1. Jena Torpin, Pharm.D. Mary Cunningham, APRN November 6, 2013
Acute Pain Management
Jena Torpin, Pharm.D.
Mary Cunningham, APRN
November 6, 2013

2. Objectives
 List 3 patient outcomes impacted by appropriate management of acute pain
Describe key patient assessment parameters in evaluating pain outcomes
Formulate an appropriate pharmacologic treatment regimen for patients experiencing acute post-operative pain.   
Demonstrate the use of an opioid equianalgesic chart to compare opioid potencies
Differentiate opioid dosing for acute pain in opioid naïve and opioid tolerant patient

3. Background Pain Acute Pain Chronic Pain Persists > 3 months
Etiology less clear
Nerve injury
Musculoskeletal
Serves no purpose
Acute Pain
Clear cause
< 3 months
serves a purpose
Pain, 1986; Managing Acute Pain A Guide For Patients, 2006; D’Arcy, Acute Pain Management, 2011

4. Manifestations of Pain
Acute
Increased BP, P, R
Dilated pupils
Sweating
Focus
Reports pain
Crying, moans, restless
Grimace
Chronic
Normal vitals
Normal pupils
Dry skin
Distraction
No report of pain
Quiet, sleep, rests
Blank/normal facial expression
Behavioral Physiologic

5. Agreement Between Caregiver and Patient
VAS 7-10
(15)
VAS 3-6
(35)
VAS 0-2
(53)
Patient and Nurse 7%
51%
82%
Patient and House Officer
20%
26%
66%
Patient and Fellow
27%
29%
70%
Patient and Professional
13%
37%
79%
Grossman, S., et al. (1991). J Pain & Symptom Management 6:

6. Factors Influencing Assessment
Chronicity
Presence of pathology
Age
Gender
Ethnicity
Functional status
Socioeconomic status
Value systems

7. Physiologic Consequences of Pain
Increased metabolic rate
Increased blood clotting
Water retention
Tissue breakdown
Impaired immune function
Autonomic hyperactivity
Pulmonary dysfunction
Delayed return of bowel function
Development of chronic pain syndromes
Carbonara Baugh, Acute Pain, 2011; Managing Acute Pain A Guide For Patients, 2006; Macintyre, Acute Pain Management, 2007;

8. Impact of Pain on Activity and QOL
Relationships
Walking
Sleep
Activity level
Mood
Work
Enjoyment of life 3 4 5 6 7 8
Pain Intensity
Cleeland C., et. al. (1994). NEJM 330.

9. Pain Is CO$TLY Decreased patient/family (staff) satisfaction
Increase co-morbidities
Increase LOS
CMS reimbursement based on satisfaction.
Public distribution of UMHC scores
Pain management is a quality indicator in value based purchasing

10. Hospital Compare

11. Pharmacologic Pain Treatment Strategies
Etiology
Mechanism of action
Match dosing formulation to temporal pattern of pain
Use a preventative approach
Tailor potency to severity
Equianalgesic dosing
Anticipate side effects
Cost

12. Degree of Pain: The W.H.O. Ladder
Image: Vargas-Schaffer, 2010; Pharmacist’s Letter, 2010

13. Non-Opioids TYLENOL Good option for: Bad option for:
Patients with kidney dysfunction
Heart failure/heart disease
GI bleeds/ulcers
Bariatric patients
Bad option for:
Patients with liver disease
Alcoholism
Malnutrition
Carbonara Baugh, Acute Pain, 2011; Managing Acute Pain A Guide For Patients, 2006; D’Arcy, Acute Pain Management, 2011

14. Not all NSAIDs are created equally:
Non-Opioids
NSAIDS
Not all NSAIDs are created equally:
Low CV Risk: Naproxen, Piroxicam
High CV Risk: Celebrex, Meloxicam, Diclofenac, Ketorolac
Low GI Risk: COX-2 Inhibitors
High GI Risk: Diclofenac, Ketorolac
Good option for:
Pain with an inflammatory component
Bad option for:
Patients with kidney dysfunction
Heart failure/heart disease
GI bleed/ulcers
Bariatric surgery patients
Carbonara Baugh, Acute Pain, 2011; Managing Acute Pain A Guide For Patients, 2006; D’Arcy, Acute Pain Management, 2011

15. Mild-Moderate Pain: Oral Options:
Opioids
Wouldn’t Recommend:
-Codeine
-Methadone
-Meperidine
Mild-Moderate Pain: Oral Options:
-Tramadol
-Hydrocodone
Severe Pain:
-Morphine
-Oxycodone
-Hydromorphone
-Fentanyl IV
Carbonara Baugh, Acute Pain, 2011; Managing Acute Pain A Guide For Patients, 2006

