Pain Management in the Emergency Department
Ken Lavelle, MD, FACEP, NR-P Fire/EMS Medical Director Clinical Instructor of Emergency Medicine Jefferson Medical College, Philadelphia
About the Speaker • • • • •
EMT, Paramedic and Firefighter for 29 years Jefferson Medical College Emergency Medicine 4 years at Albert Einstein in North Philly EMS Medical Director – 40 agencies – fire, EMS
• No financial interest in any pharmaceutical •
[email protected]
Objectives • • • •
• • • •
Keynote Objectives Student will understand the challenges of pain management in the emergency department including customer service ratings, cost and compliance Student will understand the side effects of most commonly utilized pain relief medications Student will understand the relation between medical pain management, tolerance and addiction Goals Participants will be able to modify medical care of patients to minimize risk of addiction while still treating pain, as scope permits Participants will be able to educate patients as to risks of narcotic pain medication Participants will advocate for their patients with a balance of pain management and minimizing adverse reaction
Outline • • • • • •
What is Pain? Chronic vs. Acute Pain Pain Management Abuse Addiction, Dependence and Withdrawal Diversion
What is Pain? • Protects us • Indicates something is damaged or misaligned • The perception of a noxious stimuli
What is Pain? • Sensory neurons in the skin are activated • Conducts a symbol to the central nervous system – the spinal cord and the brain • Nocicepters • Stimulated: – Damage – Drop in pH – Chemical release
What is Pain? • Acute Pain – Occurs suddenly as a result of a specific injury or procedure – May last just a few minutes or weeks/months – A warning of disease or threat to the body – Surgery – Dental Procedure – Broken Bones – Burns or Cuts
What is Pain? • Chronic Pain – Persists for a longer time even after the injury has healed – May be a result of untreated acute pain – Often indicates a damaged nerve – No known cure – 19% of Americans
What is Pain? • Causes of Chronic Pain – Fibromyalgia – RSD: Reflex Sympathetic Dystrophy – Cancer – Arthritis – Headache
– Neurogenic Pain – Chronic Fatigue Syndrome – Endometriosis – Lupus – Shingles – Multiple Sclerosis – Back Pain – Sickle Cell Disease
Pain Management • So how can we manage pain? • If we can come up with a way to make these signals not be detected at the source or not be transmitted to the spinal cord and the brain, then pain will not be perceived
Pain Management • Non Pharmaceutical – – – –
Accupuncture Heating Pads Rest Meditation
Pain Management • Over the Counter – Acetaminophen – NSAIDs • Ibuprofen • Naprosyn
Pain Management • Non-Scheduled Medication – Tramadol (Ultram, Ultracet) • Developed in 1995 • Initially thought to have little or no opioid activity • Now felt to have some and may induce dependence
Pain Management • Non-Scheduled Medication – Tramadol (Ultram, Ultracet) • • • •
In 2009 – 28.2 millions prescriptions Arkansas and Kentucky have it as a state schedule 4 Louisiana – “Drug of Abuse” More expensive
Pain Management • Muscle Relaxants – To treat spasticity and spasm in an injured muscle – Also used when a neurological condition causes contraction of a muscle – Often for • • • •
Back pain Multiple sclerosis Spinal cord injury Cerebral palsy
– 2 million Americans per year use them, primarily for back pain
Pain Management •
Muscle Relaxants – Examples • • • • • • •
Cyclopenzaprine (Flexeril) Metaxalone (Skelaxin) Chlorzoxazone (Parafon Forte) Methocarbamol (Robaxin) Carisoprolol (Soma) Orphenadrine (Norflex) Benzodiazepines
Pain Management • Soma – Carisoprodol – Can cause dependence and withdrawal – Respiratory depression if with benzos, other muscle relaxants – Metabolized to meprobamate (mild tranquilizer)
Pain Management • Flexeril – – – –
Chemical structure similar to tricyclic depressants Less abuse potential Not controlled Often used as a next step above OTC meds
Pain Management • Controlled Substances – Opioids – Benzodiazepines
• Narcotic – Any substance that induces sleep, insensibility or stupor – But often used for opioids and derivatives
Pain Management • DEA Schedule I-V – Schedule I Controlled Substances – Substances in this schedule have a high potential for abuse, have no currently accepted medical use in treatment in the United States, and there is a lack of accepted safety for use of the drug or other substance under medical supervision. – Some examples of substances listed in schedule I are: heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), peyote, methaqualone, and 3,4-methylenedioxymethamphetamine (“ecstasy”).
