Welcome to the Internal Medicine Intern Teaching Course

Welcome to the Internal Medicine Intern Teaching Course Melissa (Moe) Hagman, MD, FACP University of Washington Internal Medicine & Palliative Care mhagman@u.washington.edu pager 206-540-9725

Intern Teaching Course Objectives Provide information on topics of importance to new medicine interns Provide a forum for interns to share insights & questions regarding patient care

Intern Teaching Course Schedule highlights Conference on Thursdays July 2 Aug 13 Interns Report topics blocks 1-4 No specific topic week 2 of each block See website for details http://depts.washington.edu/uwmedres/ ***Please provide feedback***

Intern Teaching Course What to Do When You Are Called to See a Patient with Pain July 2, 2009

Ms. M RN calls to report that Ms. M is having 10/10 right hip pain Acetaminophen 500mg po q6hrs prn is not working

Ms. M Sign-out 75 yo woman Full code Fall from standing with R hip fracture; to OR in AM for repair by Orthopedics Meds enoxaparin, acetaminophen NTD Avoid CNS active medications due to risk of delirium

Ms. M Go see the patient History and physical exam Think about types of pain other than physical pain Emotional pain anxiety, anger, sadness Social or interpersonal pain loneliness, family tensions Spiritual or existential pain fears about death

World Health Organization s Stepwise Analgesia Ladder Step Pain Drug I Mild Non-opioid (acetaminophen, NSAIDS) II Moderate Non-opioid plus weak opioid (hydrocodone, codeine, oxycodone) III Severe Non-opioid plus strong opioid (morphine, hydromorphone, fentanyl, etc.) AAHPM. UNIPAC Series: Hospice/Palliative Care Training for Physicians. 2003.

Non-Opioid Analgesia Acetaminophen and/or NSAIDs can augment the pain relief provided by narcotics Caution when using combination pills acetaminophen is most common cause of acute liver failure in United States patients forget that acetaminophen is present in many OTC medications no more than 4000 mg acetaminophen/day Consider prescribing acetaminophen and/or NSAIDs separately

Ms. M Schedule acetaminophen 1000mg po QID (or q6hrs) Max 4000mg a day For elderly, start narcotics at half usual starting dose and follow closely Cr 2.0, liver function normal What narcotic and dose will you choose?

Initiating Narcotics In renal insufficiency: methadone and fentanyl optimal oxycodone and hydromorphone with caution AVOID morphine and codeine In hepatic insufficiency: fentanyl, hydromorphone, oxycodone, and methadone with caution AVOID morphine Avoid use of meperidine because of risk of seizure

Narcotics Avoid morphine in renal and/or liver failure

Initiating Narcotics If concern for prior narcotic-induced nausea give an antiemetic with the narcotic for approximately 3 days until tolerance to nausea side effect has developed Always consider prophylactic medications to prevent constipation Docusate 250 mg po bid Senna 2 tabs po qhs others

Mr. G RN calls to report that Mr. G is having 9/10 back pain Acetaminophen 1000mg PR qid and hydromorphone 0.2-0.4mg IV q4hrs are not working

Mr. G Sign-out 73 yo gentleman Metastatic prostate cancer on hormonal therapy; receiving XRT to spine Admitted with nausea/vomiting (thought to be partial SBO) and renal failure Meds acetaminophen, morphine, antiemetic, bisacodyl PR, IVF NTD

You go see Mr. G: Mr. G complains of baseline diffuse bony discomfort relieved by acetaminophen and morphine ER 60 mg po q 12hr + morphine IR two 15 mg tabs/day feels like he is not getting enough pain medication since switched from home pills to IV meds in hospital Should he continue morphine? What can we do for his pain?

Narcotic Conversions Morphine ER 60 mg po q 12hr + morphine IR two 15 mg tabs/day = 120 mg + 30 mg = 150 mg total/day Decrease dose by 1/3 rd to half for incomplete cross tolerance when changing narcotics 150 mg/day x 2/3 = 100 mg/day morphine (to convert to fentanyl)

Narcotic Conversion to Fentanyl Oral Morphine/24hr Initial Fentanyl Patch 90 mg 25 mcg/hr 180 mg 50 mcg/hr 360 mg 75 mcg/hr 100 mg/day morphine dose patches q72hrs full dose onset 12hrs

Narcotic Conversions Breakthrough dose = 10% of total daily dose 150 mg/day x 2/3 = 100 mg/day morphine (10% for break through = 10 mg morphine)

