When the patient arrives in the ED, how is his pain When the patient arrives in the ED, how is his pain assessed?assessed?

• How often should his pain be reassessed? How often should his pain be reassessed? • What are the initial nursing concerns in managing What are the initial nursing concerns in managing

this patient?this patient?

What would be your first line treatment for this What would be your first line treatment for this patient’s pain?patient’s pain?

a)a) Tylenol poTylenol po

b)b) Motrin poMotrin po

c)c) Torodol IMTorodol IM

d)d) Percocet poPercocet po

e)e) Morphine IVMorphine IV

f)f) Fentanyl IVFentanyl IV

Do you agree with nurse initiated Do you agree with nurse initiated administration of narcotics for acute pain?administration of narcotics for acute pain?

a)a) YesYes

b)b) NoNo

ManagementManagement

• How would you recommend pain control for How would you recommend pain control for debriding / cleaning this patient’s wounds?debriding / cleaning this patient’s wounds?

• Is there a role for comlimentary medicine adjuncts Is there a role for comlimentary medicine adjuncts or other nonpharmacologic approaches?or other nonpharmacologic approaches?

AnalgesicsAnalgesics

• Acetaminophen: no antiplatelet effect, no anti-inflammatory Acetaminophen: no antiplatelet effect, no anti-inflammatory effect; acts in CNSeffect; acts in CNS

• NSAIDSNSAIDS Inhibit prostaglandin synthesis by interfering with Inhibit prostaglandin synthesis by interfering with

cyclooxygenase (COX) enzymescyclooxygenase (COX) enzymes Cause platelet dysfunctionsCause platelet dysfunctions Can impact renal functionCan impact renal function Increase risk of GI bleedingIncrease risk of GI bleeding COX-2 agents preferentially inhibit the COX-2 enzyme COX-2 agents preferentially inhibit the COX-2 enzyme

that is induced by inflammatory stimuli and is responsible that is induced by inflammatory stimuli and is responsible for the activation and sensitization of nociceptorsfor the activation and sensitization of nociceptors

NonsteroidalsNonsteroidals

• Are NSAIDS contraindicated in trauma / perioperative Are NSAIDS contraindicated in trauma / perioperative patientspatients

• Do NSAIDs interfere with bone healingDo NSAIDs interfere with bone healing• Is IM or IV ketoralac better than po NSAISSIs IM or IV ketoralac better than po NSAISS

Toradol is contraindicated as prophylactic analgesic Toradol is contraindicated as prophylactic analgesic before any major surgery, and intraoperatively before any major surgery, and intraoperatively whenever hemostasis is criticalwhenever hemostasis is critical11

Does have significant antiplatelet effects in clinical trialsDoes have significant antiplatelet effects in clinical trials22

• Large case-control study did not show increased bleeding Large case-control study did not show increased bleeding when given peri-op to surgical patientswhen given peri-op to surgical patients33

NSAIDs in PerspectiveNSAIDs in Perspective

• No NSAID has been proven significantly more No NSAID has been proven significantly more efficacious than another, when given in equivalent efficacious than another, when given in equivalent dosesdoses Select agents based on toxicity profiles?Select agents based on toxicity profiles? Side-effect rates generally parallel half-life Side-effect rates generally parallel half-life

profilesprofiles• Patient response can vary between agentsPatient response can vary between agents

Multiple categories of agentsMultiple categories of agents• No difference in efficacy by mode of administrationNo difference in efficacy by mode of administration

Progressive, diffuse severe Progressive, diffuse severe abdominal painabdominal pain in in a 62 year old mana 62 year old man

• History of hypertension, History of hypertension, hyperlipidemia, smoking, hyperlipidemia, smoking, diabetesdiabetes

• Pain began 2 days prior Pain began 2 days prior and has been progressive and has been progressive with some localization in with some localization in the right lower quadrantthe right lower quadrant

• VS at triage: 140/90, 80, VS at triage: 140/90, 80, 16, pulse ox 98%16, pulse ox 98%

• Overall looks well Overall looks well

How would this patient be triaged and where would How would this patient be triaged and where would he be placed in the ED?he be placed in the ED?

On exam the patient has significant diffuse On exam the patient has significant diffuse tenderness with rebound; stool is guaiac negtenderness with rebound; stool is guaiac neg

• What is the differential diagnosisWhat is the differential diagnosis• Surgery is called; a CT is orderedSurgery is called; a CT is ordered

• Should this patient receive pain medication while Should this patient receive pain medication while waiting for the evaluation to be completedwaiting for the evaluation to be completed

a)a) YesYes

b)b) NoNo

OpioidsOpioids

• Agonists: Agonists: Rule of tenRule of ten

0.1mg fentanyl 0.1mg fentanyl (Duragesic)(Duragesic)

1 mg hydromorphone 1 mg hydromorphone (Dilaudid)(Dilaudid)

10 mg morphine10 mg morphine 100 mg meperidine 100 mg meperidine

(Demoral)(Demoral) Codeine (metabolized to Codeine (metabolized to

morphine / high nausea)morphine / high nausea) MethadoneMethadone Oxycodone (Oxycontin)Oxycodone (Oxycontin) Oxymorphone (Numorphan)Oxymorphone (Numorphan)

• Agonists – AntagonistsAgonists – Antagonists High dysphoria rates)High dysphoria rates) Ceiling analgesia and Ceiling analgesia and

respiratory depressionrespiratory depression Buprenorphine (Buprenex)Buprenorphine (Buprenex) Butorphanol (Stadol)Butorphanol (Stadol) Nalbuphine (Nubain)Nalbuphine (Nubain) Pentzocine (Talwin)Pentzocine (Talwin)

