Transcript of Case Studies In Pain Management - templefmr2020online.com
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PC5-lee-painmanagementcases-narrated-fmr20f-09082020Seung J. Lee MD
MBA University of Maryland
School of Medicine Department of Anesthesiology
Division of Pain Medicine
Disclaimer
Dr. Seung J. Lee, MD, MBA does not have any financial conflict to
disclose for this presentation
This presentation is intended to provide educational information
related to pain management strategies by case presentations
The speaker is not promoting any particular services or
products
Objectives
Following the presentation, the participants should be able
to:
1. Recognize red flags of low back pain 2. Formulate a multi-modal
analgesia plan 3. Differentiate between CRPS 1 and CRPS 2 4. Set
proper expectations for opioid therapy
PAIN CASE #1
History of Present Illness
J.H. is a 50-year-old man with low back pain worsened by activity –
Pain stays mostly on his back – No weakness, incontinence or
numbness – Pain started after two weeks ago and has been
intermittently
severe since then – He isn’t sleeping well, and his appetite is
poor
Previously, he has taken oxycodone for this pain and is asking you
to prescribe some today
Pain Assessment
What else would you like to know?
How is it impairing his functioning? What else has he tried? Who
prescribe oxycodone? Red Flag Findings
Rule out serious underlying illness
Recent Trauma?
Fever? Signs/symptoms of cancer of the prostate/bowel/lung?
You want to be sure he doesn’t have a primary spinal tumor,
infection or metastatic lesion
RED FLAGS?
Physical Exam
Appears to be in discomfort when rising from a chair
Straight leg raise negative
No neurologic deficits
Wren, Anava et al (2019) Tompkins, D., Hobelmann, J., &
Compton, P. (2017).
Recommendations
Reassurance: most back pain will resolve Advise return to normal
activities with gentle exercise
NSAIDS Referral to Physical Therapy
Gentle Exercise
• Swimming and walking are good options
• Tai Chi and qigong are other possibilities. They may be
particularly good choices to help manage stress
The patient is unhappy with the recommendations
Already taking NSAIDs and Tylenol OTC
The patient is reluctant to do PT due to the pain
YOUR PATIENT INSISTS THAT YOU “GET RID OF ALL THIS PAIN.” HOW WOULD
YOU
RESPOND TO THIS STATEMENT?
YOUR PATIENT INSISTS THAT YOU “GET RID OF ALL THIS PAIN.” HOW WOULD
YOU
RESPOND TO THIS STATEMENT?
Focus on function, not pain elimination
You would like to redirect the patient away from a goal of total
elimination of pain, towards a focus on functioning
Find out what he cannot do now because of his pain and make that to
be the goal of treatment.
I STILL NEED SOMETHING DONE TODAY!!
What else can we offer the patient today? Imaging studies?
Acupuncture? Referrals to surgeon/pain center? Opioids? Muscle
relaxants?
MRI of LS
North American Spine Society – Do not recommend advanced
imaging (e.g., magnetic resonance imaging) of the spine within the
first six weeks in patients with nonspecific acute low back pain in
the absence of red flags.
Acupuncture
YES
Has been shown to be effective in the treatment of back pain
The acupuncturist can also address stress/anxiety/depression
Opioids: oxycodone 1-2 tabs every 4 hours • NO • Short-term
effectiveness for pain relief and functioning, but
long-term effectiveness and safety are unclear • Do conservative
therapy first
Muscle Relaxants
YES
More effective pain relief and global efficacy in acute nonspecific
low back pain when compared with placebo
Cyclobenzaprine 5 mg three times per day as needed for two
weeks
Avoid benzodiazepines
AFTER 2 MONTHS OF PT, THE PATIENT CONTINUES TO HAVE
PAIN. HE HAS BEEN EVALUATED BY TWO NEUROSURGEONS
Surgical evaluation
Neurosurgery 2nd opinion recommended trial of continuing physical
therapy
Why do the 2 neurosurgeons disagree?
The surgical treatment of chronic back pain with no neurological
dysfunction is controversial
Patients should always get several neurosurgical opinions before
undergoing surgery in this circumstance
Work up
Lumbar MRI reveals multiple bulging disks and a central disk
herniation at L5-S1
His MRI makes it clear that surgery is indicated? Herniated discs
do not
necessarily need to be surgically treated, – Particularly if there
are
no neurologic deficits – Especially for axial pain
only
MRI results correspond poorly with pain
People with markedly abnormal MRIs can have no pain and people with
normal MRIs can have pain
However, in this case, if the patient has lumbar radiculopathy
symptoms, then the MRI may be correlating with his symptoms
Still continues to have pain after 4 months Consider referring him
to a multidisciplinary pain
management center
Case Scenario
22-year-old female come to the ER with Right ankle pain – Multiple
admission in past – History of drug abuse
Urine toxicology -positive for opioid (heroine) and cocaine
– Urine pregnancy test Negative
H&P
H&P Physical examination
HR 120, BP 140/89 Obvious right ankle deformity Otherwise exams
were within normal limit Ortho consult done. Imaging study
ordered.
