Pain Management in the Difficult Patient

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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
TENS and chiropractic manipulation. He comes to
the ED as he is desperate, his pain is much
worse.
3
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 patients 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