• OtherOther Tramadol (Ultram)Tramadol (Ultram)

Weak binding to the opiate Weak binding to the opiate receptorreceptor

Inhibits reuptake of both NE Inhibits reuptake of both NE and 5-HTand 5-HT

Opioids: Meperidine (Demerol)Opioids: Meperidine (Demerol)

• Many EDs no longer stock it Many EDs no longer stock it Metabolism prolonged in renal or Metabolism prolonged in renal or

hepatic diseasehepatic disease Metabolite (normeperidine) is a CNS Metabolite (normeperidine) is a CNS

toxintoxin Can induce the Serotonin SyndromeCan induce the Serotonin Syndrome

• Highest rate of associated euphoriaHighest rate of associated euphoria Problematic patients often request itProblematic patients often request it

Opioids: New strategiesOpioids: New strategies

• Less meperidine and morphineLess meperidine and morphine• Early, rapid control with fentanylEarly, rapid control with fentanyl

Titrate IVTitrate IV Limit total doseLimit total dose

• Maintenance with hydromorphoneMaintenance with hydromorphone Start 5 -30 minutes laterStart 5 -30 minutes later Well toleratedWell tolerated No maximum doseNo maximum dose

Severe sudden onset Severe sudden onset headacheheadache associated associated with vomiting in a 28 year old womanwith vomiting in a 28 year old woman

• History of migrainesHistory of migraines• No new medicationsNo new medications• Vital signs: 110/70, 60, Vital signs: 110/70, 60,

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• How would this patient How would this patient be triaged?be triaged?

Which of the following is first line treatment for Which of the following is first line treatment for treating acute severe migraine?treating acute severe migraine?

a)a) Prochlorperazine (compazine)Prochlorperazine (compazine)

b)b) Ketorolac (torodol)Ketorolac (torodol)

c)c) MorphineMorphine

d)d) FentanylFentanyl

e)e) Tramadol (ultram)Tramadol (ultram)

Centrally acting agentsCentrally acting agents

• 5HT receptor modulators5HT receptor modulators PhenothiazinePhenothiazine TriptansTriptans

• TricyclicsTricyclics• CarbamazepineCarbamazepine• GabapentinGabapentin• Valproic acidValproic acid

Pain Therapy: Point InjectionsPain Therapy: Point Injections

• ““Trigger” or other point injections may represent an Trigger” or other point injections may represent an attractive and viable option in selected patientsattractive and viable option in selected patients

Lower cervical injections for headache relief. Lower cervical injections for headache relief. Mellick GA, Mellick LB. Headache 2001.41(10): 992Mellick GA, Mellick LB. Headache 2001.41(10): 992

Pericranial injection of local anesthetics in the Pericranial injection of local anesthetics in the ED management of resistant headachesED management of resistant headaches

Brofeldt, Panacek. Acad Emer Med. 1998.Brofeldt, Panacek. Acad Emer Med. 1998.

Acute pain crisis in a 34 year old patient with Acute pain crisis in a 34 year old patient with sickle cellsickle cell disease disease

• Acute pain crisis in a Acute pain crisis in a 34 year old patient 34 year old patient with with sickle cellsickle cell disease disease

• Pain in all joints similar Pain in all joints similar to past crisesto past crises

• No preceeding illnessNo preceeding illness• Requests IV Dilaudid 4 Requests IV Dilaudid 4

mgmg

Acute on Chronic PainAcute on Chronic Pain

• What is the current best practice strategy in What is the current best practice strategy in managing sickle cell painmanaging sickle cell pain

• Is there a role for continuous infusion pumps in Is there a role for continuous infusion pumps in the EDthe ED

• Is there a role for alternative medicine Is there a role for alternative medicine approaches to modulating chronic pain approaches to modulating chronic pain syndromessyndromes

Future directionsFuture directions

• Improve nurse and physician understanding of Improve nurse and physician understanding of mechanisms of painmechanisms of pain Improve clinician / patient communicationImprove clinician / patient communication

• Improve strategies for choosing the right Improve strategies for choosing the right intervention for the right patientintervention for the right patient

• Well designed comparative clinical trialsWell designed comparative clinical trials• Improve analgesic delivery systemsImprove analgesic delivery systems• Improve strategies for providing a continuum of Improve strategies for providing a continuum of

pain management after discharge from the EDpain management after discharge from the ED

Key Learning PointsKey Learning Points

• Management of pain must be placed in the context of the Management of pain must be placed in the context of the clinical presentationclinical presentation Acute vs chronic; nociceptive vs neuropathicAcute vs chronic; nociceptive vs neuropathic Underlying mechanism of pain impacts approach to Underlying mechanism of pain impacts approach to

managing the painmanaging the pain• Treatment should not be delayed pending a diagnosisTreatment should not be delayed pending a diagnosis• IV titration is generally the preferred approach for severe acute IV titration is generally the preferred approach for severe acute

painpain Treat early, front-load, around the clockTreat early, front-load, around the clock Acute management must be linked to the continuum of careAcute management must be linked to the continuum of care

• Opioids are not always best and NSAIDs are not benignOpioids are not always best and NSAIDs are not benign• Non-pharmacologic mangementment and anxiolysis play an Non-pharmacologic mangementment and anxiolysis play an

important role in the pain responseimportant role in the pain response