Pain Management in the “Difficult Patient”

James Ducharme MD

Professor, Emergency Medicine

Dalhousie University

Saint John Regional Hospital

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 TENSand chiropractic manipulation.

He comes to the ED as he is desperate, his painis much worse….

What can you offer this patient?

What can you not offer?

More importantly, why did I ever pick up this chart?

Scenarios

Chronic non-malignant pain

– Sickle cell disease

– Complex regional pain syndrome

– Fibromyalgia

Scenarios

Cancer

Multiple trauma

Substance abuse

Chronic non-malignant pain

Establish priorities

– Highest possible quality of life

– Good balance of analgesia and side effects

– Combination therapy better than one medication

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

Opioid use

– Contractual agreement for indications for ED visits – copy of agreement with chart

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

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

Sickle Cell Crisis

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

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)

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

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

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

Complex Regional Pain Syndrome

The disease formerly known as Reflex Sympathetic Dystrophy

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

Complex Regional Pain Syndrome

If nerve injury:

– Analgesia with typical anti-neuralgic medications

– Tricyclics, anti-epileptics, lidocaine dressings

– Epidural blocks, lumbar sympathetic blocks

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

Fibromyalgia

Yes, it is a real disease!

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

Cancer/Malignancy Related Pain

Cancer/Malignancy Related Pain

Distinguish between breakthrough pain and pain from separate pathology

Determine type of pain

– Neuralgic

– Visceral

– MSK

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

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

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

Analgesic adjuvants to opioids

Transdermal nitroglycerin

Anesthesiology 1999

– 5 mg patch daily: less break through opioids

– Less adverse effects of opioids

Multiple Trauma

“In trauma, some things just have to hurt”

Trauma, Life in the ER

Analgesia without destabilization:

– Regional anesthesia

– Epidural

– Fentanyl infusion

– Ketamine

Epidural analgesia

Effective with multiple rib fractures, flail chest

Better ventilation, mobilization

Used in Britain for outpatients:

– PCA epidural: bupivicaine & fentanyl

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

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

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

Substance Abuse

Stress related to substance abuse issues is most often related to lack of knowledge

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

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

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

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

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

Final Thoughts

Do not set up an adversarial relationship with patients

Acute pain management does not lead to addiction

We do not know the patient’s degree of pain better than they do

Final Thoughts

Poor pain control arises from misdiagnosing the origin of pain, from false beliefs and from poor knowledge – all which can be corrected