pain management in the “difficult patient” james ducharme md professor, emergency medicine...
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Pain Management in the “Difficult Patient”
James Ducharme MD
Professor, Emergency Medicine
Dalhousie University
Saint John Regional Hospital
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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 TENSand chiropractic manipulation.
He comes to the ED as he is desperate, his painis much worse….
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What can you offer this patient?
What can you not offer?
More importantly, why did I ever pick up this chart?
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Scenarios
Chronic non-malignant pain
– Sickle cell disease
– Complex regional pain syndrome
– Fibromyalgia
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Scenarios
Cancer
Multiple trauma
Substance abuse
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Chronic non-malignant pain
Establish priorities
– Highest possible quality of life
– Good balance of analgesia and side effects
– Combination therapy better than one medication
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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
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Opioid use
– Contractual agreement for indications for ED visits – copy of agreement with chart
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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
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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
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Sickle Cell Crisis
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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
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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)
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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
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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
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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
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Complex Regional Pain Syndrome
The disease formerly known as Reflex Sympathetic Dystrophy
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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
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Complex Regional Pain Syndrome
If nerve injury:
– Analgesia with typical anti-neuralgic medications
– Tricyclics, anti-epileptics, lidocaine dressings
– Epidural blocks, lumbar sympathetic blocks
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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
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Fibromyalgia
Yes, it is a real disease!
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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
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Cancer/Malignancy Related Pain
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Cancer/Malignancy Related Pain
Distinguish between breakthrough pain and pain from separate pathology
Determine type of pain
– Neuralgic
– Visceral
– MSK
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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
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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
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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
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Analgesic adjuvants to opioids
Transdermal nitroglycerin
Anesthesiology 1999
– 5 mg patch daily: less break through opioids
– Less adverse effects of opioids
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Multiple Trauma
“In trauma, some things just have to hurt”
Trauma, Life in the ER
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Analgesia without destabilization:
– Regional anesthesia
– Epidural
– Fentanyl infusion
– Ketamine
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Epidural analgesia
Effective with multiple rib fractures, flail chest
Better ventilation, mobilization
Used in Britain for outpatients:
– PCA epidural: bupivicaine & fentanyl
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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
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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
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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
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Substance Abuse
Stress related to substance abuse issues is most often related to lack of knowledge
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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
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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
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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
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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
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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
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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
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Final Thoughts
Poor pain control arises from misdiagnosing the origin of pain, from false beliefs and from poor knowledge – all which can be corrected