Narcotic Equianalgesic Doses Drug PO IV Morphine 30 mg 10 mg Oxycodone 20 mg --- Hydromorphone 7.5 mg 1.5 mg Hydrocodone 30 mg --- 10 mg morphine po 0.5 mg hydromorphone IV 10 mg MS = X where X = 0.5 mg of hydromorphone IV 30 mg MS 1.5 mg hydromorphone IV

Narcotic Conversions Breakthrough dose = 10% of total daily dose Decrease total daily dose by 1/3 rd to half for incomplete cross tolerance when changing narcotics (Avoid morphine in renal and/or liver failure)

Narcotic Conversions Morphine ER 60 mg po q 12hr + morphine IR two 15 mg tabs/day = 120 mg + 30 mg = 150 mg total/day Decrease dose by 1/3 rd to half for incomplete cross tolerance when changing narcotics 150 mg/day x 2/3 = 100 mg/day morphine (to convert to hydromorphone)

Narcotic Equianalgesic Doses Drug PO IV Morphine 30 mg 10 mg Oxycodone 20 mg --- Hydromorphone 7.5 mg 1.5 mg Hydrocodone 30 mg --- 100 mg morphine po 5 mg hydromorphone IV 100 mg MS = X where X = 5 mg of hydromorphone IV 30 mg MS 1.5 mg hydromorphone IV

Narcotic Conversions 100 mg morphine po 5 mg hydromorphone IV 5 mg hydromorphone IV/24hrs = 0.2 mg/hr PCA order 0.2 mg/hr continuous infusion hourly rate q15min prn breakthrough pain Or nurse administered IV med order 0.6 mg IV q3hrs scheduled, hold for sedation 0.5 mg IV q1hr prn breakthrough pain

Mr. T RN from the Medicine floor calls you on crosscover to report that Mr. T, a 25 yo male admitted last night with endocarditis, is becoming agitated, complaining of pain, and demanding METHADONE!

Mr. T Sign-out 25 yo gentleman Full code Longstanding heroin addiction; admitted last night with presumed endocarditis Meds vancomycin, acetaminophen NTD

Approach to Evaluating Patients with Opioid Withdrawal Know the signs & symptoms pupillary dilatation, lacrimation, rhinorrhea, piloerection, yawning, sneezing, anorexia, nausea, vomiting, diarrhea Peak heroin withdrawal 36-72 hrs, lasts 7-10 d Peak methadone w/d 72-96 hrs, last >14 d Ask about: other drugs the patient may be using illicitly history of methadone maintenance patient s wishes regarding detox or no detox during this trip to the hospital

Mr. T Patient denies other illicit drug use except for heroin I use 3 grams a day! He wants methadone says he usually gets 120 mg a day when he is in the hospital What should you do?

Management of Opioid W/D in Patients Not Requesting Detox Treat or prevent acute withdrawal otherwise medical condition may not be adequately managed Methadone starting dose methadone 20 mg po times 1, then 5 mg po q2-3h until symptoms resolve (max 60 mg a day) primary team can see how much methadone was used overnight and come up with qd or tid dosing regimen

Management of Opioid W/D in Patients Requesting Detox Treat symptoms clonidine = GI distress, diaphoresis, piloerection, muscle aches NSAIDS = muscle aches promethazine (Phenergan) = nausea hydroxyzine (Vistaril) = itching, agitation Immodium = diarrhea

Mr. T 10 Days Later RN calls you on crosscover to report that Mr. T is becoming agitated, complaining of pain, and demanding MORE METHADONE!

Mr. T Sign-out 25 yo gentleman Full code Longstanding heroin addiction; endocarditis Meds vancomycin, rifampin, methadone 60mg qam, acetaminophen NTD

Methadone in General Some meds decrease methadone level Rifampin Phenytoin, steroids, carbamazepine, some antiretrovirals Some meds increase methadone levels Amitriptyline, ketoconazole, macrolides, fluoroquinolones, SSRIa, diazepam

Methadone in General Long, variable half-life (up to 190hrs) In general, do not increase dose more than once every 3-4 days Always write hold for sedation Dose conversion complex, involve pharmacy

Mr. N RN calls to report that Mr. N is having new 4/10 abdominal pain Acetaminophen 500 mg po q4hrs prn not helping

Mr. N Sign-out 57 yo gentleman s/p KP transplant for DM1 Dx two weeks ago with inflammatory bowel disease Admitted for acute PE Meds prednisone 40mg/day, tacrolimus, heparin gtt, acetaminophen, antiemetic NTD

Mr. N

Bowel Perforation and Steroids In patients on >20mg/day of prednisone, abdominal tenderness is the only consistent symptom/sign of abdominal perforation Mortality approximately 85% ReMine SG, et al. Ann Surg. 1980;192:581-6.

