Pain Management Top 10 Resident Pitfalls- 2019 Theresa Kristopaitis, MD Professor of Medicine, Division of Hospital Medicine

Pain Management Top 10 Resident pitfalls 10. Norco PRN for everyone!

“CDC Guidelines for Prescribing Opiates for Chronic Pain” Current EPIDEMIC of prescription opioid overdose and deaths As many as 1 in 4 people receiving prescription opioids long term in primary care setting struggles with addiction 2016 Guidelines developed for Primary care providers Treating patients with chronic pain Does not include patients undergoing active cancer tx and end of life care

Guideline Summary-Chronic Pain Nonpharmacologic and NONOPIOID pharmacologic tx preferred for chronic pain Consider opioid therapy only if expected benefits for pain AND function outweigh risks

Guideline Summary – ACUTE Pain Long-term Opioid Use Often Begins With Tx Of Acute Pain When opioids are used for ACUTE pain Prescribe Lowest effective dose Immediate release formulation Quantity no greater than expected duration of pain severe enough to require opiates 3 days or less often sufficient More than 7 days rarely needed

IF you are going to prescribe opioids… Now embedded when ordering in EPIC

Pain Management Top 10 Resident pitfalls 9. Percocet – that’s like lortab, right? They both have hydromorphone? 10. Norco PRN for everyone!

Pain Management Know your analgesics

WHO 3 step ladder Step 1 Acetaminophen Nonsteroidals Aspirin

Who 3 step ladder Step 2 Codeine +acetaminophen T#2, T #3, T#4 Hydrocodone + acetaminophen Norco Vicodin Lortab Oxycodone + acetaminophen Percocet Tramadol Ultram

Who 3 Step Ladder Step 3 Morphine Hydromorphone Oxycodone Methadone Dilaudid Oxycodone Methadone Fentanyl

Pain Management Top 10 Resident Pitfalls 8. Equianalgesic table? Does your i-phone have that? 9. Percocet – that’s like lortab, right? 10. Norco PRN for everyone!

Pain Management Have an opioid conversion chart with you with which you are familiar

Equianalgesic Dose Drug Name Oral (mg) Parenteral (mg) Morphine 30 10 Hydromorphone 7.5 1.5 Oxycodone 20 N/A Hydrocodone

Pain Management Top 10 Resident Pitfalls 7. Uh Yeah, 2mg of IV dilaudid sounds good 8. Equianalgesic table? Does your i-phone have that? 9. Percocet – that’s like lortab, right? 10. Norco PRN for everyone!

Pain Management --Respect potency of opioid analgesics --Know starting doses

Pain Management Always start with short-acting opioids

Starting doses of opioids Factors Age Weight Comorbidities Prior experience with analgesics Frequency, severity of pain

List the following from analgesics from least to most potent Tramadol Hydromorphone Oxycodone Hydrocodone Codeine Morphine

Least to most potent Codeine Tramadol Morphine = Hydrocodone Oxycodone Hydromorphone

Effective ORAL Starting Doses Codeine 30 mg Tramadol 25-50 mg Morphine = Hydrocodone 5 mg Oxycodone 3 mg Hydromorphone 1 mg

Effective IV Starting Doses of Opioids Morphine 1mg Hydromorphone 0.15mg Drug Name Oral (mg) Parenteral (mg) Morphine 30 10 Hydromorphone 7.5 1.5 Oxycodone 20 N/A Hydrocodone 6.66

Pain Management Top 10 Resident pitfalls 6. 2mg of IV morphine didn’t work? Go ahead and change it to 2mg IV dilaudid. 7.Uh Yeah, 2 of IV dilaudid sounds good 8. Equianalgesic table? Does your i-phone have that? 9. Percocet – that’s like lortab, right? 10. Norco PRN for everyone!

