Managing Acute Non-Cancer Pain in the Hospital · Managing Acute Non-Cancer Pain in the Hospital...

ManagingAcuteNon-CancerPainintheHospital

October21,20171

RamanaK.Naidu,MDDirectorofPainManagementatMarinGeneralHospitalMtTamOrthopedics&[email protected]

mailto:[email protected]

RamanaK.Naidu,MDhasdisclosedrelationshipswithanentityproducing,marketing,reselling,ordistributinghealthcaregoodsorservicesconsumedby,orusedon,patients.

Speaker’sBureauHalyardHealthAbbott

DisclosuresofFinancialRelationships

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BLISSFULINSENSATION?CONGENITALINSENSITIVTYTOPAIN

DENTALABSCESSESCORNEALABRASIONSBONEFRACTURES

INFECTIONS

HeckertJ.TheHazardsofGrowingUpPainlessly.NYTimesMagazine.Nov15,2012.

Thephilosophicaldichotomyofacutepain…

SufferingDepressionHelplessness

WarningSignalAvoidanceReminder

Healing

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Definitions

Pain:anunpleasantsensoryandemotionalexperienceassociatedwithactualorpotentialtissuedamage,ordescribedintermsofsuchdamage.

AcutePain:•Painthatislimitedtotheexpectedperiodofhealing.•Temporaldefinitionsvary.<1month.<3months.<6months.SubacutePain:•Atransitionalperiodbetweenacuteandchronicpainwhereoneisconcernedtheacutepainisbecomingpersistent.

•Temporaldefinitionsvary.1-6months.ChronicPain:•Painthatpersistsbeyondtheexpectedperiodofhealing.•Temporaldefinitiionsvary.>3months.>6months.

Merskey,H.(1964),AnInvestigationofPaininPsychologicalIllness,DMThesis,Oxford

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Trauma•BoneFractures•Burns•Weapons

Surgery

AcuteMedicalIllness•DentalCaries• InfectiousSequelae•Lumbago•Headache•AbdominalPain

TypesofAcuteNon-CancerPain

Rice,A.S.C.,Smith,B.H.&Blyth,F.M.Painandtheglobalburdenofdisease.Pain157,791–6(2016).

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Trauma•BoneFractures•Burns•Weapons

Surgery

AcuteMedicalIllness•DentalCaries• InfectiousSequelae•Lumbago•Headache•AbdominalPain

TypesofAcuteNon-CancerPain

Rice,A.S.C.,Smith,B.H.&Blyth,F.M.Painandtheglobalburdenofdisease.Pain157,791–6(2016).

Globalburdenofdisease:Pain4.3%ofthetheworld’spopulationisfreeofdisease,injury,orsequelae.

GlobalprevalenceofDentalCaries:2.4billionindividuals

GlobalprevalenceofTension-TypeHeadaches:1.6billionindividuals

Greatestcauseofyearslivedwithdisabilityis:Lowbackpain

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Doweneedtotreatormanageoracutenon-cancerpain?

Rich,B.Physicians’legaldutytorelievesuffering.West.J.Med.175,151–2(2001).

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Consequencesofuntreated/unmanagedacutepainforthepatient:•Autonomicchanges•Endocrinologicalchanges:increasedcortisol,insulinresistance,etc.•Psychologicaldistress•Developmentofchronicpain—>alloftheabove

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*end-of-lifecancerpaincases

Consequencesofuntreated/unmanagedpainfortheprovider:•Empatheticdistress•Ethicalconsequences

• IASPDeclarationofMontréal•LegalConsequences

• James,1991,NorthCarolina*•Chin,1998,California*

•Whatisstandardofcareinpainmanagementtoday?•Whatisthegoalofacutepainmanagement?


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*end-of-lifecancerpaincases

Consequencesofuntreated/unmanagedpainfortheprovider:•Empatheticdistress•Ethicalconsequences

• IASPDeclarationofMontréal•LegalConsequences

• James,1991,NorthCarolina*•Chin,1998,California*

•Whatisstandardofcareinpainmanagementtoday?•Whatisthegoalofacutepainmanagement?


1. Managepain2. Preventchronification

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Surgery…predictedtrauma…animpactfulacutepainmodel

SURGERY ACUTE

TRANSITIONSINCARE&TRANSITIONSINPAIN

PRE INTRA POST POST-DISHCARGE8


ACUTE CHRONICChronificationSURGERY

SURGERY ACUTE





ACUTESURGERY

SURGERY ACUTE





ACUTESURGERY

SURGERY ACUTE

CHRONICSURGERY CHRONICACUTE



PROCEDURE ApproxIncidencePPSP

ApproxIncidenceofSeverePPSP

ApproxNumberofCasesAnnuallyinUSA

ApproxMaximalNumberofPatientsatRiskforPPSPperyear

LowerLimbAmputation

30-80% 5-10% 159,000 127,000

Sternotomy 30-50% 5-10% 598,000 299,000

Thoracotomy 30-40% 10% 280,000 112,000

BreastSurgery 20-30% 5-10% 479,000 144,000

InguinalHerniorraphy 10-50% 2-4% 609,000 304,000

TotalHipReplacement

12-28% 5% 400,000 112,000

TotalKneeReplacement

8-13% 5% 605,000 78,000

CesareanSection 10% 4% 220,000 22,000

PersistentPost-SurgicalPain(PPSP)

NationalInpatientSample(NIS)2007Datahttp://www.hcup-us.ahrq.gov/nisoverview.jspKehletetal.TheLancet.2006