16. Fentanyl Patch Aside… 60% of use was inappropriate for new starts
DUE: February 2013
60% of use was inappropriate for new starts
Suggested approach to starting fentanyl patches:
Continuation of home medication = appropriate
Starting a fentanyl patch:
Only Indication: CHRONIC PAIN
Opioid tolerance
Equianalgesic patch dose:
Previous 24-hour requirements + reduction for cross-tolerance
Minimum 3 days or 6 days depending on dose titration

17. Pharmacokinetics/Dynamics
IV vs PO:
Oral access  oral route preferred
Draw back: onset averages 45 minutes
IV option appropriate when…
Severe acute pain (“rescue therapy”)
No oral access
Delayed gastric emptying
Dipiro, 2008

18. Initial Doses of Opioids in Naïve and Tolerant Patients
Opioid Naïve
Opioid Tolerant
Oral IV
Hydrocodone
5-10 mg q4-6 h
N/A
Oxycodone
5 mg-10 mg q4-6 h
Morphine
15mg q4h-6h
2-4 mg q3-4 h
6-8mg q3-4 h
Hydromorphone
2 mg-4mg q4-6h
0.5-1 mg q2-3 h
2mg q2-3 h
Fentanyl
mcg q1-2 h
50-100mcg q1-2h
Equianalgesic Dosing of Opioids for Pain Management. Micromedex, 2012, Pharmacist’s Letter, 2012, Lexicomp, 2013

19. Initial Doses of Opioids in Opioid Naive Elderly Patients
IV Dose
PO Dose
Hydromorphone
0.5mg q 3h
2mg q 4h
Morphine
2-4mg IV q 3h
5-10mg q 4h
Oxycodone
N/A
2.5mg-5mg q 4h
Start on the lower end of the dosing range for frail elderly patients
Fosnight S, Delerium in the elderly, PSAP VII,

20. UMHS PCA Order Set

21. PCA Usage

22. Epidurals Good options for patients with…
Thoracotomy
Large abdominal surgeries
Aortic aneurysm repair
Orthopedic surgery
Labor and delivery
ALL medications must be preservative free

23. Patient Factors: Allergies
True Allergy
Intolerance
Anaphylaxis
Management
Avoid cross reaction
Switch to opioid in different class
Itching
Constipation
Sedation
Nausea
Phenantherenes
Phenylpiperidines
Diphenylhepatmones
Morphine
Codeine
Meperidine
Methadone
Fentanyl
Hydrocodone
Hydromorphone
Levorphanol
Oxycodone
Carbonara Baugh, Acute Pain, 2011; Dipiro, 2008

24. Formulary Agents Shortages Cost Continually changing… unfortunately
Oral is always less expensive than IV

25. Effectiveness of pain regimen
Usage of PRNs
Maxing out their PRN usage
Consider long acting agents or oral options
Consider scheduling pain medications

26. Pain Management Summary

27. Preventing, monitoring, and alleviating ADR
Constipation: bowel regimen at the time of opioid initiation
Sedation: decrease dose, hold other sedatives
Nausea/Vomiting: take with food, decrease dose, antiemetic, scopolamine patch, change to a different opioid class
Itching: antihistamine such as diphenhydramine
Avoid morphine (histamine release)
Consider oxymorphone, oxycodone, or fentanyl (less histamine release)
Carbonara Baugh, Acute Pain, 2011; Dipiro, 2008; Managing Acute Pain A Guide For Patients, 2006; D’Arcy, Acute Pain Management, 2011

28. Preventing, monitoring, and alleviating ADR
Respiratory Depression: hold opioid, may consider naloxone 0.4 mg
Naloxone Administration: Mix 0.4 mg in 9 mL NS and administer 0.5 mL q 2 minutes
Mood Changes (dysphoria > euphoria): decrease dose, consider longer acting agent
Increase in sphincter tone (urinary retention): utilize more non-opioid agents, catheterize
Analgesic Tolerance (need larger doses for same effect): increase opioid dose, opioid rotation
Dependence (withdrawal symptoms if abrupt d/c): taper patient down
Carbonara Baugh, Acute Pain, 2011; Dipiro, 2008; Managing Acute Pain A Guide For Patients, 2006; D’Arcy, Acute Pain Management, 2011

