Acute Pain Management in the Hospital

1. Acute Pain Management in the Hospital Ken Jarman, PharmD

2. AGENDA Introduction to pain management Barriers Cases: Medication selection & dosing Equianalgesic dose conversions Rules to remember Questions

3. PAIN Subjective Physical and psychological consequences Associated with poor outcomes Fifth vital sign/ Multiple National Guidelines

4. BARRIERS Institutional Health Care professional Patient and family

5. CASE DISCUSSIONS A 22 yo male is seen in urgent care with an ankle sprain from playing basketball. What would you prescribe initially for his pain? Nonopioid analgesic is appropriate initially Do nonopioid analgesics have any role in more severe pain? They work synergistically with opioids and have been shown to provide an opioid dose-sparing effect

6. CASE DISCUSSIONS In which patients should you avoid NSAID�s? PUD, coagulopathies, history of hypersensitivity to aspirin or other NSAID�s, renal disease, ESLD, CHF Which NSAID works the best? No data demonstrating one provides more pain relief than another

7. DOSING NONOPIOIDS

8. OPIOID SELECTION AND DOSING Pain severity Prior opioid exposure Age Comorbidities Route of administration

9. OPIOIDS What are some examples of moderate potency and high potency opioids? Moderate: hydrocodone, oxycodone, morphine, meperidine, codeine High: hydromorphone, fentanyl

10. CASE DISCUSSIONS A 45 yo male is admitted for a femur fracture after a ski accident. He is not on any meds and he has no significant PMH. What do you want to do initially for his pain? What is the risk for respiratory depression in this gentleman? What about the risk of psychological dependence or addiction to opiates?

11. CASE DISCUSSIONS What is pseudoaddiction? Behavioral changes in patients that seem similar to those in patients with opioid dependence or addiction but are secondary to inadequate pain control (�drug seeking�) What is the maximum effective dose of morphine that can be given to this patient? There is not a ceiling effect with pure ? agonists Which opioid is the most effective? Unpredictable degrees of incomplete cross-tolerance amongst agents(analgesia & adverse effects) Situational needs and routes of administration available

12. CASE DISCUSSIONS What if the previous patient was 76 yo with a PMH significant for CHF, DM, COPD, and CRI w/ baseline Cr of 2.2? Would this influence your opioid selection or dosing? Why? Meperidine is metabolized to normeperidine a toxic metabolite with a long half-life that is renally excreted; limit duration to less than 48 hours and dose NTE 600mg/day in those w/ nl renal fxn Morphine is conjugated to an active metabolite and elimination is directly related to creatinine clearance; ? risk of resp depression has been observed in uremic patients

13. CASE DISCUSSIONS What if your patient was a 92 yo female admitted for a hip fracture after falling at a skilled nursing facility? Lower opioid doses generally required and duration of effect is typically longer in elderly patients (i.e. decreased dosing frequency) Elderly are more susceptible to CNS adverse effects

14. CASE DISCUSSIONS A 52 yo male w/ IVDA (heroin) admitted to medicine for an epidural abscess is complaining of 10/10 pain. He states he is allergic to codeine and ketorolac. Is there anything important about his stated allergies? Identify true allergies Agents with least cross-reactivity: meperidine, fentanyl and methadone Higher cross-reactivity: morphine, oxycodone, hydromorphone and hydrocodone Ideally we could use an NSAID in addition to opioids

15. CASE DISCUSSIONS Will opiate withdrawal potentially influence this patients perception of pain? Typically have abnormally low tolerance for pain that is worsened by withdrawal syndrome Maintenance treatment for withdrawal prevention should be considered separate from acute pain management or at least not as a substitute Set realistic goals with the patient but be aggressive in treating true pain

16. CASE DISCUSSIONS Will the patients history of IVDA with heroin influence your choice of opioid or initial dosing? Typically require HIGHER and more frequent doses of opioids to achieve adequate pain control

17. DOSING FOR COMMON OPIOIDS Typical starting doses Morphine: 2-10 mg iv/im/subq q3-4h or 15-30 mg po q3-6h Oxycodone: 5-20 mg po q3-4h Hydromorphone: 0.5-2 iv/im/subq q3-4h or 2-8 mg po q3-4h Fentanyl: 25-100 mcg iv q1-2h Methadone: 2.5-10 mg iv/im q4-8h or 5-20 mg po q4-8h Hydromorphone is ~ 5x more potent than morphine, fentanyl is ~ 100x more potent than morphine 20 mg of oxycodone is roughly equivalent to 30 mg of MSIR

18. KINETICS OF COMMON INTRAVENOUS OPIOIDS

19. ADVERSE REACTIONS Constipation Nausea Itching Sedation and cognitive impairment Respiratory depression Urinary retention Note: Hydromorphone is associated with fewer ADRs but increased psychological dependence

20. TRANSITION FROM PCA Calculate 24-hour morphine equivalent Convert to agent of choice using equianalgesic table Reduce dose by 20-30% for potential variability from absorption and difference in agents Consider ongoing changes in pain stimuli and patient needs

21. RULES TO REMEMBER Reassess patient regularly Efficacy and tolerability Administer analgesics regularly on schedule if pain is persistent Breakthrough pain meds should be included in regimen Use a nonopioid analgesic in addition to an opioid analgesic when possible

22. RULES TO REMEMBER CONT. Consider dosage increases of 50% for inadequate analgesic relief Prescribe a prophylactic bowel regimen Avoid the use of meperidine when feasible Take pain management seriously

23. INTERNET RESOURCES www.ampainsoc.org http://painconsortium.nih.gov

24. QUESTIONS?