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http://www.hcup-us.ahrq.gov/nisoverview.jsp

acutepost-operativepainpre-operative

pain

chronicorpersistent

post-operative

pain

surgicaltechnique

anesthetictechnique

psychology

genetics

age

adjuvantanalgesicsanti-hyperalgesicsregionalanesthesia

nerve-sparingtechniqueinfectionprevention

anxiety depressioncatastrophization

ModifiedfromMacrae

PersistentPost-SurgicalPain(PPSP)

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AnalgesiavsHyperalgesia

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COX-Inhibitors

Acetaminophen

Alpha-2Agonists

Lidocaine

Low-doseKetamine

Magnesium

AnalgesiaNOanti-hyperalgesia

AnalgesiaBUTHyperalgesia

Opioids

Anti-HyperalgesiaNOanalgesia

RegionalAnesthesia

AnalgesiaandAnti-Hyperalgesia

AnalgesiavsAnti-Hyperalgesia

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Themanagementofpainmustinvolvebothanalgesiaandanti-hyperalgesia

Analgesiawilladdressacutephysiologicalandpsychologicaladverseeffects.

Anti-hyperalgesiawilladdressthechronificationofpainandtheresultantlongdurationofphysiologicalandpsychologicaladverseeffects.

Pearl:AnalgesiavsAnti-Hyperalgesia

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OverviewofAnatomy:PathologicalNociception

PeripheralsensitizationDorsalRootGanglion(DRG)modulation

DorsalHorn:RexedLaminaeII,V

Descendingfacilitation

AttenuationofDescendingInhibition

Sympatheticresponse

Emotionalresponse

Memoryformation

TissueChemokines

Centralsensitization

Hypothalumus-Pituitary-Adrenalresponse

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Basbaum,A.I.,Bautista,D.M.,Scherrer,G.&Julius,D.CellularandMolecularMechanismsofPain.Cell139,267–284(2009).

BiologicalPharmacologics:Opioids

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BiologicalPharmacologics:Opioids.Americatoday.

•Americansconstitute4.6%oftheworld’spopulationandconsumeapproximately80%oftheworld’sopioids.

• Americansconsume99%oftheworld’shydrocodone

• ThereareenoughprescribedopioidsforeachAmericantotakeaprescriptionopioidevery4hoursforamonth.

• Estimated2.1millionAmericanswithprescriptionopioidsubstanceusedisorderin2012

• Estimated467,000addictedtoheroinin2012.

AmericanSocietyofInterventionalPainPhysicians(ASIPP).ManchikantiL,PainPhysicianNationalInstituteonDrugAbuse(NIDA)

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0

15,00

0

30,00

0

45,00

0

60,00

0

Year

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

Natural and Semi-synthetic opioid analgesicsMethadoneSynthetic opioid analgesics excluding methadoneHeroinAll Opioids

NumberofDeathsperyearfromOpioidsintheUnitedStates:2000-2016

Dea

ths

CDCWonderData2000-2015.Poisoning-RelatedDeathsstratifiedbydruggroupingAugust6,2017:https://www.cdc.gov/nchs/data/health_policy/monthly-drug-overdose-death-estimates.pdf

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https://www.cdc.gov/nchs/data/health_policy/monthly-drug-overdose-death-estimates.pdf

BiologicalPharmacologics:OpioidAdverseEffects

HYPOGONADISMIMMUNOSUPPRESSIONINCREASEDFEEDINGINCREASEDGROWTHHORMONEWITHDRAWALTOLERANCE,DEPENDENCEABUSE,ADDICTIONHYPERALGESIAIMPAIRMENTWHILEDRIVING

RESPIRATORYDEPRESSIONNAUSEA/VOMITINGPRURITUSURTICARIACONSTIPATIONURINARYRETENTIONDELIRIUMSEDATIONMYOCLONUSSEIZURES

ADVERSEEFFECTSWITHCHRONICUSE

ADVERSEEFFECTSWITHACUTEUSE

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BiologicalPharmacologics:OpioidAdverseEffects

HYPOGONADISMIMMUNOSUPPRESSIONINCREASEDFEEDINGINCREASEDGROWTHHORMONEWITHDRAWALTOLERANCE,DEPENDENCEABUSE,ADDICTIONHYPERALGESIAIMPAIRMENTWHILEDRIVING

RESPIRATORYDEPRESSIONNAUSEA/VOMITINGPRURITUSURTICARIACONSTIPATIONURINARYRETENTIONDELIRIUMSEDATIONMYOCLONUSSEIZURES

ADVERSEEFFECTSWITHCHRONICUSE

ADVERSEEFFECTSWITHACUTEUSE

Tracknaloxonerespiratorydepressioneventdataatyour

institutionasaqualitymeasure

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BiologicalPharmacologics:Opioid-InducedHyperalgesia(OIH)

ItistheverynotionweshouldNOTuseopioidsinpainmanagementasitleadstoaparadoxicalincreaseinpain.

TheHealth&Retirementlongitudinalcohortsawanincreaseinsevere,moderate,andmildpainfrom1998-2010.

Theoddsofrecoveryfromchronicpainwere4timeshigherfornon-opioidusersthanforchronicopioidusers.

MS,A.&Clark,J.AQualitativeSystematicReview:Opioid-InducedHyperalgesia.Anesthesiology570–587(2006)Sjøgren,P.,Grønbæk,M.,Peuckmann,V.&Ekholm,O.Apopulation-basedcohortstudyonchronicpain:theroleofopioids.Clin.J.Pain26,

763–769(2010)Grol-prokopczyk,H.Sociodemographicdisparitiesinchronicpain,basedon12-yearlongitudinaldata.158,(2017).

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POCKET GUIDE: TAPERING OPIOIDS FOR CHRONIC PAIN*

Follow up regularly with patients to determine whether opioids are meeting treatment goals and whether opioids can be reduced to lower dosage or discontinued.