Pain Management •
Schedule II Controlled Substances
•
Substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence.
•
Examples of single entity schedule II narcotics include morphine and opium. Other schedule II narcotic substances and their common name brand products include: hydromorphone (Dilaudid®), methadone (Dolophine®), meperidine (Demerol®), oxycodone (OxyContin®), and fentanyl (Sublimaze® or Duragesic®).
•
Examples of schedule II stimulants include: amphetamine (Dexedrine®, Adderall®), methamphetamine (Desoxyn®), and methylphenidate (Ritalin®). Other schedule II substances include: cocaine, amobarbital, glutethimide, and pentobarbital.
Pain Management •
Schedule III Controlled Substances
•
Substances in this schedule have a potential for abuse less than substances in schedules I or II and abuse may lead to moderate or low physical dependence or high psychological dependence.
•
Examples of schedule III narcotics include combination products containing less than 15 milligrams of hydrocodone per dosage unit (Vicodin®) and products containing not more than 90 milligrams of codeine per dosage unit (Tylenol with codeine®). Also included are buprenorphine products (Suboxone® and Subutex®) used to treat opioid addiction.
•
Examples of schedule III non-narcotics include benzphetamine (Didrex®), phendimetrazine, ketamine, and anabolic steroids such as oxandrolone (Oxandrin®).
Pain Management • Schedule IV Controlled Substances • Substances in this schedule have a low potential for abuse relative to substances in schedule III. • An example of a schedule IV narcotic is propoxyphene (Darvon® and Darvocet-N 100®).
• Other schedule IV substances include: alprazolam (Xanax®), clonazepam (Klonopin®), clorazepate (Tranxene®), diazepam (Valium®), lorazepam (Ativan®), midazolam (Versed®), temazepam (Restoril®), and triazolam (Halcion®).
Pain Management • Schedule V Controlled Substances • Substances in this schedule have a low potential for abuse relative to substances listed in schedule IV and consist primarily of preparations containing limited quantities of certain narcotics. These are generally used for antitussive, antidiarrheal, and analgesic purposes.
• Examples include cough preparations containing not more than 200 milligrams of codeine per 100 milliliters or per 100 grams (Robitussin AC® and Phenergan with Codeine®).
Pain Management • Rules – Schedule II – No refills – No multiple Rx written on one day to be filled on multiple days – No phone Rx or faxed Rx (unless original seen first)
• Schedule II, IV, V – Refills and phone/fax Rx permitted but restricted in number
Pain Management • Opioids
Pain Management • Opioids
Pain Management • Opioids – Derived from the opium poppy • Turkey, Mexico, Southeast Asia, China, India
– Cultivated since 1500 BC – Mixure of alkaloids extracted from unripened seed pods of Papaver Somniferum (poppy) – 10 days before they bloom, incisions in capsule, milky fluid oozes out • Next day – gummy brown mass scraped out and pressed into cakes of raw opium to dry
– Natural derivatives – Synthetics
Pain Management • Opioids – – – –
How do they work? Target opioid receptors Activation of these inhibits the nerve transmission Several different types of receptors that have the desired and adverse effects
Pain Management • Opioids – Adverse Effects • • • • • •
Respiratory Depression Small pupils Sedation Hallucinations Psychosis seizures
Pain Management • Opioids – Natural • Codeine • Morphine
– Semi-Synthetics • • • • •
Heroin Hydrocodone Hydromorphone Oxycodone Oxymorphone
– Synthetic • • • •
Fentanyl Meperidine Methadone Propoxyphene
Pain Management • Opioids – – – – – –
Why so many? Different strengths Different side effects Tolerance Cost Business
Pain Management • Codeine – Natural extract, mild – Generally a lousy pain medication – Good cough medicine – Used in T3 – Tylenol #3, Tylenol #4 – Liquid often used for pediatric pain
Morphine • • • • •
Prototype agonist, contained in crude opium Analgesia Cough suppression (but codeine better) Less euphoria then fentanyl, heroin Adverse effects – – – –
Respiratory depression Miosis (small pupils) Vomiting High doses – low BP and HR
Morphine • Orally – Erratic absorption so usually not given orally – Kadian – Extended Release • 20-100mg tablets
– MSIR – Immediate Release • 15, 30mg
– OxyIR • 5mg
– OxyFast • Liquid 20mg/mL
