Pain Management in the “Difficult Patient”

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. 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