GUIDELINE FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN

*Recommendations focus on pain lasting longer than 3 months or past the time of normal tissue healing, outside of active cancer treatment, palliative care, and end-of-life care.

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LEARN MORE | www.cdc.gov/drugoverdose/prescribing/guideline.html


IMPROVING PRACTICE THROUGH RECOMMENDATIONS

CDC’s Guideline for Prescribing Opioids for Chronic Pain is intended to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder and overdose. The Guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.

DETERMINING WHEN TO INITIATE OR CONTINUE OPIOIDS FOR CHRONIC PAIN

Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.

Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.

Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.

CLINICAL REMINDERS

• Opioids are not first-line or routine therapy for chronic pain

• Establish and measure goals for pain and function

• Discuss benefits and risks and availability of nonopioid therapies with patient

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POCKET GUIDE: TAPERING OPIOIDS FOR CHRONIC PAIN*

Follow up regularly with patients to determine whether opioids are meeting treatment goals and whether opioids can be reduced to lower dosage or discontinued.


*Recommendations focus on pain lasting longer than 3 months or past the time of normal tissue healing, outside of active cancer treatment, palliative care, and end-of-life care.

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2

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LEARN MORE | www.cdc.gov/drugoverdose/prescribing/guideline.html


IMPROVING PRACTICE THROUGH RECOMMENDATIONS

CDC’s Guideline for Prescribing Opioids for Chronic Pain is intended to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder and overdose. The Guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.

DETERMINING WHEN TO INITIATE OR CONTINUE OPIOIDS FOR CHRONIC PAIN

Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.

Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.

Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.

CLINICAL REMINDERS

• Opioids are not first-line or routine therapy for chronic pain

• Establish and measure goals for pain and function

• Discuss benefits and risks and availability of nonopioid therapies with patient

1.Limitingopioidsdispensedfornewacuteprescriptionsto7days.2.Reducingthedispensationofstrongerandlong-releaseopioids.3.Enhancingpharmacistcounselingfornewopioidpatients.4.Adding750newmedicationdisposalkiosks(doublingthecurrentfootprint)5.Contributing$2millioninadditionalfundstoopioidabusetreatmentcharities.

BiologicalPharmacologics:OpioidsThestandardunitforopioidriskstratification:OralMorphineEquivalents(OMEs,MEQs)

Calculateyourpatient’sOMEspriortoadmission,dailyduringadmission,andmonitortrends.

Useatable,app,spreadsheet,EMR,etc.

Riskassociatedwithoutpatientuseofopioidsisdirectlyrelatedtodailydose.

Acutecanbecomechronic.

Theunitisbecomingpartofregulation.

Dunn,K.M.etal.Overdoseandprescribedopioids :Associationsamongchronicnon-cancerpainpatients.Ann.Intern.Med.152,85–92(2010).

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BiologicalPharmacologics:OpioidsBasicPrinciplesofPatient-ControlledAnalgesia

TIME 22

THERAPEUTIC WINDOW

PLAS

MAOPIOID

CONCE

NTR

ATIO

N

MEAC

TOXICDOSE

LoadingDose

DemandDose

*Encourageuseonlywheninseverepain,andoralrouteofadministrationearly.

BiologicalPharmacologics:OpioidsTransitionsinCare

Whatarethebestpracticesfortransitionsfrominpatienttooutpatientpainmanagement?

Dunn,K.M.etal.Overdoseandprescribedopioids :Associationsamongchronicnon-cancerpainpatients.Ann.Intern.Med.152,85–92(2010).

1) Reiteratethemessagethatthepatientneedstogetoffofopioidssoonerthanlater.Iftheyareonthemforlongerthan7-10days,thereissomething“awry,”andtheyshouldseekexpertopinion.

2) Patientsshouldunderstandhowmuchtheyareon(OMEs)andmonitortrends.

3) Providepatientswithinformationonrisksandbenefitsofuse.

4) Patientsshouldbegiveninformationabouthowcontrolledsubstances1) shouldbelocked/secured2) howtheymaynotbegiventoothersandusedonlyasprescribed3) wherecontrolledsubstancesshouldbedisposed4) summaryofthestate’slawswithregardstodrivingoroperatingmachinery

5) Providepatientsandtheirprimarycareproviderswithoutpatientpainandaddictionclinicinformationincasetheyareconcernedaboutthedevelopmentofchronicpain,oraddiction. 23

BiologicalPharmacologics:OpioidsOpioidMetabolism

HYDROCODONE

OXYCODONE

MORPHINE-3-GLUCURONIDE

MORPHINE-6-GLUCURONIDE

CYP4502D6glucuronidation

UDP-glucuronosyltransferase-2B7

MORPHINE

HYDROMORPHONE HYDROMORPHONE-3-GLUCURONIDE

OXYMORPHONE OXYMORPHONE-3-GLUCURONIDE

TRAMADOL O-DESMETHYL-TRAMADOL

CODEINE

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Celecoxib CitalopramCodeine,Hydrocodone,Oxycodone,Tramadol

PHENOTYPES%POPULATION

2C9%POPULATION

2C19%POPULATION

2D6

ULTRARAPIDMETABOLIZER UM N/A 30% 7%

EXTENSIVEMETABOLIZER EM 60% 14-44% 48%

INTERMEDIATEMETABOLIZER IM >35% 24-36% 35%

POORMETABOLIZER PM 2-4% 2-20% 10%

BiologicalPharmacologics:OpioidsOpioidMetabolism

JanickiP.Chapter2:PharmacogenomicsinPainManagement.ComprehensiveTreatmentofChronicPainbyMedical,Interventional,andIntegrativeApproaches.Springer.2013.

