1. Treating Pain ADEQUATELY, and Staying Safe… Patients and Physicians Alike: Cases from the Field Laurie Lyckholm MD FACP Hematology/Oncology and Palliative Medicine Massey Cancer Center Virginia Commonwealth University

2. Objectives Examine cases in which pain management is a challenge. Demonstrate how pain management may be applied safely and appropriately in any situation

3. Rob L. 30 y/o healthy man admitted to the ED with crush injury of Lt leg Ruptured popliteal artery Bilateral compartment syndrome

4. Rob L. Given enough IV pain meds in ED to take the edge off. To OR for emergent fem-pop bypass, bilateral fasciotomies from ankles to thighs

5. Rob L. Epidural for 24 hours after surgery; fair pain control, then… Weaning begins…hydromorphone PCA initially at 2 mg every 6 minutes reduced to 1mg after 12 hours, despite pain scores 8-10. Severe pain…10/10 persists, even with patient using hydromorphone PCA regularly Patient asking for more pain medicine regularly

6. Rob L. 12 hours later, PCA discontinued and started on prn hydromorphone every 4-6 hours

7. Rob L. He shouldnt be having that much pain.

8. Rob L. 30 y/o usually very stoic, macho man crying BEGGING for pain medicine every hour Rates pain continuously as 10/10

9. Rob L. Pain consult called after 3 days of intense untreated pain, pts mother insists Full pain consult by trusted Pain/Palliative Care team None of consultant recommendations followed

10. Rob L. Pain continues Nurses are distressed Team refuses to increase pain medicine he shouldnt be having that much pain… Pain team calls charge nurse first, who says his hands are tied Pain team calls attending physician, who restarts PCA hydromorphone at appropriate dosing (1mg every 6 minutes and 4 mg bolus every hour) and patient becomes more comfortable

11. Rob L. Over the course of the next few days, Robs condition improves and he is comfortable, using 1mg IV dilaudid twice an hour on average, and 1-2 4mg boluses/day. Bolus before and during dressing changes, which involve peeling dressings off open fasciotomies.

12. Rob L. Day of discharge. To have ongoing dressing changes and wound care by Home Health PCA discontinued. Prescription?

13. Rob L. Dilaudid 2mg; 1 tablet every 6 -8 hours for pain #10 Appointment in 1 week.

14. What went wrong??? Undertreatment WHY?? –Assumptions –Biases –Fear –Lack of experience –Lack of education

15. How could it be done better?

16. Jenna T. 35 y/o woman with metastatic breast cancer Pain from primary breast lesion as well as sternal and left humerus pain from metastases. Using MS Contin 120mg every 12 hours MSIR 15-30 mg every 3-4 hours for breakthrough pain Says pain fairly well controlled

17. Jenna T. Calls clinic nurselost medications; had purse stolen

18. Jenna T. Calls the next week; pain is worse; needs more medications

19. Jenna T. Calls the next week; pain is worse; needs more medications; sister will pick up Does not show up for next appointment Calls the week after did not show; needs more medications; pain out of control. Comes in for appointment. Clearly in pain, very quiet, furrowed brow. Winces with movement. Calls the next week. Out of meds; says they were stolen.

20. Jenna T. Ways to help Jenna but stay safe: –Drug Screen, but careful…know your screens! –Weekly refills –Patient herself must come to pick up –Frequent brief appointments –Single pharmacy –Single physician writing meds –Talk with pharmacist directly to discuss plan (HIPAA – okay)

21. Final Messages Even the most difficult pain patients can be treated safely but must be collaborative and truthful Burden of proof on the physician if they do not believe the patient Dont make assumptions based on socioeconomic biases Talk with your patient about concerns

22. Final Messages Work with your pharmacist directly; call before sending patient if very large number or unusual way of taking medication. Telegraph messages on the rx pad –for cancer pain or for chronic back pain –Write out number prescribed: 100 (one hundred).

23. Final Messages DOCUMENT each visit and why pain medicines prescribed If prescribing large doses, request frequent visits and/or phone calls if patient unable to transport easily, document phone calls in patient chart

24. Final Messages DOCUMENT DOCUMENT!!!