What would be good pain medications for this patient in ER?
– Toradol 30 mg IV q6h – IV/PO Opioid therapy – Tylenol –
Gabapentin – Methadone – Ketamine – Lidoderm patch
Acute Post-Operative Pain
Wren, Anava & Ross, Alexandra & D’Souza, Genevieve &
Almgren, Christina & Feinstein, Amanda & Marshall, Amanda
& Golianu, Brenda. (2019)
Pain Treatment Plan Maintain baseline opioid, after
verification(?) with caution
Consider multi-modal analgesia
Gabapentinoids
– basal rate
Treatment - PCA
Opioid Use and Transition
24-hour Use – Day 1: 38 mg – Day 2: 34 mg – Day 3: 20 mg
Day 4: Transition to Oral Oxycodone 10- 20 mg every 4 hours as
needed
The Patient Comes To Your Office, Asking To Continue Her
Discharge
Medications Oral Oxycodone 10 - 20 mg every 4 hours as
needed Gabapentin 300 mg three times per day
Naproxen 500 mg twice per day
Who is responsible for the opioid medications?
Surgical Team
Pain Management Team
Primary Care Physician
The patient states that she needs her medication today. She is
afraid of going
through withdrawal from opioid. She was told by the surgical team
to come and get the
medication from the primary care physician.
Too high dose of opioid?
The patient is taking 20mg four times per day Oxycodone 80 mg = 120
mg of morphine
CDC Guideline Recommendation 5 Clinicians should avoid using dosage
to ≥90 MME/day
Guideline’s scope NOT INTENDED FOR
active cancer treatment Patients experiencing acute sickle cell
crises Patients experiencing post-surgical pain
Intended for primary care clinicians treating chronic pain for
patients 18 and older
So what now? Should you give opioid medications to
the patient?
It is up to the individual providers and situations
Considerations
– Expectation Management – Safety of providing opioid medications
with the patient
Family member’s involvement
– Naloxone Rx – One-month Rx of oxycodone – Refer to addiction
program – Opioid Titration
Expectation Management CDC Recommendation 2 Clinicians should
establish
treatment goals with all patients
Clinicians should consider how opioid therapy will be discontinued
if benefits do not outweigh risks
(recommendation category: A, evidence type: 4)
Safety of providing opioid medications to the patient
Family member’s involvement
CDC Recommendation 8 – Intra-nasal Naloxone Is an opioid antagonist
that can
reverse severe respiratory depression
Considering offering naloxone when factors that increase risk for
opioid overdose
– history of overdose – history of substance use
disorder – higher opioid dosages (≥50
MME/day) – concurrent benzodiazepine use
times per day?
For patients with opioid use disorder
Clinicians should offer or arrange evidence-based treatment
(usually medication- assisted treatment with buprenorphine or
methadone in combination with behavioral therapies)
Opioid Titration CDC Recommendation 7
Rapid Taper
– reducing weekly dosage by 10%–50% of the original dosage
– Ultrarapid detoxification under anesthesia is associated with
substantial risks, including death, and should not be used
Slow Taper
Experts noted that tapers slower than 10% per week (e.g., 10% per
month) also might be appropriate and better tolerated than more
rapid tapers
SIX MONTH AFTER THE OPERATION, THE PATIENT HAS SIGNIFICANT ANKLE
PAIN.
Why does she still have pain? What would be next steps?
The patient complains of
• Allodynia • Hyperalgia • Edema • Abnormal hair growth • Abnormal
skin color changes • Abnormal skin temperature (> or < 1 C) •
Limited range of movement • Motor neglect
CRPS Criteria
Complex Regional Pain Syndromes
Pain and sensory changes disproportionate to the injury in
magnitude or duration
Only difference between types is the cause. Type II is known
previously as Causalgia.