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BiologicalPharmacologics:OpioidsEfficacyinAcutePain

Richards,D.TheOxfordPainGroupLeaguetableofanalgesicefficacy.Evid.Based.Dent.5,22–23(2004).

Opioidsare… “powerful”“painkillers” “strong”

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Opioidscanbeeffectiveforstaticpain,butarethatnoteffectivefordynamicpain. Mostacutepainisdynamicpain-painassociatedwithmovement.

Considertheimportanceofdynamicpainmanagementfor:•DVT/PEprophylaxis•Atelectasis/pneumoniaprophylaxis•Urinarycatheterizationremoval

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AnalgesicanddosePeopleincomparison(n)

Proportionwith50%painrelief(%) NNT LowerCI HigherCI

Etoricoxib180/240 248 77 1.5 1.3 1.7Etoricoxib100/120 500 70 1.6 1.5 1.8Valdecoxib40 473 73 1.6 1.4 1.8Dipyrone 113 79 1.6 1.3 2.2Ibuprofen800 76 100 1.6 1.3 2.2Ketorolac20 69 57 1.8 1.4 2.5Ketorolac60(intramuscular) 116 56 1.8 1.5 2.3Diclofenac100 411 67 1.9 1.6 2.2Piroxicam40 30 80 1.9 1.2 4.3Paracetamol1000+codeine60 197 57 2.2 1.7 2.9OxycodoneIR5+paracetamol500 150 60 2.2 1.7 3.2Bromfenac25 370 51 2.2 1.9 2.6Rofecoxib50 675 54 2.3 2.0 2.6Diclofenac50 738 63 2.3 2.0 2.7Naproxen440 257 50 2.3 2.0 2.9OxycodoneIR15 60 73 2.3 1.5 4.9Ibuprofen600 203 79 2.4 2.0 4.2Ibuprofen400 4703 56 2.4 2.3 2.6Aspirin1200 279 61 2.4 1.9 3.2OxycodoneIR10+paracetamol650 315 66 2.6 2.0 3.5Ketorolac10 790 50 2.6 2.3 3.1Ibuprofen200 1414 45 2.7 2.5 3.1OxycodoneIR10+paracetamol1000 83 67 2.7 1.7 5.6Piroxicam20 280 63 2.7 2.1 3.8Diclofenac25 204 54 2.8 2.1 4.3


Morphine10(IM) 946 50 2.9 2.6 3.627

BiologicalPharmacologics:Cyclo-OxygenaseInhibitors(COX-inhibitors)(historicallyknownasNSAIDs)

ARACHIDONICACID

COX-1

PGI2

TXA2 PGE2

COX-2

PGD2

PGF2

PGE2

PGI2VasodilatorHyperalgesicInhibitsPlateletAggregation

Sleep/WakeCycleVasodilatorInhibitsPlateletAggregation

BronchoconstrictorMyometrialContraction

DecreasedStomachAcidIncreasedMucousVasodilatorHyperalgesic

VasodilatorHyperalgesicInhibitsPlateletAggregation

PlateletAggregationVasoconstrictor

Constitutive.FoundinalltissuesespGItract

Inducible.Kidney,GItract,CNS,endothelium

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DecreasedStomachAcidIncreasedMucousVasodilatorHyperalgesic


Schmidt,M.etal.Cardiovascularsafetyofnon-aspirinnon-steroidalanti-inflammatorydrugs:ReviewandpositionpaperbytheworkinggroupforCardiovascularPharmacotherapyoftheEuropeanSocietyofCardiology.Eur.HeartJ.37,1015–1023(2016).

BleedingGastritisRenalInjury

CardiovascularAdverseEvents

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Schmidt,M.etal.Cardiovascularsafetyofnon-aspirinnon-steroidalanti-inflammatorydrugs:ReviewandpositionpaperbytheworkinggroupforCardiovascularPharmacotherapyoftheEuropeanSocietyofCardiology.Eur.HeartJ.37,1015–1023(2016)

Out-of-HospitalCardiacArrest(OHCA)associatedwithNSAIDuseintheprior30days.

Statisticallysignificant:• UseofdiclofenacOR1.5• UseofibuprofenOR1.3

Notstatisticallysignificant:• UseofnaproxenOR1.29• UseofcelecoxibOR1.13• UseofrofecoxibOR1.28

Sondergaard,K.B.etal.Non-steroidalanti-inflammatorydruguseisassociatedwithincreasedriskofout-of-hospitalcardiacarrest:anationwidecase–time–controlstudy.Eur.Hear.J.-Cardiovasc.Pharmacother.pvw041(2016)

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Steroids(glucocorticoids)reducepainbyreducingprostaglandinsynthesis.However,theirsideeffectprofileissignificantandshouldnotbeusedfornon-surgical,acutenon-cancerpainunlessotheroptionsarenoteffectiveorpossible.Theyshouldnotbeusedchronically.

Dexamethasoneisroutinelyusedintheperi-operativearenaforpost-operativenauseaandvomiting.ItisassociatedwithareductioninNRS/VASandopioidconsumption,8mg>4mg.

