1. Acute Pain Management Jeff Adams MD

2. Pain Management is a Three- way Street Hopefully this functions better than a highway constructed the same way. patient  physician  nurse patient  physician  nurse PAIN PAIN This only works if there is sharing of knowledge and questioning by all parties.

3. Which of the following is a false requirement of JC 1. Pain is assessed in all patients 2. Discharge must provide for continued care of pain 3. Patients are educated about pain as part of treatment 4. Patients receiving pain medications are monitored post-procedure 5. None of the above are false

4. Why the concern about pain management? JCAHO Joint commission on accreditation of healthcare organizations: JCAHO Joint commission on accreditation of healthcare organizations: Patients have the right to appropriate assessment and management of pain. Patients have the right to appropriate assessment and management of pain. Pain is assessed in all patients. Pain is assessed in all patients. Policies and procedures support safe medication prescription or ordering. Policies and procedures support safe medication prescription or ordering.

5. Why the concern about pain management? The patient is monitored during the post-procedure period. The patient is monitored during the post-procedure period. Patients are educated about pain and managing pain as part of treatment, as appropriate. Patients are educated about pain and managing pain as part of treatment, as appropriate. The discharge process provides for continuing care based upon the patient's assessed needs at the time of discharge. The discharge process provides for continuing care based upon the patient's assessed needs at the time of discharge.

6. Which of the following is the best tool to access a child’s level of pain? 1. Assessment by physician 2. Assessment by nurse 3. Assessment by parent 4. Self reporting using a numeric scale 5. Self reporting using a face scale

7. The 5th vital sign Evaluating Assume patient self-reporting is the best method to assess pain Assume patient self-reporting is the best method to assess pain Numeric scale works well in adults if no cognitive dysfunction Numeric scale works well in adults if no cognitive dysfunction In children, parents are better at accurately rating pain then the physician. Faces scale or poker chip tool work well. In children, parents are better at accurately rating pain then the physician. Faces scale or poker chip tool work well.

8. The 5th vital sign Evaluating Revaluate pain levels Revaluate pain levels Have system in place for patient to contact care provider if pain not well controlled Have system in place for patient to contact care provider if pain not well controlled Minorities, are less likely than Caucasians to be treated with analgesics in the ED. the elderly and children also receive suboptimal treatment. Minorities, are less likely than Caucasians to be treated with analgesics in the ED. the elderly and children also receive suboptimal treatment.

9. Which of the following types of pain is most typically in a elderly patient with ischemic bowel, notable for classically presenting with pain disproportionate to clinical findings? 1. Neuropathic pain 2. Somatic nociceptive 3. Viseral nociceptive 4. Homeopathic pain 5. Allopathic pain

10. Types of pain Patients may have a combination of types Patients may have a combination of types Nociceptive Nociceptive 2 types somatic and visceral 2 types somatic and visceral Neuropathic Neuropathic

11. Nociceptive Tissue damage occurs Tissue damage occurs Histamine, serotonin, bradykinen, substance P, prostaglandins are released Histamine, serotonin, bradykinen, substance P, prostaglandins are released Trigger the nerve Trigger the nerve Reduce future stimuli needed to depolarize the nerve Reduce future stimuli needed to depolarize the nerve

12. Neuropathic Results form damage to the nerve, not stimulation Results form damage to the nerve, not stimulation Dysesthesias occur: burning, tingling, stabbing, electric-like Dysesthesias occur: burning, tingling, stabbing, electric-like DM, MS, Herniated disc, AIDS, post shingles, radiation, chemotherapy DM, MS, Herniated disc, AIDS, post shingles, radiation, chemotherapy

13. Somatic Nociceptive Pain Localizing pinprick, stabbing Localizing pinprick, stabbing Travel via fast A delta fibers Travel via fast A delta fibers Cross over in the spinal cord and ascend to brain stem Cross over in the spinal cord and ascend to brain stem

14. Visceral Nociceptive Pain Dull, generalized, ache Dull, generalized, ache Travel via slow c-fibers Travel via slow c-fibers Synapse in the spinal cord with other interneurons Synapse in the spinal cord with other interneurons Referred pain caused by contact with somatic afferent fibers Referred pain caused by contact with somatic afferent fibers Travel with the autonomic nerves creates associated symptoms such as N/V, hypotension, bradycardia, and sweating. Travel with the autonomic nerves creates associated symptoms such as N/V, hypotension, bradycardia, and sweating.