• IV – More reliable
Morphine • Extended Release – Cellulose matrix – Slowly dissolves in stomach and small intestine – MS Contin
Pain Management • Hydrocodone – – – –
For pain and cough Vicodin, Lortab: includes acetaminophen Schedule III Most frequent opiate Rx • 139 million Rx in USA in 2010
Pain Management
Pain Management • Hydromorphone – Dilaudid – Most common request in the ER for IV pain medication in seekers – Strongest we currently have – Oral pills available also
Pain Management • Oxycodone – The narcotic present in Percocet, combined with acetaminophen – Approved in 1976 – Schedule II – 5/325 is the most common
Pain Management • OxyContin – Sustained release oxycodone – Used for moderate to severe pain – First developed in 1995
Pain Management • OxyContin – $3 billion in revenue in the first 6 years – If crushed, dissolved, injected – the controlled release mechanism is avoided – Large amount of narcotic and euphoria – Newer version is resin based • Harder to pound into powder and tougher to dissolve
OxyContin • Increase in prescriptions
OxyContin
Pain Management • Oxymorphone – – – – –
Opana-ER On market in 2006 Cheaper, less itching and sedation reported Shorter high (so can be more habit forming) Old Numorphan (“blues”) (off market in 1970s)
Fentanyl • • • • •
Chemically related to meperidine 80x then potency of morphine Rapid onset, short duration of action Expensive Multiple forms – IV – Transdermal – Sublingual
Fentanyl • Transdermal – – – –
Fentanyl patch Reservoir of fentanyl and alcohol Adhesive layer has a “bolus” once applied Alcohol increases the permeability of the skin to fentanyl – Contains 10mg – Designed to last 3 days then change – Some can remain once removed
Fentanyl
Fentanyl • Sublingual – Beneficial if unable to tolerate oral administration • Very sick, cancer patients
– Abstral
Fentanyl • Actiq • Fentanyl popsicle – berry flavored lozenge on a stick – – – – – –
“perc-a-pop” 200-1600 mcg 25% absorbed 75% swallowed $7 for 200mcg $21 for 1600mcg
• No sustained release – breakthrough only • Approved in 1998 for severe cancer patients only – But being used for other patients as well
Actiq
Fentanyl • Fentora – Buccal (cheek) tablet
Pain Management • Methadone – Synthetic opioid – Developed in 1940s – Initially only used for detox/maintenance • Restriction on this lifted in 1976
– Schedule II
Pain Management • Methadone – Now being used more for pain management – Benefits • Cheap • Bioavailability in oral form is 80% compared to 26% of morphine • Long acting liquid form – Good for terminally ill
• Safe in kidney failure
Pain Management • Methadone – – – –
Maintenance Has less euphoria Quells the withdrawal Most studies show less crime and illegal drug use in those on programs – Administered at specific clinics • After 3 years some patients can be managed by private physicians
– Some patients are on methadone maintenance forever
Pain Management • Opioids – Some drugs bind and only partially activate or even block effects
Pain Management • Partial Agonists – Buprenorphine • Narcotic analgesic, but a lousy one • Partial antagonist – binds to receptors but activates them only a little bit • Drug Addiction Treatment Act of 2000 – Approved by the FDA for narcotic addiction – Allows maintenance outside of clinics
Buprenorphine • Subutex – Buprenorphine
• Suboxone – – – –
Buprenorphine + naloxone Naloxone is inactive orally But if crushed an injected, counteracts the narcotic 2, 8mg sublingual tablets
• Butrans – Transdermal film
Buprenorphine • Office Maintenance – Initially any physician can take an 8 hour training course and then treat up to 30 patients – Later can treat up to 100 patients – Little to no euphoria – Decreases cravings for other opioids – Low ceiling – more medication does not increase the high
Pain Management • Antagonists – Fit into the receptor, but block the effects of the narcotic and cause no euphoria – Naloxone
Pain Management • Naloxone – Narcan – Antagonist • Binds to the receptors but does not activate them • Rapid reversal in respiratory depression and narcotic effect • Causes an immediate withdrawal syndrome • Lasts 4-6 hours (some narcotics last longer)
Pain Management • Why are these meds so commonly used? – Often not much else medicine can do – Society wants a quick fix
• Pain as a vital sign
Pain Management • Who treats pain?