Sideeffects:•Increasedweightgain•Proximalmuscleweakness•Insomnia•Gastrointestinalsideeffects•Gastrointestinalbleeding•Psychatricsideeffects•Osteoporoseswithlong-termuse•Infections•Hyperglycemia•CushingSyndrome•Thromboembolism

BiologicalPharmacologics:Steroids

Vyvey,M.Steroidsaspainreliefadjuvants.Can.Fam.Physician56,1295–7,e415(2010)DeOliveiraGSJr.;AlmeidaMD;BenzonHT;McCarthyRJ.PerioperativeSingleDoseSystemic

Dexamethasonefor.Anesthesiology115,575–588(2011)

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BiologicalPharmacologics:Acetaminophen/Paracetamol

•Lachiewicz,P.F.TheRoleofIntravenousAcetaminopheninMultimodalPainProtocolsforPerioperativeOrthopedicPatients.Orthopedics36,15–19(2013)•Toms,L.etal.Singledoseoralparacetamol(acetaminophen)forpostoperativepaininadults(Review)Singledoseoralparacetamol(acetaminophen)for

postoperativepaininadults.4–6(2012).•Tzortzopoulou,A.etal.Singledoseintravenouspropacetamolorintravenousparacetamolforpostoperativepain.CochranedatabaseSyst.Rev.CD007126

(2011).

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BiologicalPharmacologics:Acetaminophen/ParacetamolAnilineanalgesic.Mechanismofactionremainsunknown.TheproposedCOX-3mechanismiscontroversial.

Safety:4grams/daylimitissafeinadults.Lean-bodyweightbased:60mg/kg/dayProspectivetrialsinvolvingcentralpainrelatedtostrokeshowssafetyupto6g/day

•Hepatitis:ifindolent,4g/dayok• Alcoholism:ifnotdrinking>2drinks/day,4g/dayok• CombinationHepatitisandAlcoholism:depends.2g/daylimitoravoid?

CautionincombinationwithCYP4503A4/2E1inhibitors:considereffectofcoumadin,anticonvulsants,andantipsychotics



(2011).

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BiologicalPharmacologics:Acetaminophen/ParacetamolAnilineanalgesic.Mechanismofactionremainsunknown.TheproposedCOX-3mechanismiscontroversial.

Safety:4grams/daylimitissafeinadults.Lean-bodyweightbased:60mg/kg/dayProspectivetrialsinvolvingcentralpainrelatedtostrokeshowssafetyupto6g/day

•Hepatitis:ifindolent,4g/dayok• Alcoholism:ifnotdrinking>2drinks/day,4g/dayok• CombinationHepatitisandAlcoholism:depends.2g/daylimitoravoid?

CautionincombinationwithCYP4503A4/2E1inhibitors:considereffectofcoumadin,anticonvulsants,andantipsychotics

Efficacy:Singledoseoralparacetamol/acetaminophenprovideseffectivepainreliefforabouthalfofpatientsaftersurgery.(Cochrane,2008).Intravenousparacetamolprovidedpainrelieffor36%ofpatientsaftersurgery.(Cochrane,2016).

Cost:OralacetaminophenisOTCandcostspennies.Intravenousacetaminophen,dependingonyourcontract,$100s/day



(2011).

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ClonidineEffectiveinanimalmodelanalgesictrials.Whileitcanbeeffectiveinreducingpainandopioidconsumption,itislimitedbyitssideeffectofbradycardiaandhypotension.

BiologicalPharmacologics:Alpha-2Agonists

Dexmedetomidine:(alpha-2agonist)1620:1(alpha-1agonist)canbeusedforbothanalgesicandsedativeproperties.Itisparticularlyusefulinpatientswithheroinabusebecauseithelpswithwithdrawalsymptoms,providesanalgesia,andcalms/sedates.ThedrugcrossestheBBBandhasbeenstudiedviaseveralroutesofadministration:IM/IV/IN/RegionalthoughnotPO.

Itisexpensive,andcanonlybeusedintravenouslyinmonitoredsettingsduetothesameconcernsregardingbradycardiaandhypotension.

Stillearlyinourexperienceasfarastheliterature.Wehavesupportforitsuse,particularlyintheICUorinpediatrics.Itsbenefitremainsduringtheinfusion,anddoesnotseemtoprovidelonger-termbenefitduetoaneliminationhalf-liveof2hours.

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Gabapentinoids(GabapentinandPregabalin):MOA:alpha-2-deltaligandantagonists(calciumchannelmembranestabilizer).Usefulinperi-operativepainmanagementresultinginreduceopioidconsumptionandpotentiallyinreducingthedevelopmentofchronicpainaftersurgery.

Useislimitedwithsideeffectswhichincludesedation,cognitiveimpairment,tremor,hallucinations,swelling,visualchanges,drymouth,etc.Useparticularcautioninthegeriatricpopulationandinpatientswithrenalimpairment.

Morebenefitandadverseeffectsseenwithhigherdosing.

BiologicalPharmacologics:NeuropathicAnalgesics

• Clarke,H.etal.Thepreventionofchronicpostsurgicalpainusinggabapentinandpregabalin:Acombinedsystematicreviewandmeta-analysis.Anesth.Analg.115,428–442(2012)

• Wong,K.etal.AntidepressantDrugsforPreventionofAcuteandChronicPostsurgicalPain.Anesthesiology121,591–608(2014).

SNRI/SSRIAntidepressants(Duloxetine,Venlafaxine,Desvenlafaxine,Milancipran,etc.)Havenotbeenproventobeusefulinacutepain.

Ca-channelMembraneStabilizers

e.g.gabapentinoids

Na-channelMembraneStabilizers

eg.carbamazepine

TricyclicAntidepressants

e.g.amitriptyline

SNRI/SSRIAntidepressants

e.g.duloxetine

Anti-EpilepticDrugs(AEDs)

Antidepressants

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BiologicalPharmacologics:NMDA-antagonists:Ketamine

Ketamineisananestheticdrug(ControlledSubstanceIII).Itexertsvariouseffectsdependingonthedoseandhasmanymechanismsofaction:

• NMDAantagonist• Kappaopioidagonist• Potentiatesantinociceptionofmu-opioideffect• Inhibitsalpha-6nicotinicreceptors

Inadditiontoitsimpactonanti-hyperalgesia,itisalsobeingwidelystudiedforanti-depressionandmayplayaroleintheaffectivecomponentofpainperception.

