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Pain Plan

Hello, this post is inspired by a few recent discussions that have been taking place on the FOAMed Twitter space.  It is all about how we should approach the ongoing pain for patients whom we are sending home from the ED.

There is a big tension here.  We are good people; we went into Medicine to relieve suffering and pain. Yet, recent years have shown that we can, and do, cause a lot of harm in the management of pain in outpatients.  The opiate epidemic is not unique to North America – it happens wherever there are doctors and patients with pain… especially in the First World.

So now we are in a pickle.  How can we sensibly manage our patient’s pain and minimise the risk of creating a longer-term problem?  I have seen a lot of discussion about the evils of various common analgesic drugs (e.g. Tramadol, Oxycodone, Fentanyl).  There has also been a recent spate of data showing that the “simple analgesics” such as paracetamol / acetaminophen or NSAIDs have little of no effect for the common pain syndromes that we encounter in the ED.  So I think we need a plan, a strategy to walk this thin line between harm and relief.

Here is how I like to think about this problem – lets walk through a simple algorithm that I carry around in my mind.

First question.  Is this ACUTE PAIN or CHRONIC PAIN.  Although this seems like a simple question – it is not.  It can be very tough to tease out how long this pain has been present and of course patients with known chronic pain also develop new, acutely painful problems.  The key here though is to recognise with which syndrome we are dealing.  Acute pain management is wildly different to chronic pain management and requires a whole different set of tools.  For the sake of discussion let us define chronic pain as pain that has been present for more than a month (some use 3 months).

This is something I see quite a bit in the ED.  Patients with chronic pain tend to get the exact same analgesia as patient with sudden, acute pain…. and it doesn’t work.  The crucial thing to do is to spend a few minutes exploring the patient’s pain history and understanding which sport you are playing before picking up the appropriate kit.  Beware that not ALL chronic pain sufferers are on 5 agents and allergic to everything else! Sometimes they are on nothing, but they have the pain… the neurobiology remains similar.  Opiates are not a great option here.

OK, so this post is not about chronic pain.  That is a whole different subject.  The patient with chronic pain is extremely difficult to manage in the ED within the magic 4 hours!  This is a problem for the pain clinic, GP or physiotherapist.

However, it needs to be addressed before we move onto acute pain.  Your main tasks in the ED when seeing chronic pain sufferers with acute pain superimposed is to:

1.     Ensure they are getting their ‘baseline’ analgesia / not going into withdrawal

2.     Use local anaesthesia / blocks liberally and creatively

3.     Optimise non-pharmacological strategies e.g. ice, heat, splints, elevation, compression, topical irritants.

4.     Manage their pain in liaison with their usual clinician.  Try not to disrupt the long negotiated pain management plans without consultation. Respect the relationship they have with their usual provider by making a simple phone call.

Right, let us move onto the true ACUTE PAIN patients.  This is our core business.

In an ideal world we should aim for early, adequate analgesia in the ED.  Note I write “adequate” rather than “absolute” analgesia.  This is one of the myths of Medicine that has, in part, been responsible for the current opiate dilemma.  Pain scores are a pet peeve of mine.  My pain scale is a much simpler, 3-tiered scoring system…  none, some and A LOT!  I ask the patient if they can function (walk, breathe, move, think) at present and if they would like more analgesia to achieve that goal.

Aiming for a pain score of ZERO is folly and will most certainly require doses of drugs that will cause harm.  Opiates are predictable in their harm / benefit effects.  Ask any Recovery room nurse in your local operating room.  Too little and the patient is in pain, too much and they become drowsy, nauseated and dysphoric.  In my experience most people are happy to settle for a little pain if they can avoid nausea.  Most importantly for the patients whom we are not admitting, they need to be able to walk out, breath easily and go about their lives.  That is the goal – not an arbitrary pain score.

I also use the adjective “early” analgesia.  This is not something we teach, but good ED docs do well.  Pain goes hand in hand with anxiety.  When a patient with acute, severe pain comes into the ED – they have an expectation that they will get some relief. Unfortunately our modern, busy, protocolled EDs sometimes get in the way of this simple goal.  Early analgesia means that we aggressively treat the pain as soon as practical (eg. PO meds at triage, by doing a quick block before we can do a more thorough assessment / Xray etc. )

Early, effective analgesia achieves a few things:

1.     Interrupts the potential for wind-up & hyperalgesia (we know that pain begets more pain)

2.     Provides anxiolysis – the patient gets the reassurance that we can relieve their pain.  We must understand that anxiety amplifies pain.  Leaving a patient in pain for just 30 minutes can sometimes result in a situation where you need to use even more agents to reduce their now-amplified pain response.

