OLIGOANALGESIA IN THE ER

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OLIGOANALGESIA IN THE ER

• Improving Our Practice

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WE UNDERESTIMATE PAIN

• GENDER
• AGE
• ETHNICITY
• COGNITION

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Quantifying Pain

• Visual analogue scale for research
• 10 points change significant on the low end, 17
  on the high
• 0-10 scale for clinical practise

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The Scope of the Problem

• Most studies suggest only 40-50 of adults
  presenting with acute pain, get pain medication
• Even fewer children get pain medication

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What about after ED discharge?

• Ngai, B et al, Acad Emerg Med 4(12)1176, Dec
  1997
• Retrospective chart review from Saint John NB
  266 patients discharged from ED with long bone
  fracture
• Miserably few were prescribed pain med

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The Scope of the Problem

• Pain noted for 64 adults
• Analgesia in ED for 13
• Discharge analgesia for 24
• Pain noted for 61 of kids
• Analgesia in ED for 26
• Discharge analgesia for 6

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The Scope of the Problem

• Most commonly acetomenophen, NSAIDS, codeine
• Is this adequate for long bone fractures?
• Is codeine a good pain killer?
• Is a fracture an inflammatory condition?

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The Paradox

• Patients are satisfied with inadequate analgesia!
• Dawson et al J Pain Symp Man 23(3)211 March 2002
• 316 cancer patients with pain management by their
  family physicans, answered phone surveys

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The Paradox

• Nearly half reported recent moderate or severe
  pain
• ¾ were happy with their pain management!

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Patient expectations for analgesia

• Fosnocht, D.E. et al Am J Emerg Med 19(5)399,
  Sept 2001
• Prospective study 458 adults
• Mean pain intensity score 69 for those who
  received a pain med, 55 for those who did not
• At discharge, scores were 37 42
• Yet 71 felt their pain needs had been met
• Those who felt their pain needs had been met
  reported much more overall satisfaction

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Patient Expectations for Analgesia

• No difference in satisfaction between groups who
  did and did not get analgesia
• Asking have your pain needs been met is more
  important than giving an analgesic
• Asking gives the impression that the doctor cares

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How can we improve?

• Education helps
• Mandatory pain management training increases
  analgesic prescribing to 95 from 40-50
• Is this a sustained improvement?

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Drugs

• Acetaminophen
• NSAIDS
• Narcotics
• Nerve Blocks
• Salmon Calcitonin

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Medical Myth Codeine is a good pain killer

• Addition of 60 mg codeine to 400-1000 mg
  acetaminophen increased analgesia by only 5 in
  one large series.
• Discontinuation of analgesic more common if
  treated with codeine
• Side effects of codeine limit the maximum dose
• Codeine is not itself a pain killer. It is
  metabolized to morphine. 7-10 of the population
  cannot metabolize

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NSAIDS?

• Not effective enough for long bone fractures
• Use NSAIDS in inflammatory conditions
• Beware the side effects

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Medical Myth Ketorolac is a special pain
medication

• It has the worst safety profile of all NSAIDS
• It is the most expensive NSAID
• Marketing studies compared it to homeopathic
  doses of meperedine

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How did Codeine and Ketorolac Become so Popular?

• Isaacs, d., ET AL, Br Med J 3191618, December
  18-26, 1999
• Seven Alternatives to Evidence Based Medicine

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Eminence-Based Medicine

• Experience (making the same mistakes with
  increasing confidence over an impressive number
  of years) is believed to be more important than
  anything as mundane as evidence

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Vehemence-Based Medicine

• Volume is substituted for evidence as a means of
  convincing more timid colleagues, patients and
  their families

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Elegance-Based Medicine

• Requires a perpetual tan, an Armani suit and a
  smooth tongue and substitutes sartorial elegance
  and verbal eloquence for scientific evidence

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Nervousness-Based Medicine

• Driven by fear of litigation and manifests as
  overinvestigation and overtreatment (the only bad
  test is the test you didnt think of ordering)

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Confidence-Based Medicine

• Characterized by sheer bravado and is limited to
  surgeons

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Which analgesics are effective?

• Theraputic doses of acetaminophen (15-20 mg/kg)
• Narcotics
• NSAIDS (Ibuprofen cheapest, safest)

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What about muscle relaxants?

• There is no evidence they relax muscles.

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Narcotics the Good, the Bad and the Ugly

• Percocet is good
• Fentanyl is good
• Morphine is good
• Meperedine (Demerol) is bad-ish
• Codeine is ugly
• Cervical collars, ace bandages, back braces and
  rib splints are ugly too

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Meperidine the Bad-ish

• The metabolite normeperidine is long-lasting and
  can produce toxicity (CNS effects, seizures)
• Meperidine is contra-indicated with SSRIs,
  MAOIs
• Reversal of Meperidine-induced respiratory
  depression may precipitate normeriperidine-induced
  seizures
• Extensive first pass effect erratic absorption
  and unpredictable pain relief with oral doses

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Morphine and Fentanyl the good

• Easy to titrate
• No metabolite accumulations
• No risk of causing serotonin syndrome

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Codeine the Ugly

• Once you choose to use an opiate, why not choose
  one that works
• Percocet
• Titrate the dose, caution with drowsiness, take
  no other acetaminophen

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Nerve Blocks

• Consider the femoral nerve block in hip fracture
• Most effective in extra-capsular fracture
• Gets around the problems associated with opiates
  in the elderly

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Intranasal Salmon Calcitonin

• Useful for osteoporotic compression fractures
• Not for acute control

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Medical Myth Withhold analgesia in the acute
abdomen

• Only 6 studies out there (none very good)
• None support the above
• May save laparotomy rate
• Localizing findings dont change but pain
  perception does
• The consent issue

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Summary

• Treat pain aggressively
• If the patients say they are in pain, they are
• Rapid iv analgesia for severe pain
• Morphine, Fentanyl,acetaminophen
• Non-pharmacologic treatment
• Give narcotics to patients with abdominal pain