Donotuse,orexercisecautioninindividualswithschizophrenia,schizoaffectivedisorder,post-traumaticstressdisorder,ClusterApersonalitydisorders.

USE DOSE

ANESTHETIC 2-5mg/kg

DISSOCIATIVE(PEDI) 1-2mg/kg

CHRONICPAININFUSION 0.5-1mg/kg/hr

LOW-DOSEINFUSIONforOIH0.1-0.2mg/kg/hr1-3mcg/kg/min

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Nys

tagm

us

Trem

or

Psyc

hom

otor

Agi

tatio

n

Hal

luci

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ns

Hyp

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livat

ion

Dis

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Com

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path

omim

etic

Effe

cts

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17studies,withvariabletiminganddosing,demonstratedstatisticallysignificantreductionsinthedevelopmentofPPSPat3and6months.

Comparisonsofpainseveritydidnotreachstatisticalsignificance.

ANTI-H

YPERALGESIA

ANALGESIA


37



ANTI-H

YPERALGESIA


37



ANTI-H

YPERALGESIA


39clinicaltrials,5meta-analyses,wereincluded.Variabletiminganddosing,demonstratedstatisticallysignificantreductionsinopioidconsumptionby40%

37

BiologicalPharmacologics:Voltage-GatedSodiumChannelBlockade:LidocaineInfusion.

Lidocaineisananti-arrhythmicandlocalanestheticdrug.Itrelievespainatdosesfrom1-2mg/kg/hr

Ithasbeenwidelystudiedincolectomy,laparoscopicsurgery,andreducesopioidconsumption.Inchronicpain,ithasbeenstudiedforCRPS,headache,andotherneuropathicpainconditionssuchaserythromelalgia,whereitcanbethe“cure”forsodiumchannelopathy.

Itseffectlastsduringtheinfusionandshortlywearsoff.

Donotuse,orexercisecautioninindividualswheresodiumchannelcardiacblockadewouldbeproblematic,e.g.sinoatrialblockor2ndor3rddegreeblock.

Dunn,L.K.,Ph,D.,Durieux,M.E.&Ph,D.PerioperativeuseofLidocaine.Anesthesiology(2017)

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BiologicalMulti-ModalAnalgesia

Ana

lges

ia

Resp

Dep

ress

ion

Seda

tion

Del

irium

N/V

Con

stip

atio

n

Prur

itus

Gas

triti

s

Rena

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func

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Plat

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Inhi

b

LAST

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Ana

lges

ia

Resp

Dep

ress

ion

Seda

tion

Del

irium

N/V

Con

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atio

n

Prur

itus

Gas

triti

s

Rena

l Dys

func

tion

Plat

elet

Inhi

b

LAST

Michelet D, 2012. Anesth Analg De Oliveira, 2012. Anesth Analg

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Ana

lges

ia

Resp

Dep

ress

ion

Seda

tion

Del

irium

N/V

Con

stip

atio

n

Prur

itus

Gas

triti

s

Rena

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func

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Plat

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LAST

Tiippana E, 2007. Anesth Analg

41


Ana

lges

ia

Resp

Dep

ress

ion

Seda

tion

Del

irium

N/V

Con

stip

atio

n

Prur

itus

Gas

triti

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Rena

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func

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Plat

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Inhi

b

LAST

Blaudszun, 2012. Anesthesiology

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Ana

lges

ia

Resp

Dep

ress

ion

Seda

tion

Del

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N/V

Con

stip

atio

n

Prur

itus

Gas

triti

s

Rena

l Dys

func

tion

Plat

elet

Inhi

b

LAST

Kehlet, 2005. Anesthesiology Koppert, 2004. Anesth Analg

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Ana

lges

ia

Resp

Dep

ress

ion

Seda

tion

Del

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N/V

Con

stip

atio

n

Prur

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Gas

triti

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Rena

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Plat

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LAST

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Ana

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Resp

Dep

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Seda

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Del

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N/V

Con

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Prur

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Gas

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Plat

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Seda

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Con

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LAST

RECEPTOR MEDICATIONEXAMPLES ADVERSEEFFECTS

alpha-2 Dexmedetomidine, Clonidine Bradycardia, Dry Mouth

COX-inhibition Ketorolac, Ibuprofen, Celecoxib, APAP GI Ulcers, Renal Dysn, Bleeding

Mu-Opioid Morphine Fentanyl

N/V, Constipation, Resp Depression, Pruritus, Urinary Ret, Delirium,

Kappa-Opioid Nalbuphine

GABA-A Diazepam Lorazepam Sedation, Delirium, Resp Dep c Op

Na-Channel Local Anesthetics LAST

NMDA-Antagonism Ketamine Memantine Depends. Psychomimetic FX

Glucocorticoid Dexamethasone Hyperglycemia, Acute Angle Glaucoma, Perineal Dysesthesia

Ca-Channel Neuropathic

Gabapentin Pregabalin Sedation, Impaired Cognition

Na-Channel Neuropathic

Topiramate Carbamazepine Sedation, Nephrolithiasis

SNRI Antidepressant

Duloxetine Venlafaxine Insomnia, Malaise, Stomatitis,

BiologicalRegionalAnesthesia

NEURAXIAL Intrathecal Epidural,Caudal

PARA-NEURAXIAL Paravertebral LumbarPlexus

PROXIMALPERIPHERALNERVE Interscalene,Supraclavicular,Infraclavicular Intercostal TransversusAbdominisPlane(TAP)

DISTALPERIPHERALNERVE Median,Radial,Ulnar Femoral,Saphenous Sciatic,Tibial,CommonPeroneal

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Regionalanesthesiaisthemostimpactfulmodalityofacutepainmanagement.Itcaneliminateacutepain.