Pain Management Describe the principles of opioid dose escalation

Dose Escalation Recommended frequency of dose escalation -depends on peak effect time and the half- life of the drug

Escalation Short-acting PO single-agent  every 2 hours IV opioids  every 15-30 minutes Short-acting PO single-agent  every 2 hours ?what about combination products? Sustained release oral opioids ->every 24 hours Transdermal fentanyl no more frequently than every 72 hours

Common Formula For ongoing moderate to severe pain increase opioid doses by 50-100% For ongoing mild to moderate pain increase by 25-50%

Rotation to another opioid is not the first choice So long as a dose-response effect is being seen patient is tolerating the regimen

Math Time 2mg of IV morphine didn’t work? Go ahead and change it to 2mg IV dilaudid. Hydromorphone 2mg IV is the equivalent of what dose of morphine? Does that follow the rule of dose escalation?

13mg IV morphine !!!!! 2mg IV hydromorphine x 10mg IV morphine = 1.5mg IV hydromorphone 13mg IV morphine !!!!! 2mg IV morphine to 13mg IV morphine = 200%+ increase

2mg IV morphine administered and 30 minutes later patient still in pain For ongoing moderate to severe pain increase opioid doses by 50-100% For ongoing mild to moderate pain increase by 25-50%

Family arrives and says STOP – morphine made him crazy – we want something else!! 2mg IV morphine x 1.5mg IV hydromorphone 10mg IV morphine 0.3mg IV hydromorphone

Public Service Announcement  ORDERING PAIN MEDICATIONS and AVOIDING “OPIOID STACKING” PRN pain medications require an associated  pain severity scale to assist nursing administration.                         mild pain, (pain score 1-3)                         moderate pain (pain score 4-6)                         severe pain (pain score 7-10) If medications are ordered for different pain levels then dosing intervals should be the same for all of these meds to avoid medication stacking                          ie: ibuprofen 600mg every 6 hours for mild pain                               hydrocodone/acetaminophen 5mg/325mg every 6hours for moderate pain                               hydrocodone/acetaminophen 10mg/325 mg every 6hours for severe pain Additional medications can be given between these intervals, and the prn indication should be documented as "breakthrough pain."  The physician team should be contacted to enter orders specifically for "breakthrough pain."  

EXAMPLE OF PAIN MEDICATION STACKING   Pain score assessment =5 Norco 5mg given   Pain is reassessed in 1 hour; pain score assessment= 8         Norco 10mg given             ->Patient is not due for another pain medication; next dose can be given 6hours after initial administration. **Pain medication stacking should be avoided to prevent iatrogenic adverse reactions and complications.

Pain Management Top 10 Resident pitfalls 5. Still in pain on hospital day #2? Slap on a fentanyl patch 6. 2mg of IV morphine didn’t work? Go ahead and change it to 2mg IV dilaudid. 7. Yeah, 2 of IV dilaudid sounds good 8. Equianalgesic table? Does your i-phone have that? 9. Percocet – that’s like lortab, right? 10. Norco PRN for everyone!

Pain Managment Extended release/long acting (ER/LA) opioids are NOT for acute pain management ER/LA opioids are NOT for chronic (nonmalignant) pain management CDC Guideline - When starting opioid tx prescribe IMMEDIATE RELEASE instead of ER/LA opioids

Long Acting Opioids Morphine Oxycodone Hydromorphone MS Contin, Kadian, Avinza Oxycodone Oxycontin Hydromorphone Exalgo Fentanyl Transdermal Duragesic

Long Acting Opioids For opioid tolerant patients Pt taking at least 60 mg oral morphine/day 30 mg oral oxycodone/day 8 mg oral hydromorphone/day or equianalgesic dose of another opioid for one week or longer (FDA) For management of moderate to severe pain when a continuous, around-the-clock opioid analgesic is needed for an extended period of time

Acute Pain in an opioid tolerant patient? Uncontrolled pain must be controlled via short acting oral or IV opiates BEFORE the start/titration of a long acting agent

Pain Management Top 10 Resident pitfalls 4. Still in pain after 24 hours Fentanyl 25mcg/hr patch? Go ahead and increase to a 50 patch 5. Still in pain on hospital day #2? Slap on a fentanyl patch 6. 2mg of IV morphine didn’t work? Go ahead and change it to 2mg IV dilaudid. 7. Yeah, 2 of IV dilaudid sounds good 8. Equianalgesic table? Does your i-phone have that? 9. Percocet – that’s like lortab, right? 10. Norco PRN for everyone!

