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