3.     Means that when you do review them, the drugs have had a chance to work and you can assess the response.  This is valuable information in planning your next move.

There is myth in some departments that once we use parenteral opiates that mandates admission / prolonged ED stay.  This is of course untrue.  This makes no physiological / pharmacological sense! The IV route is a good option as it allows us to titrate agents and judge effect more easily than PO administration.  Often early on in the work up we are unsure of the diagnosis and prognosis – so it is completely fine to use IV up front.  However, once the disposition to home is clear we need to change tactics.

As soon as you have made the decision to discharge (which may be at triage!) then we need to start trialling the agents with which we are going to send home.  The failure to do this is, in my experience, a common cause for pain-bounce-backs.  Patients get loaded with IV drugs, and then discharged on inadequate PO agents with no attempt to assess the efficacy in the ED.  IF you have used initial IV / IM agents – then please do keep the patient a little longer to ensure the PO meds are ADEQUATE.  Of course, I can hear the complaints, this means more time in the ED – however if you do the first part EARLY, then this actually saves time I reckon.  Besides – “time in ED” is a poor metric to measure anything sensible in our practice other than efficient inpatient bed flow!

Now, let us get down to the next decision point.  Ask yourself: “do I know what the diagnosis is?”  This is really important.  If you have a clear diagnosis and presumably prognosis for the pain then you are in a great place to make a PAIN PLAN.  However, if the diagnosis is uncertain then we have a few things to ponder.

I am a GP. I am comfortable with uncertainty.  If you have read my recent writings on diagnostics you will understand I live in a ‘Bayesian haze’ of uncertainty!  As such I do think it is completely OK to discharge a patient from the ED with no clear diagnosis… but a plan is important.  However, when it comes to discharging a patient, who is still in pain (Defined as: functional analgesia not yet achieved) this is tiger territory.  (For a harsh example of this please go back and listen to the first ever Lessons Hard Learned podcast with Dr Tor Ercleve.)  Acute, undiagnosed pain that requires strong analgesia with no clear cause is the opening gambit of many tales of woe.  There really are only 2 safe options here:

1.     Diagnose it – be more aggressive with your investigation, phone a friend or redo the history / exam etc

2.     Admit and observe with good analgesia – sometimes we just need time.

Sending any “undiagnosed” headache, chest pain or belly pain home with strong drugs is ill-advised in my opinion.  Especially: BEWARE the POOP-syndromes (Pain Out Of Proportion).  Think compartment syndrome, mesenteric ischemia, necrotising fasciitis, SAH…

If you have been unable to get them comfortable enough in the ED with all your therapies, then the patient has little chance at home with what you are going to hand them.  You are setting the scene for either a bounce-back for pain or worse – a missed, important diagnosis.  In my world they need at least a short admission for serial observation and further specific work-up.

OK, so that leaves us with patients who have a clear diagnosis which is suitable for outpatient management. Typically these are people with acute injuries, non-urgent predictable problems or self-limiting diagnoses.

The basic plan I adopt is based along the lines of the WHO pain pyramid. I think that we tend to underutilise non-pharmacological options or pay lip service to them.

Non-pharmacological options

  • Elevation – especially for any inflammatory / infectious problems on the limbs, oedema and swelling are a big contributor to pain, so aim to minimise this.  Be specific, give the patient instructions and permission to get their limb up, rest and avoid ongoing use where possible.
  • Compression where tolerated can also reduce swelling and improve pain in acute injuries.
  • Ice for acute injuries is a bit controversial.  However if used it should be used intermittently for 20 – 30 minutes and repeated 2 – 3 hourly for the first 48 hours.
  • Heat has NO role in acute injuries but some data for its use in acute back or neck strains.  So don’t use it directly on injured tissue, it can be useful on the surface as a “distraction” of pain fibres.
  • Massage is good for some muscular conditions but in my experience is tough to use consistently unless your patient has a very willing family / friend

These area all low cost, low risk and easy things to do.  They are somewhat time-consuming and we need to encourage their use with specific instructions.  Ideally your ED should have simple written instructions that they can put on the fridge and follow.

Paracetamol / acetaminophen

  • We have traditionally advocated for routine use of regular paracetamol to provide a “baseline” of analgesia.  However, in recent years the data to support this for some indications (eg. lumbar pain) has waned.  It also requires 6 – 8 tablets a day, dosed every 6 hours which is really tough to do in reality. Having said that – if you patient can do this – then go for it. Little harm, small gains, it just might be enough to get them to a level of comfort that allows function.
  • In some tablets paracetamol is combined with other agents eg. Codeine, oxycodone etc… this may appear to be simpler and more convenient but it is a bit of a problem. What happens is that people with milder pain end up using more opiates than they need, or they get a lot less paracetamol than would be therapeutic.       I do not use combination meds in order to allow sensible titration of analgesia.