15. Treatment of Neuropathic Pain May be resistant to opioid therapy May be resistant to opioid therapy Mainstay of therapy: Mainstay of therapy: Anticonvulsants: may work best for burning pain (gabapentin/Neurontin) Anticonvulsants: may work best for burning pain (gabapentin/Neurontin) Antidepressants: may work best for lancinating pain Antidepressants: may work best for lancinating pain

16. Which of the following medications, using comparable dosages, is the most effective for pain management? 1. Ketorolac (Toradol) 2. Acetaminophen 3. Ibuprofen 4. Aspirin 5. Celecoxib (Celebrex)

17. Non-narcotic Pain Medications They all are co-analgesics and can enhance pain relief even if a narcotic is being used. They all are co-analgesics and can enhance pain relief even if a narcotic is being used. They all may diminish bone formation, healing, and remodeling. They all may diminish bone formation, healing, and remodeling. ASA = Acetaminophen = ~5mg oxycodone for analgesia ASA = Acetaminophen = ~5mg oxycodone for analgesia 1000 mg ASA < 600-800 mg of ibuprofen for analgesia 1000 mg ASA < 600-800 mg of ibuprofen for analgesia ~ all equal ~ all equal

18. Non-narcotic Pain Medications Acetaminophen: 4 gram maximum / day in a healthy individual Acetaminophen: 4 gram maximum / day in a healthy individual Lortab has 500 mg APAP/tab which limits total number of tablets to 8/ day Lortab has 500 mg APAP/tab which limits total number of tablets to 8/ day Ibuprofen < 1600 mg has a risk of GI bleed equal to placebo Ibuprofen < 1600 mg has a risk of GI bleed equal to placebo

19. Non-narcotic Pain Medications Cox-2s Cox-2s traditional NSAIDs produce equal analgesia traditional NSAIDs produce equal analgesia May have less GI protection then CLASS trial suggest May have less GI protection then CLASS trial suggest Have prothrombotic activity Have prothrombotic activity Increased risk for MI Increased risk for MI Not necessarily cost effective Not necessarily cost effective

20. A 20 year old female has had a severe sore throat(7/10) for two days. Her quick strep test is positive. You suspect Strep. and would like to treat her pain. Which of the following medications would you select? 1. Acetaminophen with codeine (Tylenol #3) 2. Propoxyphene (Darvon) 3. Acetaminophen with hydrocodone (Lortab, Vicodin) 4. Acetaminophen with oxycodone (Percocet) 5. Oxycotin

21. Propoxyphene Not superior to acetaminophen alone Not superior to acetaminophen alone 100 mg of propoxyphene = 50 mg of codeine 100 mg of propoxyphene = 50 mg of codeine Toxic metabolite - norpropoxyphene that can cause cardiac conduction abnormalities and seizures, hallucinations, confusion Toxic metabolite - norpropoxyphene that can cause cardiac conduction abnormalities and seizures, hallucinations, confusion

22. Codeine vs. Hydrocodone vs. Oxycodone

23. Codeine 10% of the population can not metabolize codeine to its active opioid and therefore receive no benefit 10% of the population can not metabolize codeine to its active opioid and therefore receive no benefit Codeine has been shown to add < 5% increase in analgesia with a disproportionate increase in side-effects. Codeine has been shown to add < 5% increase in analgesia with a disproportionate increase in side-effects. 60 mg of codeine is = to 650 mg of ASA or acetaminophen 60 mg of codeine is = to 650 mg of ASA or acetaminophen

24. Oxycotin Just as effective as oxycodone, just longer acting Just as effective as oxycodone, just longer acting Not indicated for acute pain management (FDA) Not indicated for acute pain management (FDA)

25. 16 year old male presents with a knife wound to the RLQ with pain described as 8/10. He is tender with palpation around the 2 cm, closed, laceration. 16 year old male presents with a knife wound to the RLQ with pain described as 8/10. He is tender with palpation around the 2 cm, closed, laceration. Physical exam is otherwise normal. Vital signs stable BP: 125/80, P:68, R: 18. The patient has an IV. Physical exam is otherwise normal. Vital signs stable BP: 125/80, P:68, R: 18. The patient has an IV.

