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

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

4. “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

5. 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

6. 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

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

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

10. Pain Management
Know your analgesics

11. WHO 3 step ladder
Step 1
Acetaminophen
Nonsteroidals
Aspirin

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

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

14. 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!

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

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

17. 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!

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

19. Pain Management
Always start with short-acting opioids

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

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

22. Least to most potent Codeine Tramadol Morphine = Hydrocodone Oxycodone
Hydromorphone

23. Effective ORAL Starting Doses
Codeine 30 mg
Tramadol mg
Morphine = Hydrocodone 5 mg
Oxycodone 3 mg
Hydromorphone 1 mg

24. 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

25. 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!

26. Pain Management
Describe the principles of opioid dose escalation

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

28. Escalation Short-acting PO single-agent  every 2 hours
IV opioids  every 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

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

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

31. 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?

32. 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

33. 2mg IV morphine administered and 30 minutes later patient still in pain
For ongoing moderate to severe pain increase opioid doses by %
For ongoing mild to moderate pain increase by %

34. 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

35. 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."

36. 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.

37. 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!

38. 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

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

40. 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

41. 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

42. 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!

43. 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

44. 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

45. 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!

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

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

48. 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!

49. 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

50. 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

52. 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.

53. 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!

54. 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

55. Managing Chronic Pain

56. Questions?