Non-steroidal anti-inflammatory drugs

NSAIDs are generally safe and have some effect for most of the common pain syndromes. Specifically the can be quite useful for inflammatory problems as you might expect.

  • The concerns around safety are somewhat overstated. GI, respiratory and renal problems with NSAIDs are uncommon after a short course. These are also often predictable and reversible with cessation.
  • So I think we should use NSAIDs liberally in patients with no clear contraindications. To get maximal effect they need to be dosed appropriately. The choice of NSAIDs if large – so we need to use the agents which are easiest for patients.
  • Ibuprofen is popular but needs to be used qid – which is tough. I reserve it for people with intermittent pain issues, not ongoing / continuous pain.
  • Patients with ongoing, continuous pain need a long acting option. I like to use the once daily options – eg. Naproxen SR or meloxicam. Taken once a day they are more consistent with their effects than shorter agents
  • Good doses of NSAIDs are the basis of the outpatient Pain Plan. Used with paracetamol we can reduce most pain syndromes to “functional”. Yes, they are not strong analgesics, yet hey go a long way to achieving ADEQUATE analgesia. They rarely get the pain to ZERO, but they do little harm and have few long-term problems.
  • I will throw a quick word in here for steroids (eg, dexamethasone) – this can be very useful in people with swelling in a confined space, inflammation and nausea too.  Sometime a dose of dex can really make the difference in selected players.

Opiates

  • Opiates have been used for thousands of years. They work, they reduce pain and this is good. Unfortunately they come with some serious side effects – both immediately and into the longer term as the last decade has shown us.
  • The key to using opiates is to use them
    • in minimum doses,
    • for the shortest period possible ( 2 – 3 days maximum),
    • with careful & specific instructions
    • Tailor the drug / formulation to the pain pattern
  • Generally I use oxycodone as the easiest option in our population.  It is titratable, comes in a variety of formulations (short & longer acting and with naloxone).  There are very few interactions and it does not rely on renal metabolism – which is an omnipresent issue in Broome!
  • Codeine has been king in Australia for 50 years – but that is about to change with its rescheduling to a “prescription-only” med.  Codeine is a horrible opiate compared to the others.  It is converted to morphine by the liver – sometimes too quickly, sometimes not at all.  It is unpredictable – in everything except is’s constipation effects!  Just use morphine or oxycodone instead!
  • The main downside to Oxycodone is that it does have euphoric properties which can be highly desired by people who misuse medications.  However this is less of an issue if you dose low and use longer acting formulations where appropriate.
  • Dr Ruben Strayer is a pain guru from NYC and he tends to use oral morphine preparations – which we do not have here in Australian.  You can hear Rubens thoughts on this in his excellent lecture “Pain, Compassion, Addiction, Malingering: How To Use Opioids”   over at EMUpdates here.  
  • Importantly – use the smallest dose that achieves ADEQUATE analgesia.  So use low doses and have a plan that includes a backup option.  e.g  in an opiate, naive, adult male 2.5 mg of oxycodone is low dose.  Use this, repeat in 30 – 60 minutes and aim for enough relief rather than getting to the point of sedation and euphoria – that is where the troubles start.  The important thing is to coach the patient and modify their expectations before handing them a script / bottle of pills.
  • I never prescribe past 72 hours.  Usually just for 24 hours.  If the patient is not back to usual function or out of pain by a day or two – they need to be reviewed and the plan rethought.  This is how the “opiate epidemic” got started.  Prolonged, unsupervised use of opiates is lazy medicine and carries serious harms.  Dependence can develop in just a few days.  You need to monitor for this if you have prescribed these agents.  It is our duty of care to ensure we are not harming with these early pain prescriptions.
  • Think about the patient and their risk for developing dependence on opiates.  There are a few scoring systems you can use – but largely we recognise these people… but are unsure how to deal with them.
  • One of the easiest ways to identify patients with occult dependence issues is to tell them that you are going to aim for a “non-opiate” regime and gauge their reaction to that plan.
Screen Shot 2017-10-30 at 9.42.14 pm

courtesy Dr R Strayer

Short vs. Long opiates.

This is a common question in my ED.  If we are discharging a patient with pain that requires opiates – should we use an immediate-release formulation? Or should we give them a longer-acting agent that is more convenient and consistent?