26. The ED doctor is evaluating the patient, so you speak to the surgeon who will be there in 20 minutes. The surgeon request that you order labs, a CT of the abdomen and not give any pain medications. You relay this information to the ED doctor. Your expectation of the ED doctor would be to: 1. order the labs, call for a CT abd., and await the surgeon 2. order the labs, call for a CT abd., and give IV narcotics

27. Treating abdominal pain does not mask physical findings. It may actually help localize the area of pain. Treating abdominal pain does not mask physical findings. It may actually help localize the area of pain. The surgeon can reverse the opioid with naloxone if he wishes. The surgeon can reverse the opioid with naloxone if he wishes.

28. Which of the following would be your choice to managing his pain? 1. Meperidine (Demerol) 2. Morphine 3. Hydromorphone (Dilaudid) 4. Fentanyl 5. Butorphanol (Stadol)

29. The best choice would be fentanyl since the patient has the potential to hemorrhage and fentanyl is least likely to cause hypotension. The best choice would be fentanyl since the patient has the potential to hemorrhage and fentanyl is least likely to cause hypotension. The following slides will discuss fentanyl as well as the other choices. The following slides will discuss fentanyl as well as the other choices.

30. Fentanyl Dosage is different (100 mcg) IV = 10 mg MS IV Dosage is different (100 mcg) IV = 10 mg MS IV Works well Works well Faster onset then MS by ~5 minutes Faster onset then MS by ~5 minutes Cost: less now that it is generic Cost: less now that it is generic Muscle rigidity of chest wall and laryngospasm has occurred but a high dosages. Muscle rigidity of chest wall and laryngospasm has occurred but a high dosages.

31. Morphine Morphine 6-10 mg IV Morphine 6-10 mg IV Cheap Cheap Effective Effective Titrate every 10-15 minutes with no upper limit Titrate every 10-15 minutes with no upper limit Causes histamine release which can produce hypotension Causes histamine release which can produce hypotension

32. Hydromorphone (Dilaudid) 1 mg IV of Hydromorphone = 6-7 mg IV of MS 1 mg IV of Hydromorphone = 6-7 mg IV of MS Less histamine release but can still can cause hypotension Less histamine release but can still can cause hypotension

33. Butorphanol (Stadol) Agonist / antagonist Agonist / antagonist Antagonizes its own analgesia at higher dosages. Antagonizes its own analgesia at higher dosages. Can cause opioid withdrawal Can cause opioid withdrawal Increased incidence of confusion and hallucinations compared to agonist-only narcotics Increased incidence of confusion and hallucinations compared to agonist-only narcotics

34. Which of the following is the most accurate statement about meperidine (Demerol)? 1. It can be titrated to achieve pain relief 2. It can be used with SSRIs 3. It is absorbed well IM 4. It has a 4 hour duration of action 5. It is more addictive than other narcotics

35. Meperidine (Demerol) Can be used for acute pain Can be used for acute pain 10 mg of MS q 4 hours = 100-150 mg meperidine q 3 hours 10 mg of MS q 4 hours = 100-150 mg meperidine q 3 hours Problems with it: Problems with it: Originally developed as an atropine analog and therefore has anticholinergic side-effects (dries secretions, tachycardia, etc.) Originally developed as an atropine analog and therefore has anticholinergic side-effects (dries secretions, tachycardia, etc.) Short, 2-3 hour duration of action Short, 2-3 hour duration of action

36. Meperidine (Demerol): More Problems: Active metabolite normeperidine is a CNS irritant, with a half-life of 15-20 hours Active metabolite normeperidine is a CNS irritant, with a half-life of 15-20 hours Contraindicated for patients on MAO inhibitors and SSRIs (serotonin syndrome) Contraindicated for patients on MAO inhibitors and SSRIs (serotonin syndrome) Meperidine is erratically absorbed when given IM Meperidine is erratically absorbed when given IM

