Challenges of Pain Management In the Emergency Department

Transcription

1 Challenges of Pain Management In the Emergency Department Joe Johnsey MD FACEP Medical Director Emergency Services North Mississippi Medical Center

2 Disclosures

3 THE END

4 Objectives So what is the issue? The patient populations we are discussing Warning signs for the opioid prescriber Chronically treated Alternatives to opioid first or opioid only therapy Take home message

5 Definitions Pain relief Pain Management Chronic vs Acute Pain

6 What is pain? We all may share common accountings of pain, but in reality, our experiences with pain are deeply personal, filtered through the lens of our unique biology, the society and community in which we were born and live, the personalities and styles of coping we have developed, and the manner in which our life journey has been enjoined with health and disease. Preface to Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research

7 An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.... Pain is always subjective.... It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience. SOURCE: IASP, 1994.

8 WE ARE NEVER

9 N Engl J Med 2010; 363: November 18, 2010

10 Every 19 minutes there is one overdose death in the US For every death there are: 9 Abuse treatment admissions 35 ED visits for misuse or abuse 161 people with abuse/dependence Drug Abuse Warning Network nonmedical users

11 Over 50 % of Emergency Department visits are for painful complaints (maybe as much as 80%) Pletcher MJ, Kertesz SG, Kohn MA, Gonzales R. Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA 2008;299:70 8. O'Connor AB, Zwemer FL, Hays DP, Feng C. Outcomes after intravenous opioids in emergency patients: a prospective cohort analysis. Acad Emerg Med 2009;16: McCabe SE, West BT, Boyd CJ. Leftover prescription opioids and nonmedical use among high school seniors: a multi-cohort national study. J

12 AAEM Guidelines Administer a short-acting opioid analgesic for the treatment of acute pain as a second-line treatment to other analgesics Start with the lowest effective dose of an opioid analgesic. Prescribe a short course (up to 3 days) of opioid medication for most acute pain conditions. Address exacerbations of chronic pain conditions with non-opioid analgesics, non-pharmacological therapies, or referral to pain specialists for follow-up. Consider assessing for opioid misuse or addiction using a validated screening tool. Use the PMP. Don t use long-acting opioids Avoid prescribing opioid analgesics to patients currently taking sedative- hypnotic medications or concurrent opioid analgesics. Refrain from replacing prescriptions for lost, stolen, or destroyed opioid prescriptions. Refrain from refilling chronic opioid prescriptions.

13 17% of discharged patients from EDs receive narcotics 99% are immediate release Average number 15 Despite these facts more than 70% of patients presenting with pain receive no treatment Annals of Emergency Medicine Volume 66, Issue 3, Pages e1 (September 2015) Ann Emerg Med. 2015;66:

14 The Good The good and the bad of opioids Essential for severe pain management, both acute and chronic Titratable analgesic An integral part of palliative and hospice care Lack of any other class of analgesic as effective for acute severe pain The Bad Overmedication leading to unexpected death Adolescent misuse Smarties Parties Diversion for abuse and sale Hyperalgesia Addiction Adverse effects

15 So what s the harm patients receiving an opioid prescription within 7 days of surgery were 44% more likely to become long-term opioid users within 1 year compared with those who received no such prescription

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17 The Wind-up

18 Acute pain leading to chronic pain Persistent pain after breast cancer treatment: a critical review of risk factors and strategies for prevention. Pain management after ambulatory surgery. Curr Opin Anaesthesiol Dec;22(6): J Pain Jul;12(7): doi:

19 Pain-Addiction Savage SR, Kirsh KL, Passik SD. Challenges in using opioids to treat pain in persons with substance use disorders Addict Sci Clin Pract Jun;4(2):4-25

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21 Chronic Pain I have a master s degree in clinical social work. I have a well- documented illness that explains the cause of my pain. But when my pain flares up and I go to the ER, I ll put on the hospital gown and lose my social status and my identity. I ll become a blank slate for the doctors to project their own biases and prejudices onto. That is the worst part of being a pain patient. It strips you of your dignity and self-worth. A patient with chronic pain

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23 But How Can You Tell?

24 Chronic Pain IS an ED disease End-of-life care Cancer pain Migraine Sickle Cell Disease Trigeminal Neuralgia Other Neuropathic pain syndromes

25 Chronic Pain and Substance Abuse in the ED 24 million patients with chronic pain visit the ED annually 50% of those with exacerbations of chronic pain syndromes 8.2% of the age >12 population have used an illicit drug within the last month K. Todd, Pain and Prescription Monitoring Programs in the Emergency Departm Volume 56, NO. I: July 2010 Annals of Emergency Medicine

26 We aren t consistent

27 Who are we talking about?

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29 People Are Different

30 Table 3. Socio-demographic and substance abuse covariates (%) of the four latent prescription opioid use classes (N = 26,314). Green TC, Black R, Grimes Serrano JM, Budman SH, Butler SF (2011) Typologies of Prescription Opioid Use in a Large Sample of Adults Assessed for Substance Abuse Treatment. PLoS ONE 6(11): e doi: /journal.pone

31 Illicit User

32 Medically Healthy Abuser

33 Prescribed Misuser

34 Use as Prescribed

35 Impression of Addicted Patients Asked to estimate amount of addicted patients in a Sickle Cell population >50% of the Emergency Department Physicians estimated that >20% of these patients were addicts Actual percentage <2% ShapiroBS,BenjaminLJ,PayneR,etal.Sicklecell-relatedpain:perceptionsof medical practitioners. J Pain Symptom Manag

36 Pseudo-Addict vs. Addict Pain Justification Disappears when pain adequately controlled Magical things do not happen to their Rx Willing to accept valid alternatives to opioids May describe an allergy but often adverse events they wish to avoid Addiction Behavior usually worsens if patient receives opiates Frequent return visits Magical things happen Fall down sink Get eaten by dog Are stolen by others Ask for drugs by name Other Tx does not work Allergic

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38 Know the Warning Behavior

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41 Warning Signs

42 What about the chronically treated patient with acute pain? IV fentanyl to control breakthrough cancer pain Calculate total daily morphine dose Divide by 20 Give equivalent dose of fentanyl (1 mg = 10 mcg) Repeat q 5 minutes Good pain relief within minutes

43 Or the OAT treated patient 4 Common misconceptions 1) The maintenance opioid agonist provides analgesia; 2) use of opioids for analgesia may result in relapse 3) the additive effects of opioid analgesics and OAT may cause respiratory and central nervous system (CNS) depression 4) the pain complaint may be a manipulation to obtain opioid medications, or drug-seeking, because of opioid addiction.

44 New ideas for acute treatment

45 Alternatives

46 Blocking the pain

47 Similar degree of pain reduction No failure in lidocaine arm (1 in sedation arm) 20 min reduction in total treatment time

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49 Can we treat with other medications?

50 Things that Work? Annals of Emergency MedicineVolume 56, Issue 1, July 2010, Pages e3

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53 Some people don t desire pain treatment Almost ½ did NOT desire pain treatment despite presenting with pain (avg score 7.2) Loss of control, concern for cause, risk of addiction among concerns Ann Emerg Med Dec;52(6): doi: /j.annemergmed

54 What do the patients say?

55 Screen Docs cannot do this with objective measure Screened in 20% of subjects DAST-20 or similar

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57 Key Points for Our Practice Treat acute pain aggressively especially when objective source can be identified Do not prescribe long-acting opoids Drive therapy toward specific source and disease Inform and instruct your patients Have difficult conversations (and document) Examine PMP Screen for metal health disease and substance abuse

58 Questions Thank You Joe Johnsey