29. Equianalgesic Dosing MEDICATION IV (mg) PO (mg) RATIO DURATION (Hours)
Morphine 10 30 3
3-4
Hydromorphone (Dilaudid)
4-8
3-5
Oxycodone (Tylox, Percocet) 15
3-6
Meperidine (Demerol) 75
300 4
2-4
Hydrocodone (Lortab)
Codeine
130
200
.75
4-6

30. Opioid Conversion Change drug, keep route
Example: Change ER morphine 90 mg q 12 hours to oral hydromorphone
Calculate the 24 hour current dose:
90 mg Q12 hours x 2 doses = 180 mg PO morphine/24 hours
Use the equianalgesic ratio:
30 mg PO morphine = 7.5 mg PO hydromorphone
Calculate new dose using ratios:
180 mg = ___X___ X= 45 mg PO hydromorphone/24 hours
30 mg mg
Reduce dose 50% (incomplete cross-tolerance):
45 mg x 0.5 = 22 mg/24 hours = 4 mg oral hydromorphone q 4 hours

31. Opioid Conversion
Change drug and route
Example: Change ER Morphine 90 mg q 12 hours to IV Hydromorphone
Calculate the 24 hour current dose:
MSER 90 mg Q12 hours x 2 doses = 180 mg PO morphine/24 hours
Use the equianalgesic ratio of PO to IV morphine:
30 mg po morphine = 10 mg IV morphine
Calculate new dose using ratios:
180 mg_ = __X__ X = 60 mg IV morphine/24 hours
30 mg mg

32. Opioid Conversion Change drug and route
Example: Change ER Morphine 90 mg q 12 hours to IV hydromorphone
Use the equianalgesic ratio of IV morphine to IV hydromorphone:
10 mg morphine = 1.5 mg hydromorphone
Calculate new dose using ratios:
60 mg = __X__ X= 9 mg IV hydromorphone/24 hours
10 mg mg
Reduce dose 50% (incomplete cross-tolerance):
9 mg x 0.5 = 4.5 mg/24 hours = 0.2 mg/hour IV continuous infusion hydromorphone

33. Example CB is a 63 year old male who underwent
right knee arthroplasty 2 days ago
Opioid use in the past 24 hours:
2 doses of 100 mcg IV fentanyl
3 doses of oxycodone 10 mg
His pain is decreasing, but you would like to
send the patient out on an equivalent dose
of MSIR PRN
What is the equivalent dose of morphine?

34. Example Calculate total fentanyl dose: 0.1 mg x 2 = 0.2 mg daily
Calculate total oxycodone dose: 10 mg x 3 = 30 mg daily
Convert fentanyl IV to morphine using the equianalgesic chart: 0.1 mg Fentanyl = MSIR 30 mg
0.2 mg = __X__ X= MSIR 60 mg
0.1 mg mg
Convert oxycodone PO to MSIR using chart
30 mg = __X__ X= MSIR 45 mg
20 mg mg

35. Example Add total Morphine Dose: Reduce dose by 25-50%:
60 mg + 45 mg = 105 mg IR Morphine/Day
Reduce dose by 25-50%:
Decreased by 25%: 105 * 0.75 = 78.8 mg/Day
Decreased by 50%: 105 * 0.5 = 52.5 mg/Day
Daily Dosing Range: mg/Day
Divide by dosing interval and round to nearest tablet size:
78.8 mg/6 times per day = mg q 4 hours PRN
52.5 mg/6 times per day = 10 mg q 4 hours PRN

36. What would you do?
Ms Ima Lone 57 yr old with small cell lung cancer receiving concurrent chemoradiation
Taking MS Contin 200 mg q 12 hours
Dilaudid 4-8 mg po q 2 hours PRN (Required 6 doses in past 24 hours)
Developed esophagitis and no longer able to take oral medications. Staff were developing change in therapy as she fell in outpatient RAD ONC and broke R hip
She is out of RR after repair, unable to swallow, and reporting pain
Start Ms Lone on a PCA pump

37. What would you do?
ML 46 yr old healthy man underwent Whipple as curative surgery for pancreatic cancer
On minimal pain medication prior to surgery
Post-op RX:
Morphine 1 mg q 6 min IV prn (Max 12)
Over past 24 hrs:
75 PCA doses/113 attempts
Awake all night; Unable to get out of bed due to pain; Does not want to cough
What would you do?

38. What would you do? 75 PCA doses x 1 mg = 75 mg MS IV/24 hours
Basal: 50% of 24hr total = 37.5 mg/24 hours
37.5 mg ÷ 24 hours = 1.5 mg/hours
PCA dose considerations
Percentage of 1 hour dose 100% - 200%
Intensity of pain
Temporal pattern

39. Questions/Discussion?