Pain Management • Who treats pain? • Acute Pain – Emergency Medicine – Surgeons – Family Medicine and Primary Care
• Chronic Pain – – – –
Psychiatrists Neurologists Primary Care Pain Clinics
Tolerance • Adaptation in the body where the effects of the drug decrease over time, requiring higher doses for the same degree of relief • Change in the number of receptors • Normal physiologic phenomenon • Also concern for disease progression
Withdrawal • Physiologic responses to abrupt discontinuation or reduced use of a drug • Alcohol, opioids, cocaine, benzodiazepines, marijuana, nicotine • Common signs/symptoms – – – – – –
Irritability Anxiety Nausea Agitation Rapid heart rate and high BP Piloerection, tearing, yawning (narcotics)
Withdrawal • From opioids – 8-16 hours after discontinuation – 26-72 hours is the worst – 5-8 day duration
• Not fatal (but may wish it was) • Treated with – – – –
Antiemetics Clonidine (BP med) NSAIDs Mild Muscle relaxants
Abuse • Maladaptive pattern of substance use – repeated adverse social consequences • Outside the normally accepted standards resulting in disability or dysfunction • Use – 30% - tobacco – 51% - etoh – 8% - illicit drugs
• Abuse – 7% etoh – 3% illicit substances
Prescription Narcotic Abuse • Increasing in popularity – Pure – Less risk – Not considered as ‘bad’
• In 2007 – 27,000 deaths from prescription drug abuse – More than heroin and cocaine combined
Prescription Drug Abuse • Manufacturer methods to fight (barrier strategy) – Irritant added to affect nose if inhaled – Sudsy if mixed with liquid – Adding other medications • Niacin – causes flushing • Naltrexone – no effect orally but has effects if inhaled
Addiction and Dependence • Dependence – Psychiatric Definition – Not necessarily addicted – 3 or more of: • • • • • • •
Tolerance Withdrawal Substance taken in larger amount for longer period Persistent desire or repeated attempts to quit Much time/activity spent to obtain/use/recover Giving up social/occupational/recreational activities Use continues despite knowledge of adverse effects
Addiction and Dependence • Addiction (Physical and Psychological Dependence) – Maladaptive pattern of substance use leading to clinically significant impairment of distress – Dysfunctional and compulsive pattern of use – Craving, obtaining and using a drug constitute the principal focus of the user’s life – Continued use despite harm
Addiction and Dependence • Pseudoaddiction – Commonly seen in patients with severe and unrelenting pain – Patients are preoccupied with finding opioids – Underlying focus in finding relief from their pain – Drug seeking behavior typically resolve when pain is adequately controlled
Drug Seeking • Common behaviors – Demands end-of-office-hour appointments or arrives just after close (running late) – Needs immediate action – Refuses physical examination or tests – Prohibits release of medical records – Cannot or will not provide past providers – Uses excuses of visiting from out of town and lost or stolen prescriptions – No medical basis for allergies to nonopioids – Unusual knowledge of controlled substances
Addressing the Drug Seeker • Thorough patient evaluation • Adequate documentation • Agreement with patient to curtail drug seeking behavior • Limit to 1 doctor and 1 pharmacy • Reasonable treatment goals • No early refills • No changes without and office visit • No illicit drug use • Random urine drug screening
Drug Seeker in the ER • Evaluate the Patient – Physical examination – Vital signs
• Review of old records – Only at the current hospital system – Number of visits – Notes from other physicians
• Contact the primary care doctor – Although there rarely is one
Drug Seeker in the ER • Evaluate the request – Reasonable or not
• Offer certain management – An injection in the ER (it cannot be diverted, effects only one person) – A single dose of oral meds – A limited prescription
• Be honest – What I will not give you
• Their reaction tells a lot • Document the visit extensively
Drug Seeker in the ER • Why do some docs cave in? – – – –
Doubt as to whether they have pain or not Desire to avoid confrontation Easier to get them out Fear
Questions?
References • • • •
•
Boyer, E. Management of Opioid Analgesic Overdose. N Eng J Med 2012; 367: 146-55 Davis, MP. et al. Controversies in Pharmacotherapy of Pain Management. Lancet Oncol 2005; 6: 696-704 McClean, G. Smith, H. Opioids for Persistent Non-Cancer Pain. Med Clin N Am 91 (2007) 177-197 Robertson, TM. et al. Intranasal Naloxone is a Viable Alternative to Intravenous Naloxone for Prehospital Narcotic Overdose. Prehospital Emergency Care 2009; 13:512-515 Walley, A. et al. Opioid Overdose Prevention with Intranasal Naloxone Among People Who Take Methadone. J of Substance Abuse Treatment 2012
Summary • Pain is a major problem and reason patients seek medical care • Alleviating pain is a fundamental of medicine and very important to every physician • Most of us would rather have 10 patients receive pain medication when not really in pain than have one patient in true pain go untreated – Perspective
• Medicine and law enforcement can and must be a team in the prevention of prescription drug abuse and diversion •
[email protected]