Regionalanesthesiacansignificantlyreduceopioidconsumption

Regionalanesthesiareducesthedevelopmentofchronicpainaftersurgery.

Epiduralanalgesiareducespersistentpost-surgicalpainafterthoracotomy Paravertebralanalgesiareduespersistentpost-surgicalpainaftermastectomy

Risksincludenerveinjury,hematoma,infectiouscomplications,localanestheticsystemictoxicity,cardiovascularcollapse,anaphylaxis

BiologicalRegionalAnesthesia

Andreae,M.H.&Andreae,D.A.Regionalanaesthesiatopreventchronicpainaftersurgery:ACochranesystematicreviewandmeta-analysis.Br.J.Anaesth.111,711–720(2013).

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BiologicalComplementaryandIntegrativeMedicine

MUSICTOUCH

MASSAGEACUPUNCTUREACUPRESSURE

HYPNOSISBIOFEEDBACK

GUIDEDIMAGERYDISTRACTIONCREATIVEARTS

HERBALTHERAPYHOMEOPATHY

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ThefirstAcutePainServicestartedattheUniversityofWashingtonin1986andtheypublishedtheirdevelopmentofananesthesiology-basedpostoperativepainmanagementservicein1988.

AnAcutePainService(APS)canbedirectedby:•Anesthesiologists•InternalMedicine•FamilyPractice•EmergencyMedicine•Psychiatry•Neurology•Physiatrists•NursePractitioners

TheAcutePainService

Physicianoversight

Nursingleadership

PharmacyMedicalCenter

QualityGoals:•Patientsafety:Reducecomplications•Reducelengthofstay•Improvepatientsatisfaction

Economics:Willnotbeprofitablewithdirectbilling.Itwillreduceveryexpensivecomplications,andtherefore,wouldneedtobesupportedbythehospital/medicalcenter.

49

ThefirstAcutePainServicestartedattheUniversityofWashingtonin1986andtheypublishedtheirdevelopmentofananesthesiology-basedpostoperativepainmanagementservicein1988.

AnAcutePainService(APS)canbedirectedby:•Anesthesiologists•InternalMedicine•FamilyPractice•EmergencyMedicine•Psychiatry•Neurology•Physiatrists•NursePractitioners

TheAcutePainService

Physicianoversight

Nursingleadership

PharmacyMedicalCenter

Quality

PainPsychology

PT/OT

AddictionologistsClinicalSocial

Worker

Goals:•Patientsafety:Reducecomplications•Reducelengthofstay•Improvepatientsatisfaction

Economics:Willnotbeprofitablewithdirectbilling.Itwillreduceveryexpensivecomplications,andtherefore,wouldneedtobesupportedbythehospital/medicalcenter.

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TheFutureofAcutePainMedicineGeneralMedicalEducationinPainMedicine

Mezei,L.&Murinson,B.B.PaineducationinNorthAmericanmedicalschools.J.Pain12,1199–208(2011).

WhatarethemediannumberofhoursdevotedtopaineducationinAmericanmedicalschoolsover4years?

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UnitedStates:9hoursCanada:19.5hours

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ITISACONTRIBUTINGCOMPONENTTOOUROPIOIDEPIDEMICTHISMUSTCHANGE.


50




ITISACONTRIBUTINGCOMPONENTTOOUROPIOIDEPIDEMICTHISMUSTCHANGE.


ACGMEFellowshipinAcutePainMedicineandRegionalAnesthesiaStartinginJuly2017.1yeardurationafteraresidencyinanesthesiology.

50

TheFutureofAcutePainMedicineCodingandBillingInfluence.ICD-11MJ42.13

ICD-11willhaveapersistentpost-surgicalandpersistentpost-traumapaincode.Thiswillhaveanimpactintherecognitionandmanagementofchronifiedpain.

WehavenooutcomeparametersfromCMS,theJointCommission,orinsurersthatlookspecificallyatchronicpainaftersurgeryortrauma.EuropedoesbecauseofsinglepayersystemsandthisiswheremostoftheliteratureregardingPPSPorchronificationcomesfrom.

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TheFutureofAcutePainMedicineTheneedforlong-termoutcomes.MorbidityvsMortality.

QUALITY-ADJUSTEDLIFEYEARS(QALYs)100%

4020 60 80AGE(YEARS)

QUAL

ITYOFLIFE

0%

Trauma

52

Surgery

Conclusion

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Pharmacologic RegionalAnesthesia

PainPsychology

Rehabilitation/PTComplementary&

IntegrativeMedicine

Futureeffortsshouldgointo:•Publichealtheducation,egsmokingcessation•Healthcareprovidereduction•Legislation/Regulation•Non-pharm,Non-interventionalresources•Outcomes

Conclusion

53


PainPsychology


IntegrativeMedicine

Understandthedifferencesbetweenanalgesiaandanti-hyperalgesia.

•Opioidshavearoleinacutepainmedicine,but…theyarenotthesolutiontopain.They,infact,canmakepainworseovertime.

•MultimodalAnalgesiaisimportanttoreduceconsequentialsideeffects•Non-PharmandNon-Interventionalmodalitiesshouldalwaysbeused.•Regionalanesthesiacanbeimpactful,thoughmustweighrisks.•GoalsaretoMANAGEPAINandPREVENTCHRONICPAIN


Conclusion

53


PainPsychology


IntegrativeMedicine

Understandthedifferencesbetweenanalgesiaandanti-hyperalgesia.