CRPS
management Sympathetic Blocks Spinal Cord Stimulator Intrathecal
pump
CRPS Treatments
PT PT
Mirror Therapy
Lesser Used agents – IV immunoglobulin – Calcitonin –
Bisphosphonate – Low dose oral naltrexone? – Subanesthetic
ketamine
METHADONE
Methadone Advantages Potency
– May control pain even when large doses of other opioids
failed
Infrequent dosing – is intrinsically long acting
Works for neuropathic pain Usable in renal failure Low cost
Methadone Disadvantages
Can cause potentially dangerous over-sedation
Difficult equal-analgesic conversion Can only increase dose every 5
days Don’t use if QT is prolonged – can cause Torsades
Methadone: Conversion
Schuster, Michael, Oliver Bayer, Florian Heid, and Rita Laufenberg-
Feldmann. 2018. “
Methadone – big picture
• Very effective and good for mixed somatic & neuropathic
pain
• Builds up so can cause over-sedation (potentially fatal) days
after you increased the dose
• Challenging to manage at first – be sure to get help from an
experienced colleague when first using methadone
Lumbar Sympathetic Block
vicious sympathetic hyperactive feedback, these blocks along with
physical therapy and medication help restore normal limb
function
Spinal Cord Stimulation
Spinal cord stimulator (SCS) is a device, which delivers low
voltage electrical stimulation to the spinal cord
Replace the sensation of pain with a tingling sensation
CHRONIC PAIN CASE #3
Case 3
A 27-year-old woman who underwent emergency C-section in 2014 under
general anesthesia after failed neuraxial block, who developed a
non-healing wound infected with Pseudomonas
Workup revealed that she had a previously undiagnosed
immunodeficiency disorder diagnosed as common variable immune
deficiency IgG for which she receives IVIG therapy every 3
weeks
Case 3
The patient states she has had multiple revision surgeries and
multiple admissions for abdominal infection over the past 5
years
She recently had a motor vehicle accident on New Year's Eve and
then admitted to University of Maryland Medical Center on January
2nd and discharged January 8th. Her prior admission was about 5
weeks ago
Case 3
PAST MEDICAL HISTORY: Consists of chronic abdominal wound
infection; status post emergency C-section in 2014; common variable
immune deficiency, IgG, receiving IVIG therapy every 3 weeks;
asthma; hypertension; anxiety; depression; endometriosis
Case 3
SIGNIFICANT OPERATIVE HISTORY: Multiple I and D's from October 9th
to present of the abdominal wound; C-section; appendectomy,
September 2002; cholecystectomy; PICC insertion with removal on
01/07/2020
Case 3
CURRENT MEDICATIONS:
Ambien 10 mg once ciprofloxacin 750 mg Colace 100 mg doxycycline
100 mg hydrochlorothiazide 12.5 mg ibuprofen 800 mg IVIG
injection
lisinopril 20 mg multivitamin ondansetron 4 mg oxycodone immediate
release
15 mg QID OxyContin ER 40 mg 2 times
daily Tylenol 1000 mg Xanax 1 mg TID RRN
Case 3
PDMP Review from December 2019 to beginning of January 2020
OxyContin 40 mg 21 tablets Percocet 5/325 110 tablets OxyIR 15 118
tablets OxyIR 5 mg 130 tablets 155 tablets of 1 mg Xanax 70 tablets
of 0.5 mg Xanax
Case 3
The patient was informed of our University practice and our
multimodal nature of it. Due to patient's opioid prescription
history, the patient was informed that we would not be able to
continue any opioid medication at this time
The patient was informed of our some of interventional therapeutic
options. The patient is going to IVIG treatment; however, the
patient still has an open wound. Therefore, the patient may be a
candidate about 6 months after the infection has healed
CHRONIC PAIN CASE #4
Case 4
Patient is 58-year-old who presents to clinic complaining of lower
back pain which radiates into his right groin
The pain is in the lower back, it is shooting, feels like being
stabbed with a hot poker, it is also sharp and it shoots his groin.
Denies any burning sensation. Endorses cramping in his right leg.
Denies numbness, tingling, and weakness
Case 4
Currently the patient is not receiving any medications, so the
patient is using intravenous heroin to help with this pain, using
every few days
Both the patient and the patient's family expressed frustration
about getting the health care and the medical management for the
patient since the opioid medication worked for the patient. The
patient states that due to the inadequate treatment of pain, the
patient must utilize street drugs
Case 4
PAST MEDICAL HISTORY: Hepatitis C, per the family he has end-stage
liver disease. Patient also has bronchitis, chronic obstructive
pulmonary disease, spinal stenosis
ALLERGIES: Skelaxin, recently in the hospital it gave him some
delirium
MRIs, which showed diskitis and osteomyelitis with phlegmon
formation, right psoas. Per record review, ESR and biopsy were
negative for the active infection at this time
Case 4
So what would you do for this patient? What is the opioid risk? Is
the patient appropriate for opioid medications?