This can be tricky.  Dr Strayer in his lecture advocates for NO longer acting drugs.  This is sensible from a drug-dependence perspective – however in low risk patients with pain that is continuous it seems to make sense to dose it slowly for 1 – 2 days, avoid the peaks and troughs of euphoria and side-effects which come with shorter acting preps.

In my practice – I try to match the dose / formulation to the clinical syndrome.  Use short agents for intermittent bad pain, use longer agents for constant pain.

Other Agents

Recently there has been an expansion of drugs that are being marketed as “non-opiates” for acute pain.  The commonly used agents in Australia are tramadol, tapentadol and pregabalin.  So I will make a few comments on these here;

  • Tramadol is a bit of a dirty drug.  Twitter is all over the evils and side effects of this agent.  It tends to cause a lot of nausea at decent doses, interacts with other psychoactive meds and is implicated in old folk going a bit dotty.  So I use it as a distant 3rd line option, and almost exclusively in the small cohort of patients who can say “it worked for me in the past” – there are a few people out there whom have this idiosyncratic benefit from tramadol.
  • Tapentadol seems to be all the rage in the private Pain clinics this year – it seems every patient discharged from a shiny tertiary hospital has it onboard!  To be clear – its main mode of action is as an agonist of the mu receptor – it is an opiate!  Somehow because of its weaker noradrenaline re-uptake inhibition action this seems to have been marketed as a “safer” option.  There is no data to support this contention.  It is listed as “high risk” of dependence.  So I think I will not be changing my practice towards this drug – just use an opiate if you need to – oxycodone is predictable.
  • Pregabalin (GABApentin precursor) is commonly prescribed in chronic neuropathic conditions and in acute pain postoperatively.  It has no real data in the acute outpatient pain scenario.  There may be a few patients with very specific pain symptoms – eg. diabetic neuropathy, post-herpetic neuralgia who might be worth trying it upon.  these are rare.

THE SUMMARY

  1.  Is this acute or chronic pain?
  2.  Have we achieved ADEQUATE analgesia in the ED?
  3.  Have we trialled suitable oral agents in the ED PRIOR to discharge?
  4.   Do I know what the diagnosis / pain prognosis is for this patient?
  5.  Have we really tried the non-pharmacological options?
  6.   Give appropriate doses of simple / non-opiate drugs.
  7.   Consider the risk or causing harm, dependence or diversion of drugs onto the street market. Use a score or your Gestalt, ask the questions…
  8.   Give a written PAIN PLAN.  Specific doses, timing and plan for what to do if options A, B, C… are not effective i.e. allowing functional / adequate pain relief
  9. Place a clear timeframe on the PLAN.  “Return if worse” is not appropriate!  Instead say – “We want you to return on Tuesday morning if your pain is still bad enough to need more than paracetamol or NSAIDs.”
  10. Make it clear that the opiates are dangerous drugs and that they should be flushed / returned if no longer required.

Comments

  1. good post Casey
    Re tapentadol apparently it has no blackmarket price suggesting it has minimal addictive potential so is a hands down winner over oxycodone in terms addiction safety.
    The main issue in Oz is that the IR formulation is not on the pbs. When it is, I think it will be hard to argue that it should not be our first line opioid agent in most patients before oxycodone. It is critical that we take the necessary steps to reduce opioid addiction and this is definitely one of them.
    On tramadol -- I think it gets a bad wrap partly as people use too high a dose. Many patients tolerate 50mg but don’t tolerate 100mg; yet ED docs often jump in with 100mg and then get surprised by the vomiting. Also the elderly need even lower doses. Tramadol drops are on the pbs and allow you to prescribe low doses such as 25-30mg which can be well tolerated in the elderly. In palliative care they use tramadol effectively in the elderly using the tramadol drops at reduced dose.
    Using the right doses I find tramadol a useful drug and it helps me minimise my need to write discharge scripts for oxycodone which I think is a plus.
    The other technique I find that help me minimise opioid use in the ED is to use potent rapid acting non-opioids choosing optimal dose and route. There’s good evidence about the high efficacy of IV paracetamol (equivalent to 0.1mg/kg morpine) as there is for IV/IM ketorolac. Additionally the 800mg dose of ibuprofen is a potent rapid acting NSAID shown to be equivalent to ketorolac in at least moderate pain. Using the right combinations/routes/doses of non-opioids can control pain effectively so that the need for opioids can be substantially reduced in my experience.
    low dose ketamine is the other “non-opioid” gem in the right patient -- especially your acute on chronic back pains with intractable pain.

  2. tom fiero says:

    very well done, Casey. thank you

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