Acute Pain Management

Solomon Liao, M.D.Clinical Professor

Director of Palliative Care Service

UCI Hospitalist Program

ObjectivesBy the end of this session, participants will be able

to:

Use opioids appropriately in an inpatient setting Address side-effects

Master opioid conversions Choose the appropriate opioid

PRACTICAL

WHO pyramid

Mild PainNon-opioids: Tylenol, NSAIDS

Moderate PainMild opioids: Codeine, Vicodin

Severe PainPure opioids: Morphine

Back Pain 56 yo chronic back pain Pain well controlled with Oxycontin

20 mg bid Developed dysphagia

Unable to swallow pills Now admitted in severe pain How do you write admit pain med?

Conversion

Oxycodone 1 mg = 1.5 mg Morphine 40 mg Oxycodone/day = 60 mg PO

Morphine/day 1 mg IV Morphine = 3 mg PO

Morphine 60 mg PO Morphine = 20 mg IV

Morphine 20 mg IV Morphine/24 hrs ≈ 1 mg/hr

Epigastric Pain 46 yo Admit from ER for severe

acute epigastric pain Radiates to back Curled up in a fetal position Amylase and lipase elevated What pain medication would

you use? How would you give it to her?

Opioid Choices Morphine - IV, SQ, IM, PO, PR, SL Dilaudid - IV, SQ, IM, PO, SL Oxycodone - PO, SL Fentanyl - IV, transQ,

transmucosal Levorphanol - IV Methadone – PO, SL, IV, SQ Hydrocodone - PO

PCA Titration Better pain control Less medication, less side effects Titration Principle

Smaller dose, more frequent Matches pain curve

Anticipatory pain effect PRN match continuous rate

2 mg/hr & 0.5 mg q 15 min PRN

Trauma 76 yo Adm to trauma Svc, s/p

MVA Pulmonary contusion, rib Fx Delirious - confused Pulling off O2, hard collar on, 4

point restraints, pulling at foley Started on morphine PCA by

surgery team What is wrong with the picture?

Morphine Titration Short acting agent (fast route) For opioid naïve – start 2 mg

IVP q 1-2 hr Can safely increase by 50-

100% q day No ceiling (Max. dose) for pure

opioids Add PRN to standing dose

Morphine Pharmacokinetics

Onset Peak Duration

IVP 8-10 min 1 hr 2-3hrs

Immediate Release

30-60 min 2 hrs 4-6 hrs

Ext Release

3-4 hrs 6-8 hrs 12-16 hrs

Fentanyl Case Geriatric Fellow called by NP:

nursing home patient with pain Fentanyl patch applied Next day patient still in pain Another Fentanyl patch added Next day patient still in pain Another Fentanyl patch added 2 days later Pt obtunded

Discharge to Outpatient

Around the Clock “An ounce of prevention is

worth a pound of cure” Rules of thumb

Rescue dose = 10% of 24 hr dose PRN q 4 hrs

Call if use more than 2 PRN dose or use more than 2 days

Narcan? 87 yo small Japanese lady S/p TAH/BSO, POD # 2 Allergy to morphine MD orders Dilaudid 0.5 mg q 2 hrs RN gives in error Dilaudid 5 mg IVP RR 10, Pt sleeping – arousable What should the RN do?

Side-effects

Acute All resolve within 3-5 days Respiratory depression (rare) - hours Sedation – 1-2 days Nausea/vomiting (33%) – 3-5 days

Chronic - constipation “The hand that writes the opioid, writes the

laxative”

Indications for Narcan Not for mental status change

Just hold – let wear off Cause significant acute withdraw

pain RR < 6 Oxygen saturation <90% If respond then

Narcan drip & transfer to ICU Because duration <2 hrs

Summary Titration

PCA best short acting convert to long acting

Long-acting for outpatient Monitor side-effects