•Opioidshavearoleinacutepainmedicine,but…theyarenotthesolutiontopain.They,infact,canmakepainworseovertime.

•MultimodalAnalgesiaisimportanttoreduceconsequentialsideeffects•Non-PharmandNon-Interventionalmodalitiesshouldalwaysbeused.•Regionalanesthesiacanbeimpactful,thoughmustweighrisks.•GoalsaretoMANAGEPAINandPREVENTCHRONICPAIN


ThankYou

Questions?

54

An64yogentlemanwithh/orheumatoidarthritis,CKD(eGFR=43ml/min/1.73m2),CAD,trippedoveracordatnightintryingtogotothebathroomathome.IntheED,hehasfoundtohaveafemoralneckfractureandorthopedicsurgeryisdeterminingwhetherheisasurgicalcandidate.Youarecalledtoevaluateandmanagehisacutepain.

Heissupineinthegurney,crying,statinghehas10/10pain.Heisabletoconverseandisalert,aware,andorientedx3.Already,hehasreceivedmorphine10mgIVapproximately10minutesbeforeyouarrive.

PMH:InflammatoryBowelDiseaseCKD(Stage3B)CAD,haddrug-elutingstentin2013.Chronicinflammatoryandosteoarthritisofshoulders,hips,andknees.

PSH:s/pcolectomywhenhewas38yearsold.Hasbeenonchronicopioidtherapysince.

CurrentMeds:Aspirin162mgPOdailyValsartan80mgPOBIDMetoprolol50mgPOBIDAcetaminophen650mgPOevery6hoursasneededforpainMorphineIR15mgPOevery6hoursasneededpainNaloxegol12.5mgPOdaily

Allergies:Codeine

SocialQuitsmoking10yearsagoConsumes<2alcoholicbeveragesperweekLivesalone.

ClinicalVignette

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Whatisyournextstepformanaginghisacutepain?

ClinicalVignette

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Whatisyournextstepformanaginghisacutepain?

ClinicalVignette

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Possiblequestions:1)Askhimonaveragehowmuchmorphineoranyotheropioidheconsumes?Answer:“Itakethemorphine15mg4timesaday.ButIusedtobeOxyContin40mgPO3timesadaylikeamonthago.”WhatarehisOMEs?Isthathighrisk?WhatistheOMEofwhathereceived,morphine10mgIV?

2)Whereisyourpain?Answer:“Myhipandthighandshoulder…”

3)Canyoudescribethesethreepains?Whichoneistheworst?Answer:“Theshoulderfeelsachy,it’snotbadthough.Thehipisasharpstabbingpainandthethighisastrongache.It’s10/10,canyougetmesomething?”

4)Whydoyoutakemorphineonadailybasis?Answer:“ShoulderpainI’vehadforyears.”

5)Areyoutakinganybloodthinnersbesidestheaspirin?Answer:No

6)Doyouhaveanyonewholiveswithyouorsupportsyou?Answer:“Myex-wife.Theyalreadycalledherandsheiscomingin.”

6)Consider:Regionalanesthesia,low-doseketamineinfusion,acetaminophen,oralopioidtherapythatmustbeatleastwhathewastakingathome.WouldyougiveaCOX-inhibitor?Wouldyougiveagabapentinoid?Youcanconsiderlidocaine,dexmedetomidineaswell,buttheseshouldonlybeusedintheICU,andarenotwarrantedunlesspainwastoodifficulttomanagewiththecurrentregimen.Ice/heat,music,guidedimagery,therapydog,possiblyacupuncture/acupressure,psychologicalevaluationandsocialworkerevaluation.

ClinicalVignette

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Hehasafasciailiacacatheterplacedandthenextmorninghehasafemoralintramedullarynailplacedbyorthopedicsurgery.Post-operatively,thefasciailiacacatheterisre-inserted.Hehasbeenmaintainedonlow-doseketamineandistakingmorphineIR15mgevery4hoursasneeded.

HeisdoingwellwithPT/function,satisfaction,POD0,1,andistoldhecangohomeonPOD2withhomehealth.

Theanesthesiologistremovestheregionalanesthesiacatheter,youstoptheketamineinfusion,andhestatesthepainhasreturnedto7/10.

Whatdoyoudo?

ClinicalVignette

57

Hehasafasciailiacacatheterplacedandthenextmorninghehasafemoralintramedullarynailplacedbyorthopedicsurgery.Post-operatively,thefasciailiacacatheterisre-inserted.Hehasbeenmaintainedonlow-doseketamineandistakingmorphineIR15mgevery4hoursasneeded.

HeisdoingwellwithPT/function,satisfaction,POD0,1,andistoldhecangohomeonPOD2withhomehealth.

Theanesthesiologistremovestheregionalanesthesiacatheter,youstoptheketamineinfusion,andhestatesthepainhasreturnedto7/10.

Whatdoyoudo?YouincreasethemorphineIRto15-30mgPOq4hPRN.

Whatdoyoutellhimondischarge?Opioidconsumptionreduction,Opioid-inducedhyperalgesia,DiscussopioidweaningwithyoursurgeonandPCPIsheaddicted?Screeningtools(COMM)canbeusedbyhisPCPWouldyougivehimCOX-inhibitorsnow?Whatabouttakingthemwithhisaspirin?Wouldyougivehimanythingelsebesidesacetaminophenandmorphine?Gabapentin?Whatwouldyoudoforhischronicshoulderpain?

Managing Acute Non-Cancer Pain in the Hospital · Managing Acute Non-Cancer Pain in the Hospital...

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Transcript of Managing Acute Non-Cancer Pain in the Hospital · Managing Acute Non-Cancer Pain in the Hospital...