What is wrong with that management decision? Long Acting, Sustained Release Opioids are NOT for acute pain management this includes fentanyl transdermal Uncontrolled pain must be controlled via short acting oral or IV opiates BEFORE start/titration of long acting agent Dose escalate transdermal fentanyl no more frequently than every 72 hours

More about transdermal fentanyl Onset of action? 18-24 hours Patch strengths 12, 25, 50, 75, 100mcg/hr What dose of ORAL MORPHINE in a 24 hour period is equianalgesic to fentanyl 25mcg/hr patch? 50mg

Pain Management Top 10 Resident pitfalls 3. A morphine PCA sounds good. Do I have to fill in all of the blanks on the order set? 4. Still in pain after 24 hours Fentanyl 25mcg/hr patch. Go ahead and increase to a 50 patch 5. Still in pain on hospital day #2? Slap on a fentanyl patch 6. 2mg of IV morphine didn’t work? Go ahead and change it to 2mg IV dilaudid. 7. Yeah, 2 of IV dilaudid sounds good 8. Equianalgesic table? Does your i-phone have that? 9. Percocet – that’s like lortab, right? 10. Norco PRN for everyone!

PCA orders Opioid Concentration Demand dose Lockout 4 hour limit BASAL RATE Loading dose

Pain Management A BASAL rate in an opioid naive patient is NOT recommended

Pain Management Top 10 Resident pitfalls 2. If you don’t poop, we’ll prescribe a laxative 3. A morphine PCA sounds good. Do I have to fill in all of the blanks on the order set? 4. Still in pain after 24 hours Fentanyl 25mcg/hr patch. Go ahead and increase to a 50 patch 5. Still in pain on hospital day #2? Slap on a fentanyl patch 6. 2mg of IV morphine didn’t work? Go ahead and change it to 2mg IV dilaudid. 7. Yeah, 2 of IV dilaudid sounds good 8. Equianalgesic table? Does your i-phone have that? 9. Percocet – that’s like lortab, right? 10. Norco PRN for everyone!

He or she who writes the opioid order writes the bowel regimen. Stimulant laxative senna or bisacodyl Stimulant laxative + osmotic laxative Milk of magnesia Miralax Lactulose/sorbital

How/why do opioids induce constipation? Opioid Receptors Reduce peristalsis: Inhibit longitudinal smooth muscle Segmentation: increase contraction of circular smooth muscle Impair absorption of fluid from bowel Impair secretions

Article Recommendation: In patients with constipation or at risk for constipation, use laxatives with proven efficacy for treatment or prophylaxis of constipation instead of using docusate. Discuss de-prescription for patients using docusate prior to admission. Remove docusate from your hospital formulary.

Pain Management Top 10 Resident pitfalls 1.But my old back pain (HA, abdominal pain) is still a 10/10. I need more dilaudid 2. No BM in 2 days – fire up the Mag Citrate 3. A morphine PCA sounds good. Do I have to fill in all of the blanks on the order set? 4. Still in pain after 24 hours Fentanyl 25mcg/hr patch. Go ahead and increase to a 50 patch 5. Still in pain on hospital day #2? Slap on a fentanyl patch 6. 2mg of IV morphine didn’t work? Go ahead and change it to 2mg IV dilaudid. 7. Yeah, 2 of IV dilaudid sounds good 8. Equianalgesic table? Does your i-phone have that? 9. Percocet – that’s like lortab, right? 10. Norco PRN for everyone!

CDC Guideline Summary Before starting opioid tx for chronic pain, establish treatment goals with patient Realistic goals for pain AND function PEG assessment scale Pain average (0-10) Interference with Enjoyment of life (0-10) Interference with General activity (0-10) 30% = Clinically meaningful improvement Continue opioids only if there is meaningful improvement in pain and function that outweigh risks to patient safety

Managing Chronic Pain

Questions?