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“My arm hurts.”
Pain Management
Stephanie Kim PGY-3
Intern Bootcamp, July 2014
OUTLINE
•
Types of pain
•
Tylenol
•
NSAIDs
•
Opioids
•
Conversions
•
PCAs
•
Special situations
•
Anticonvulsants
•
Antidepressants
NEUROPATHIC PAIN
•caused
•eg.
by damage within nervous system
DM neuropathy, postherpetic neuralgia,
stroke
NEUROPATHIC PAIN:
TREATMENT
•
•
•
1st line:
•
Anticonvulsants: pregabalin, gabapentin
•
SNRIs: duloxetine, venlafaxine
•
TCAs: amitriptyline, nortriptyline (better SE profile)
2nd line:
•
weak opioids
•
opioids
Others: topical anesthetics (lidocaine patch)
NOCICEPTIVE PAIN
•
caused by stimuli threatening tissue damage
•
eg. musculoskeletal, inflammation,
mechanical/compressive
NOCICEPTIVE PAIN:
TREATMENT
•
•
Mild-Mod:
•
topical: lidocaine, capsaicin
•
inflammatory w/out RFs: NSAIDs + PPI
•
non-inflammatory or RFs for NSAIDs: tylenol
Severe/Refractory:
•
TCAs or SNRIs
•
Opioids
ACETAMINOPHEN
•
Initial Dose: 325-650mg q4-6h
•
Max: 4gm/day if short-term; 3gm/day in general
•
Considerations:
•
if increased risk of hepatotoxicity: 2gm/day max dose
•
don’t forget about IV tylenol, we can give 1gm q6h x 4
NSAIDs
•
General considerations:
•
synergy with opioids
•
AVOID in
•
•
•
•
•
•
•
renal insufficiency CrCl <60, increased age
heart failure, resistant hypertension
hepatic failure, cirrhosis
PUD, GIB
h/o platelet dysfunction, on aspirin
on anticoagulation
CAUTION with steroids
IBUPROFEN
•
Initial Dose: 400mg q4-6h
•
Max:
•
•
3200mg qd if acute
•
2400mg qd if chronic
Considerations:
•
200mg to 400mg comparable with 650mg tylenol
NAPROXEN
•
•
•
Dose:
•
naproxen base 200-500mg q12h
•
naproxen sodium 220-550mg q12h
Max:
•
base: 1250mg qd acute, 1000mg qd chronic
•
sodium: 1375mg qd acute, 1100mg qd chronic
Considerations:
•
naproxen sodium has more rapid onset than naproxen base
•
naproxen may have less CV toxicity than other NSAIDs
•
if rheumatologic d/o, 1500mg qd max
IV KETOROLAC
•
•
•
Initial dose:
•
if >65yo and >50kg: 15-30mg q6h
•
if >65yo or <50kg: 15mg q6h
Max:
•
if >65yo and >50kg: 120mg qd x 5 days
•
if <65yo or <50kg: 60mg qd x 5 days
Considerations:
•
used for short-term acute pain control
•
increased risk of gastropathy after 5 days
•
PO ketorolac has no advantage over other PO NSAIDs
•
not indication for chronic pain control
OPIOIDS
•
Properties of receptors
•
Mu1: supraspinal analgesia, bradycardia, sedation
•
Mu2: respiratory depression, euphoria, dependence
•
Delta: spinal analgesia, respiratory depression
•
Kappa: spinal analgesia, respiratory depression, sedation
OPIOIDS
•
•
•
General considerations:
•
in back pain, opioids vs placebo – no diff in pain scores
•
in neuropathic pain, opioids are 2nd line
Assessing risk:
•
HIGH RISK: personal or family history of EtOH/drugs
•
HIGH RISK: psych d/o
Things that mitigate risk:
•
poor performance status
•
restricted prognosis
PRINCIPLES OF USE
•
•
WHO Ladder: a stepwise approach
•
Mild pain: Tylenol, NSAID, +/- adjuvant
•
Moderate: Codeine/tramadol, +/- nonopioid, +/- adj
•
Severe: Opioid, +/- nonopioid, +/- adj
If chronic, may need a fixed dose schedule for opioids
•
•
50-75% long-acting, rest short-acting
DON’T FORGET A BOWEL REGIMEN
SIDE EFFECTS
•
N/V 2/2 activation of chemoreceptor trigger zone in medulla
•
delayed gastric emptying, constipation
•
hyperalgesia
•
narcotic bowel (hyperalgesia of gut – severe chronic abd pain)
•
sedation
•
respiratory depression
TRAMADOL
•
weak Mu agonist, reuptake inhibitor of NE and SE
•
Dose: 50-100mg q4-6h
•
Max: 300mg qd
•
Considerations:
•
not recommended in renal insufficiency
•
SE: seizure, worsening depression, SI
MORPHINE
IMMEDIATE RELEASE
•
Initial Dose:
•
2-5mg IV q2-4h
•
2-10mg SQ q3-4h
•
15-30mg PO q3-4h
EXTENDED RELEASE / MSCONTIN
•
Initial dose:
•
15mg PO q8-12h
AVOID IN RENAL FAILURE!