Opioid Risk Tool
Case 4
If the patient's life expectancy is less than six 6 months, then we
will pursue palliative care/hospice care for the patient
https://www.lmhpco.org/palliative-care
Case 4
If patient's life expectancy is longer, then we will use the active
addiction treatment options which include involvement of an
addictionologist as well as outpatient maintenance program,
methadone or Suboxone
If the patient has been stable for three to six months with the
stabilization of his active addiction issue, then we can consider
chronic opioid therapy
CHRONIC PAIN CASE #5
Case 5
39-year-old female with a history of chronic low back pain status
post laminectomy and lumbar fusion at L5-S1, sarcoidosis,
fibromyalgia, bilateral lower extremity pain, and shoulder
pain
The patient returns today for follow-up complaining of pain that is
constant, aching and dull with a burning sensation, especially in
the thoracic area of the back. She rates the pain 8/10 in
intensity
Case 5
She notes improvement in her ability to perform activities of daily
living because the sarcoid is now more stable and she is not
coughing as much. She states that her energy levels are beginning
to return to normal
Case 5
Currently, her medications consist of methadone 5 mg every eight
hours and Percocet 10/325 mg up to five times a day as needed
Overall, her analgesia is the same but she is able to breathe
better which makes her feel better overall. The patient denies any
nausea, sedation, constipation, itching, diarrhea or vomiting
related to her medications
Case 5
What is morphine equivalent per day?
Are you concerned about the dose?
What is your recommendation?
CDC Opioid Conversion Chart
A major flaw with the CDC calculator is the methadone to morphine
conversion, as the conversion is neither linear nor bidirectional
due to the unique and complex pharmacokinetics of methadone.
Fudin, J., Raouf, M., Wegrzyn, E. L., & Schatman, M. E. (2018).
Safety concerns with the Centers for Disease Control opioid
calculator. Journal of Pain Research, 11, 1–4.
Case 5
What do you think about the dose?
What is morphine equivalent per day? 60mg from methadone 15 mg per
day 75 mg from oxycodone 50 mg per day
Are you concerned about the dose?
What is your recommendation?
Case 5 – Pain Psychology
SUBSTANCE ABUSE HISTORY: The patient denies any lifetime use of
illicit drugs, alcoholism, or opioid abuse. She also denies any
lifetime history of intravenous drug abuse
The opioid risk assessment places the patient within the low risk
classification. As a result, the patient is treated with chronic
opioid therapy. She would benefit from intermittent psychological
review to reassess risk factors or emergence of high-risk
behavior
Opioid Risk Tool
References
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing
Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep
2016;65(No. RR-1):1–49.
Oliveira, C., Maher, C., Pinto, R., Traeger, A., Lin, C., &
Chenot, J. et al. (2018). Clinical practice guidelines for the
management of non-specific low back pain in primary care: an
updated overview. European Spine Journal, 27(11), 2791-2803.
Qaseem, A., Wilt, T., McLean, R., & Forciea, M. (2017).
Noninvasive Treatments for Acute, Subacute, and Chronic Low Back
Pain: A Clinical Practice Guideline From the American College of
Physicians. Annals Of Internal Medicine, 166(7), 514.
Perez, R., Zollinger, P., Dijkstra, P., Thomassen-Hilgersom, I.,
Zuurmond, W., Rosenbrand, K., & Geertzen, J. (2010). Evidence
based guidelines for complex regional pain syndrome type 1. BMC
Neurology, 10(1). doi:10.1186/1471-2377-10-20
Complex regional pain syndrome in adults (2nd edition). (2018).
Royal College of Physicians London. Retrieved 22 February 2020,
from https://www.rcplondon.ac.uk/guidelines-
policy/complex-regional-pain-syndrome-adults
References
Richebé, P., Brulotte, V., & Raft, J. (2019). Pharmacological
strategies in multimodal analgesia for adults scheduled for
ambulatory surgery. Current Opinion In Anaesthesiology, 32(6),
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Treillet E, Laurent S, & Hadjiat Y. (2018). Practical
management of opioid rotation and equianalgesia. Journal of Pain
Research, 2587.
Schuster, Michael, Oliver Bayer, Florian Heid, and Rita
Laufenberg-Feldmann. 2018. “Opioid Rotation in Cancer Pain
Treatment: A Systematic Review.” Deutsches Aerzteblatt
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