Ms. D RN calls to report that Ms. D is having new 6/10 suprapubic pain Acetaminophen 500 mg po q4hrs prn not helping

Ms. D Sign-out 41 yo woman Metastatic breast cancer to spine/brain Admitted pain control and brain XRT Meds prednisone, morphine (recently increased), acetaminophen, antiemetic NTD

Some Side Effects of Opioids Urinary retention Rx: Foley, decrease opioid dose, BPH meds in men Constipation Rx: senna, senna, senna, and more senna Rx: docusate, MOM, lactulose, polyethylene glycol, bisacodyl, enema Confusion Search for underlying causes other than opioids Myoclonus Reduce dose or change to a different opioid

Nausea and Narcotics Approximately 30% of folks have nausea with narcotics Try giving low dose narcotics with an antiemetic and then withdraw antiemetic in several days after the patient has developed tolerance to the side effect of nausea If nausea does not resolve or cannot be treated with adjuvant antiemetics, change to a different narcotic

Ms. D 3 Days Later RN calls to report that Ms. D is not arousable and RR 6

Ms. D Sign-out 41 yo woman DNAR/DNI Metastatic breast cancer to spine/brain Admitted pain control and brain XRT Meds prednisone, morphine (recently increased), acetaminophen, antiemetic NTD

Naloxone RR 6-12/min in resting patient is usually OK (especially if the goal of care is comfort) Be careful though in patients on chronic opioids, naloxone can precipitate withdrawal & pain If you must give naloxone to pt on chronic opioids: Dilute 1 amp (0.4mg) in 10ml of saline and give 1ml IV q5 minutes

Other Pain Med Tid Bits Routes of administration PO Buccal (liquids, lollipops) PR Transdermal IM SQ IV

Other Pain Med Tid Bits Careful with inpatient NSAIDS Renal failure (especially if volume depletion) GI bleeding risk Other bleeding risk (including surgical) Toradol (avoid in most inpatient situations) Very limited reasons for inpt use No more than 5 days No more than 120 mg/day

Adjuvant Treatments for Pain Control Cutaneous Stimulation Heat, cold, massage, exercise, repositioning Counterstimulation Transcutaneous electrical stimulation (TENS), acupuncture Cognitive-Behavioral Interventions Relaxation and imagery, patient education, psychotherapy, support groups, pastoral counseling Storey et al. Pocket Guide to Hospice/Palliative Medicine. 2003. AAHM: Glenview, IL.

Adjuvant Treatments for Pain Control Steroids The ultimate anti-inflammatory Especially useful for discomfort and loss of function from intracranial and spinal cord lesions Radiation Remember that this can cause local irritation, nausea, and other side effects Storey et al. Pocket Guide to Hospice/Palliative Medicine. 2003. AAHM: Glenview, IL.

Adjuvant Treatments for Pain Control Antidepressants (i.e. TCAs) Anticonvulsants (i.e. gabapentin) Muscle relaxants Bisphosphonates Antispasmotics (i.e. oxybutynin) Nerve blocks/local injections Surgery or interventional radiology (i.e. for bowel obstructions, fractures, decompression) Storey et al. Pocket Guide to Hospice/Palliative Medicine. 2003. AAHM: Glenview, IL.

Collaboration

Remember to Call Your Resident if You Have ANY Questions There are no badges for independence, bravery, courage

Mr. T Mr. T is a 73 yo gentleman on chronic opioids who presents with new hip fracture. He will be NPO prior to surgery and must stop his po meds including: morphine SR 160mg po q12 morphine IR prn pain, four 30mg tabs/24hr Clinical Question: How would you order his IV pain meds?

Narcotic Conversions Morphine SR 160mg po BID + morphine IR four 30mg tabs = 320mg + 120mg = 440mg total/24hr Morphine conversion PO to IV is 3:1 440 mg/24 hr PO 145mg/24hr IV morphine gtt at 6mg/hr Breakthrough morphine IV dose could be 10% of daily total 10-15mg IV q30-60 min or the continuous infusion hourly rate q15 min Check with pharmacy

Fatigue Anorexia Anxiety/ Depression Nausea/Vomiting Pain Delirium

Narcotic Equianalgesic Doses Drug PO IV Morphine 30 mg 10 mg Oxycodone 20 mg --- Hydromorphone 7.5 mg 1.5 mg Hydrocodone 30 mg --- 10 mg morphine po 6.6 mg oxycodone po 10 mg MS = X where X = 6.6 mg of oxycodone 30 mg MS 20 mg oxy