OXYCODONE
IMMEDIATE RELEASE
•
Initial dose:
•
5-15mg PO q4-6h
EXTENDED RELEASE / OXYCONTIN
•
Initial Dose:
•
10mg PO BID
HYDROMORPHONE
•
•
Initial Dose:
•
0.2-1mg IV q2-4h
•
0.2-1mg SQ q3-4h
•
2-8mg PO q3-4h
Considerations:
•
high potency
•
give for short-term acute pain
•
when PO route is not available
FENTANYL
•
•
Initial Dose:
•
12-25mcg TD q72h
•
25-50mg IV/SQ q1-2h
Considerations:
•
not recommended for acute pain
•
not recommended for opioid naive patients
•
IV infusions used in the ICU
caution
•
•
CODEINE
•
not recommended for chronic pain
•
dose-related side effects
•
polymorphic metabolism, multiple drug interactions
METHADONE
•
call Palliative Care
EXAMPLES
•
Mild-mod pain: schedule tylenol q6h, with oxycodone 5mg prn
•
Mod-sev pain:
•
if opioid-naive, start short-acting prn
•
eg. oxycodone 5mg q4h prn
•
if chronic pain, convert 50-75% of daily use to long-acting
•
eg. oxycodone ER 10mg BID, oxycodone IR 5mg q4h prn
•
if acute/or no PO route, IV morphine or dilaudid prn
TITRATION
50-100% increase
25-50% increase
25% increase
Mild pain
1-3/10
Severe pain
7-10/10
Moderate pain
4-6/10
Weinstein, Pain Presentation 10/2013
CONVERSION
Drug
PO/PR (mg)
IV/SC (mg)
Morphine
30
10
Oxycodone
20
n/a
Hydromorphone
7.5
1.5
Codeine
200
120
Hydrocodone
30
n/a
Fentanyl
n/a
Methadone
Complex
Weinstein, Pain Presentation 10/2013
MORE CONVERSION
Fentanyl patch conversion
•
1 mcg transdermal fentanyl = 2 mg oral morphine
•
Fentanyl 25 mcg/hr patch = 50 mg oral morphine/24 hrs
•
Fentanyl 100 mcq/hr patch = 200 mg oral morphine/24 hrs
•
Use caution in opioid-naïve patients
•
Titrate every 72 hours
Weinstein, Pain Presentation 10/2013
Starting a PCA
•
Demand
•
Lockout
•
Basal
•
Bolus prn: default in EMR
•
example: dilaudid 0.2mg demand with q6min lockout
Sickle Cell Crisis
•
in ED or Acute Care Clinic, pt will be given IV boluses
•
check to see if there is a Care Path in Portal
•
if not, and no other contradictions, start IVF and PCA
•
can augment with IV toradol if no renal insufficiency
•
transition to home PO regimen when pain controlled
End-of-life
•
opioids prescribed for pain and dyspnea
•
oxycodone and morphine oral liquid concentrate
•
can give q1h prn
•
morphine gtt for increased work of breathing at the end
•
•
start at 3mg/hr, have RN titrate to RR <20
•
may need to bolus until effective dose found
•
be careful with renal failure
don’t forget prn ativan, haldol, zofran, glycopyrrolate
ANTICONVULSANTS
GABAPENTIN
•
Dose: start a low dose 300mg qhs, uptitrate to TID
•
Max: 3600mg qd in 3 divided doses
•
studied in postherpetic neuralgia and DM neuropathy
PREGABALIN
•
•
Dose: start at 75mg BID
•
Max: 300mg qd in divided doses
•
studied in postherpetic neuralgia and DM neuropathy
•
used but less effective in central neuropathic pain, FM
Considerations: RENALLY DOSE, sedation
ANTIDEPRESSANTS
General Considerations
•
analgesic effects occur earlier (1 wk)
•
used at lower dose
•
TCAs and SNRIs
TCA
NORTRIPTYLINE
•
DOSE:10mg qd, max 75mg qd
•
SE:
•
•
anticholinergic: dry mouth, constipation, urinary retention
•
CV: arrhythmias, heart block, MI
•
GI: N/V, dyspepsia
•
Neuro: ataxia, tremors, sedation
Avoid in:
•
heart disease, conduction disturbances (prolonged QT)
•
GI dysfunction
SNRI
VENLAFAXINE
•
DOSE: 150-225mg qd
•
Used in DM neuropathy
•
Avoid in conduction abn
DULOXETINE
•
DOSE: 60mg qd
•
Used in DM neuropathy, FM, back pain, OA
•
Avoid in hepatic or renal insufficiency
THANKS
•
to Dr. Elizabeth Weinstein and Dr. Christine Koniaris
•
CONGRATS on making it to Block 1b!
•
EMAIL me @ [email protected]