37. A 55 year old presents with a 2 hour history of sudden onset, severe, 10/10 right flank pain and has 300 RBC in his urinalysis. Which of the following would you recommend to manage his pain? 1. Morphine 2. Ketorolac (Toradol) 3. Morphine and ketorolac 4. Morphine and ibuprophen

38. Opioids work quicker than NSAID (takes ~ 20 minutes) Opioids work quicker than NSAID (takes ~ 20 minutes) NSAIDs is at least as effective as opioids for ureteral colic NSAIDs is at least as effective as opioids for ureteral colic Smooth muscle tension is directly mediated by prostaglandins. Smooth muscle tension is directly mediated by prostaglandins.

39. Some urologist are concerned about NSAIDs effect on platelets. Some urologist are concerned about NSAIDs effect on platelets. The only benefit of ketorolac is it’s parental route The only benefit of ketorolac is it’s parental route Oral NSAIDs have been shown to have equal onset to parental ketorolac Oral NSAIDs have been shown to have equal onset to parental ketorolac

40. A 40 year old female presents with RUQ pain for 4 hours described as 8/10. She has a history of similar pain, after meals, twice in the last two months. A 40 year old female presents with RUQ pain for 4 hours described as 8/10. She has a history of similar pain, after meals, twice in the last two months. One week ago she had an ultrasound and was told she had gallstones. The patient has an IV. One week ago she had an ultrasound and was told she had gallstones. The patient has an IV.

41. Which of the following pain medications would you choose? 1. Meperidine (Demerol) 2. Morphine 3. Hydromorphone (Dilaudid) 4. Fentanyl 5. Butorphanol (Stadol)

42. An equianalgesic dosage of meperidine has the same risk of causing biliary muscle spasm as other opioids. An equianalgesic dosage of meperidine has the same risk of causing biliary muscle spasm as other opioids.

43. Which of the following pain medications has a similar action to butorphanol (Stadol) ? 1. Hydromorphone 2. Fentanyl 3. Hydrocodone 4. Pentazocine (Talwin) 5. Oxycodone 6. Propoxyphene (Darvon)

44. Pentazocine (Talwin) is an agonist / antagonist Pentazocine (Talwin) is an agonist / antagonist Same problems as with other agonist / antagonist: Same problems as with other agonist / antagonist: Antagonizes its own analgesia at higher dosages. Antagonizes its own analgesia at higher dosages. Can cause opioid withdrawal Can cause opioid withdrawal Can cause confusion and hallucinations Can cause confusion and hallucinations

45. With an opioid IM injection, consider adding hydroxyzine (Vistaril)? 1. True 2. False 3. Trick question

46. Which of the following is an accurate description of tramadol (Ultram)? 1. It has been shown to be consistently better then placebo 2. It adds no additive analgesic effect when combined with NSAIDs 3. It has one mechanism of action 4. It has an opioid-like effect yet has a low abuse potential

47. Tramadol (Ultram) It has an opioid-like effect yet has a low abuse potential It has an opioid-like effect yet has a low abuse potential Some studies have found it to be less effective than codeine and hydrocodone when used in pain management in acute pain Some studies have found it to be less effective than codeine and hydrocodone when used in pain management in acute pain It works on different sites than NSAIDs. There are studies which have shown synergistic effects. It works on different sites than NSAIDs. There are studies which have shown synergistic effects.

48. Tramadol (Ultram) It has two mechanisms of action; one is via the liver just like codeine to an active opioid, the other inhibits serotonin and norepinephrine reuptake. It has two mechanisms of action; one is via the liver just like codeine to an active opioid, the other inhibits serotonin and norepinephrine reuptake. It may be of use in neuropathic pain due to its inhibiting serotonin and norepinephrine reuptake. It may be of use in neuropathic pain due to its inhibiting serotonin and norepinephrine reuptake.

49. History and Exam: 13 year old child with a swollen ankle secondary to a fall in gym. Ambulatory at the scene but not now. Only tenderness is inferior to the lateral malleolus. Pain 8/10. Wt: 60 Kg

50. What would you do at this time? 1. Treat pain and get a x-ray of the ankle 2. Treat pain 3. Get a x-ray of the ankle