Acute Pain Management Solomon Liao, M.D. Associate Clinical Professor Director of Palliative Care Services Hospitalist Program

PRACTICAL Objectives Use opioids with comfort in an inpatient setting By the end of this session, participants will be able to: Use opioids with comfort in an inpatient setting Address side-effects Master opioid conversions Choose the appropriate opioid PRACTICAL

WHO pyramid Severe Pain Pure opioids: Morphine Moderate Pain Mild opioids: Codeine, Vicodin Mild Pain Non-opioids: Tylenol, NSAIDS

Back Pain 56 yo chronic back pain Pain well controlled with Oxycontin 20 mg bid Developed dysphagia Unable to swallow pills Now admitted in severe pain How do you write admit pain med?

Conversion Oxycodone 1 mg = 1.5 mg Morphine 40 mg Oxycodone/day = 60 mg PO Morphine/day 1 mg IV Morphine = 3 mg PO Morphine 60 mg PO Morphine = 20 mg IV Morphine 20 mg IV Morphine/24 hrs = 1 mg/hr

Epigastric Pain 46 yo Admit from ER for severe acute epigastric pain Radiates to back Curled up in a fetal position Amylase and lipase elevated What pain medication would you use? How would you give it to her?

DEMEROL

Demerol Side-effects Partial mu agonist, most kappa effects Most addictive short acting high peaking Lowers seizure threshold active metabolite - normeperidine Anticholingeric - not for elderly

PCA Titration Better pain control Less medication, less side effects Titration Principle Smaller dose, more frequent Matches pain curve Anticipatory pain effect PRN match continuous rate 2 mg/hr & 0.5 mg q 15 min PRN

Trauma 76 yo Adm to trauma Svc, s/p MVA Pulmonary contusion, rib Fx Delirious - confused Pulling off O2, hard collar on, 4 point restraints, pulling at foley Given MS PCA by surgery team What is wrong with the picture?

Titration Short acting agent (fast route) For opioid naïve – start 2 mg IVP q 1-2 hr Can safely increase by 50-100% q day No ceiling (Max. dose) for pure opioids Add PRN to standing dose

Morphine Pharmacokinetics

Fentanyl Case Geriatric Fellow called by NP: nursing home patient with pain Fentanyl patch applied Next day patient still in pain Another Fentanyl patch added 2 days later Pt obtunded

Opioid Choices Morphine - IV, SQ, IM, PO, PR, SL Dilaudid - IV, SQ, IM, PO, SL Oxycodone - PO, SL Fentanyl - IV, transQ, transmucosal Levorphanol - IV Methadone – PO, SL, IV, SQ Hydrocodone - PO

Discharge to Outpatient Around the Clock “An ounce of prevention is worth a pound of cure” Rules of thumb Rescue dose = 10% of 24 hr dose PRN q 4 hrs Call if use more than 2 PRN dose or use more than 2 days

Narcan? 87 yo small Japanese lady S/p TAH/BSO, POD # 2 Allergy to morphine MD orders Dilaudid 0.5 mg q 2 hrs RN gives in error Dilaudid 5 mg IVP RR 10, Pt sleeping – arousable What should the RN do?

Side-effects Acute Chronic - constipation All resolve within 3-5 days Respiratory depression (rare) - hours Sedation – 1-2 days Nausea/vomiting (33%) – 3-5 days Chronic - constipation “The hand that writes the opioid, writes the laxative”

Indications for Narcan Not for mental status change Just hold – let wear off Cause significant acute withdraw pain RR < 6 Oxygen saturation <90% If respond then Narcan drip & transfer to ICU Because duration <2 hrs

Summary Titration NO DEMEROL Monitor side-effects PCA best short acting convert to long acting NO DEMEROL Monitor side-effects