1. Pain Management in the “Difficult Patient”
James Ducharme MD
Professor, Emergency Medicine
Dalhousie University
Saint John Regional Hospital

2. A 41 year-old man comes in with a 12 year
history of back pain. He has been seen in the
Pain Clinic, and has had failed attempts of TENS
and chiropractic manipulation.
He comes to the ED as he is desperate, his pain
is much worse….

3. What can you offer this patient?
What can you not offer?
More importantly, why did I ever pick up this chart?

4. Scenarios Chronic non-malignant pain Sickle cell disease
Complex regional pain syndrome
Fibromyalgia

5. Scenarios
Cancer
Multiple trauma
Substance abuse

6. Chronic non-malignant pain
Establish priorities
Highest possible quality of life
Good balance of analgesia and side effects
Combination therapy better than one medication

7. Chronic non-malignant pain
Opioid use
Long acting oral preparations, IV infusions or patches not IM injections or short-acting preparations
Distinguish between addiction and dependence for both patient and caregiver

8. Opioid use
Contractual agreement for indications for ED visits – copy of agreement with chart

9. Chronic non-malignant pain
Assess for affective component
Depression requires intervention with antidepressants not more analgesia
Verify origin/nature of pain
Neuralgic pain responds poorly to opioids

10. Chronic non-malignant pain
Ensure that new pain is not new pathology instead of worsening of old problem
Assessment may be long, may require contact with primary care MD
Establish what can and cannot be provided

11. Sickle Cell Crisis

12. Sickle Cell Disease Pain crisis often no objective findings
Pain often under treated
Patients ask repetitively for analgesia
Patients perceived as manipulative
Very low addiction rate in sicklers: 3/1900 in BMJ study

13. Sickle Cell Disease Lifelong history of inadequate care
Inability to influence quality of care
Patients feel obliged to “legitimize” their pain
Waters et al: 100% of patients had to draw attention to their pain (50% in post op setting)

14. Sickle Cell Disease
Treat sickle crisis like any other acute on chronic pain
Ann Int Med:
5 mg IV morphine followed by IV infusion (2 –12 mg/hr)
Rescue doses prn q1h

15. Ann Int Med:
D/C with MS Contin x 2 weeks if pain control within 6 hours
44% decrease in admissions
67% decrease in ED visits

16. Sickle Cell Disease
The more aggressive the pain management, the better the pain control, the shorter the stay, the fewer the ED visits
J Pain Symptom Management 2000
Dedicated team, IV loading of opioid, titrated, combination therapy, identify precipitants

17. Complex Regional Pain Syndrome
The disease formerly known as Reflex Sympathetic Dystrophy

18. Complex Regional Pain Syndrome
Chronic pain and hyperalgeisa
Sensory, motor, autonomic and dystrophic changes extending beyond the original injury site
Pain due to causalgia (pain due to nerve injury) or absence of supraspinal inhibitory pain control

19. Complex Regional Pain Syndrome
If nerve injury:
Analgesia with typical anti-neuralgic medications
Tricyclics, anti-epileptics, lidocaine dressings
Epidural blocks, lumbar sympathetic blocks

20. Complex Regional Pain Syndrome
If no nerve injury
NMDA inhibition to consider
Amantadine, ketamine
Worsening of pain resulting in ED visit cannot be well controlled during that visit
Splinting, IV lidocaine infusion,low dose ketamine are possible solutions

21. Fibromyalgia
Yes, it is a real disease!

22. Fibromyalgia
Multiple different painful sensations raise concerns about new pathology
Eliminate other illness
Combination therapy: NSAID, tricyclic, opioid if necessary, splinting if affected extremity
The difficulty is distinguishing from malingerers that profess to have this illness – no objective findings in acute setting

23. Cancer/Malignancy Related Pain

24. Cancer/Malignancy Related Pain
Distinguish between breakthrough pain and pain from separate pathology
Determine type of pain
Neuralgic
Visceral
MSK

25. Breakthrough Pain Ensure patient receiving combination therapy
NSAID either PO or even S/C infusion excellent in reducing acute pain – ibuprofen still the best choice PO
If using opioid, use SAME one patient already taking: titrate small IV doses or IR oral doses

26. Cancer/Malignancy Related Pain
Switching opioids
Variation in mu receptors
Start with no more than 50-60% of equi- analgesic dose
Eg: 200 mg morphine/day = 25 mg hydromorphone, so only start with about 15 mg

27. Analgesic adjuvants to opioids
Anesthesiology 1999: 0.5 mg/kg ketamine PO q12h
Decreased need for breakthrough oral opioids, less somnolence
J Pain and Symptom Management 1999
0.1 – 0.2 mg/kg/hr infusion ketamine in terminal patients relieved pain morphine could not

28. Analgesic adjuvants to opioids
Transdermal nitroglycerin
Anesthesiology 1999
5 mg patch daily: less break through opioids
Less adverse effects of opioids

29. “In trauma, some things just have to hurt” Trauma, Life in the ER
Multiple Trauma
“In trauma, some things just have to hurt”
Trauma, Life in the ER

30. Analgesia without destabilization:
Regional anesthesia
Epidural
Fentanyl infusion
Ketamine

31. Epidural analgesia Effective with multiple rib fractures, flail chest
Better ventilation, mobilization
Used in Britain for outpatients:
PCA epidural: bupivicaine & fentanyl

32. Fentanyl No histamine release
Can drop BP if only sustained with sympathetic discharge
Infusions easy to adjust
Level of analgesia/sedation according to need
Start infusion/hour at 2/3 dose required with boluses

33. Head Trauma and Ketamine
Anesthesiology 1997
8 patients with brain injury, ICP monitoring
Baseline sedation with propofol
1.5 – 5 mg/kg ketamine: significant decreases in ICP

34. Multiple Trauma and Ketamine
Anaesth Intens Care 1996
Fixed dose IV morphine vs. 0.1 mg/kg/hr ketamine
Less breakthrough morphine required
Better ventilation
Better mobilization

35. Substance Abuse
Stress related to substance abuse issues is most often related to lack of knowledge

36. Chronic opioid use in patients with history of abuse
Less likely to abuse prescriptions:
Isolated alcohol abuse
Remote abuse history
Good support system
AA participation

37. Chronic opioid use in patients with history of abuse
More likely to misuse prescriptions
Early abuse
History of poly-substance abuse
Abuse of oxycodone
J Pain and Symptom Management 1996

38. Acute Pain Management and Abuse
If painful condition, will need larger doses to control pain. Accept this and treat patient
Consider options:
Combination or balanced analgesia: epidural or regional anesthesia, ketamine infusion, NSAID use

39. Drug seeking behavior Address this directly, but not confrontation
Suggest the patient has a problem with substance abuse
Offer options of care for both the acute problem as well as the abuse problem

40. Drug seeking behavior
When confronted with a possible painful condition, but you suspect abuse
State your suspicions
Obtain info from other sources
If still uncertain provide oral analgesia – morphine if short acting, or long acting preparation – but only enough to see FMD

41. Final Thoughts Do not set up an adversarial relationship with patients
Acute pain management does not lead to addiction
We do not know the patient’s degree of pain better than they do

42. Final Thoughts
Poor pain control arises from misdiagnosing the origin of pain, from false beliefs and from poor knowledge – all which can be corrected