Treating Pain ADEQUATELY, and Staying Safe…

Patients and Physicians Alike: Cases from the Field

Laurie Lyckholm MD FACPHematology/Oncology and Palliative Medicine

Massey Cancer CenterVirginia Commonwealth University

Objectives

Examine cases in which pain management is a challenge.

Demonstrate how pain management may be applied safely and appropriately in any situation

Rob L.

• 30 y/o healthy man admitted to the ED with crush injury of Lt leg

• Ruptured popliteal artery

• Bilateral compartment syndrome

Rob L.

• Given enough IV pain meds in ED to “take the edge off.”

• To OR for emergent fem-pop bypass, bilateral fasciotomies from ankles to thighs

Rob L.

• Epidural for 24 hours after surgery; fair pain control, then…

• “Weaning” begins…hydromorphone PCA initially at 2 mg every 6 minutes reduced to 1mg after 12 hours, despite pain scores 8-10.

• Severe pain…10/10 persists, even with patient using hydromorphone PCA regularly

• Patient asking for more pain medicine regularly

Rob L.

12 hours later, PCA discontinued and started on prn hydromorphone every 4-6 hours

Rob L.

• “He shouldn’t be having that much pain.”

Rob L.

• 30 y/o usually very stoic, “macho” man crying

• BEGGING for pain medicine every hour

• Rates pain continuously as 10/10

Rob L.

• “Pain consult called after 3 days of intense untreated pain, pt’s mother insists

• Full pain consult by trusted Pain/Palliative Care team

• None of consultant recommendations followed

Rob L.

• Pain continues• Nurses are distressed• Team refuses to increase pain medicine• “he shouldn’t be having that much pain…”• Pain team calls charge nurse first, who says his

hands are tied• Pain team calls attending physician, who restarts

PCA hydromorphone at appropriate dosing (1mg every 6 minutes and 4 mg bolus every hour) and patient becomes more comfortable

Rob L.

• Over the course of the next few days, Rob’s condition improves and he is comfortable, using 1mg IV dilaudid twice an hour on average, and 1-2 4mg boluses/day.

• Bolus before and during dressing changes, which involve peeling dressings off open fasciotomies.

Rob L.

Day of discharge. To have ongoing dressing changes and wound care by Home Health

PCA discontinued.

Prescription?

Rob L.

• Dilaudid 2mg; 1 tablet every 6 -8 hours for pain #10

• Appointment in 1 week.

What went wrong???

• Undertreatment

• WHY??– Assumptions– Biases– Fear– Lack of experience– Lack of education

How could it be done better?

Jenna T.

• 35 y/o woman with metastatic breast cancer

• Pain from primary breast lesion as well as sternal and left humerus pain from metastases.

• Using MS Contin 120mg every 12 hours• MSIR 15-30 mg every 3-4 hours for

breakthrough pain• Says pain fairly well controlled

Jenna T.

• Calls clinic nurse—lost medications; had purse stolen

Jenna T.

• Calls the next week; pain is worse; needs more medications

Jenna T.

• Calls the next week; pain is worse; needs more medications; sister will pick up

• Does not show up for next appointment• Calls the week after did not show; needs more

medications; pain out of control. • Comes in for appointment. Clearly in pain, very

quiet, furrowed brow. Winces with movement.• Calls the next week. Out of meds; says they

were stolen.

Jenna T.

• Ways to help Jenna but stay safe:– Drug Screen, but careful…know your screens!– Weekly refills– Patient herself must come to pick up– Frequent brief appointments– Single pharmacy– Single physician writing meds– Talk with pharmacist directly to discuss plan

(HIPAA – okay)

Final Messages

• Even the most difficult pain patients can be treated safely but must be collaborative and truthful

• Burden of proof on the physician if they do not believe the patient

• Don’t make assumptions based on socioeconomic biases

• Talk with your patient about concerns

Final Messages

• Work with your pharmacist directly; call before sending patient if very large number or unusual way of taking medication.

• Telegraph messages on the rx pad– “for cancer pain” or “for chronic back pain”– Write out number prescribed: “100 (one hundred)”

• .

Final Messages

• DOCUMENT each visit and why pain medicines prescribed

• If prescribing large doses, request frequent visits and/or phone calls if patient unable to transport easily, document phone calls in patient chart

Final Messages

• DOCUMENT

• DOCUMENT

•DOCUMENT!!!