#299 Acute Pain Management for the Hospitalist

October 11, 2021 | By Carolyn Chan

Optimizing Opioids for Analgesia and Safety

Confidently manage acute pain in the hospital! In this episode listeners will learn  how to develop a multimodal analgesia plan for acute pain in the hospital, as well as how to safely initiate and discharge a patient on opioids. We’re joined by Dr. Melissa Weimer @DrMelissaWeimer  (Yale School of Medicine).

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Credits

Producer and Writer: Carolyn Chan, MD

Script: Carolyn Chan, MD, Avi O’Glasser, MD

Cover Art and Infographic: Edison Jyang

Hosts: Matthew Watto MD, FACP; Carolyn Chan, MD

Reviewer: Emi Okamoto, MD

Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com

Guest: Melissa Weimer DO

Sponsor: ACP’s National Internal Medicine Day

Help the American College of Physicians celebrate National Internal Medicine Day on October 28th. Visit https://www.acponline.org/NIMD2021 to learn how you can show your internal medicine pride. Be sure to tag @ACPInternists and use the hashtag #NationalInternalMedicineDay.

Sponsor: Green Chef
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CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org .

Show Segments

• 01:39 Intro, disclaimer, guest bio
• 03:20 Guest one-liner, Picks of the Week
• 09:18 Case from Kashlak; Definitions
• 11:00 Assessing Acute Pain
• 12:12 Types of Pain
• 15:08 Initiating Opioids
• 22:32 Counseling on Opioid Exit Strategy
• 25:26  Opioid Dependence vs. Opioid Use Disorder
• 29:50 Post-Op Pain Management
• 31:00 Other cool stuff
• 37:00 PCA
• 41:00 Opioid Taper
• 46:50 Acute Pain and Opioid Use Disorder
• 58:00 Methadone Titration
• 1:04:00 Outro

Acute Pain Management for the Hospitalist Pearls

1. Assessing acute pain:  Ask the patient where the pain is the most severe, to describe the characteristics (e.g. dull, achy), determine if it is acute vs. chronic and review current medical and/or surgical conditions.
2. Based on patient’s history, classify the pain into nociceptive (visceral or somatic) versus neuropathic pain as this will help dictate a patient’s treatment plan
3. All patients should start with non-opioid analgesics such as acetaminophen, NSAIDS, and muscle relaxants for acute pain. 
4. Selecting an opioid: One tip is to ask patients in a non-judgmental manner, “what has worked for you in the past in regards to pain management? Genetic polymorphisms exist in how individuals respond to different opioids, thus assessing a patient’s prior experience can help you select an opioid for their pain management. 
5. Transition those using opioids to PO formulations instead of IV as soon as possible. Oral opioid provide longer analgesic relief than IV or SC delivery routes
6. Don’t forget to consult your acute pain anesthesiology colleagues for challenging pain management scenarios! They may be able to offer interventions such as IV ketamine, peripheral or neuraxial blocks, and more!
7. Opioid Exit Strategy: When indicated for patients who have been on a high dose of opioids for several days, co-create an opioid taper plan with the patient and write it out explicitly. Be sure to partner with a patient’s outpatient provider and nursing facility physician to help ensure a safe taper. 
8.  Individuals with opioid use disorder will require higher doses of opioids for acute pain management due to their opioid tolerance.
9. For patients with an underlying opioid use disorder (OUD), make sure to treat their OUD with an evidence based medication (e.g.  methadone or buprenorphine-naloxone), in addition to using full opioid agonists for their acute pain if needed.

Acute Pain Management for the Hospitalist Show Notes

Assessing Acute Pain

First ask the patient: “Help me understand what your pain feels like”. Consider providing them adjectives such as dull, achy, burning, and radiating to help them characterize the type of pain. Ask additional questions outlined below to further assess an individual’s pain.

• Where is the most severe pain?
• Characteristics
• Acute or chronic
• Other considerations: numerical or visual analogs, prior painful experiences, current medical or surgical conditions, GI distress such as nausea and vomiting

Types of Pain

Nociceptive pain – dull aching, throbbing type pain.  This is pain arising from direct tissue damage.

• Visceral pain (type of nociceptive pain) – examples: pancreatitis, myocardial infarction
• Somatic Pain – musculoskeletal, joint, bone pain

Neuropathic pain – burning, stinging, radiating symptoms. This is pain arising from neural damage or inflammation.

Kashlak Pearl: It’s important to assess and further determine the type of pain, as it will help dictate a pain management plan.

Approach to Management of Acute Pain

First start with non-opioid analgesics such as acetaminophen, NSAIDS, and muscle relaxants.  

In addition, treat other symptoms such as nausea, emesis, and anxiety with appropriate adjunctive medications.

Dr. Weimer reminds us that poorly treated pain can lead to persistent pain, so it is important to quickly and sufficiently address acute pain (Dunwoody, 2008). One tip is to ask patients in a non-judgmental manner, “what has worked for you in the past in regards to pain management?”.

If a patient has inadequate analgesia with non-opioid analgesics, then consider the initiation of an opioid. Genetic polymorphisms among patients may result in varying analgesic responses to different opioids (e.g. morphine vs oxycodone vs hydromorphone) (Pereira Vieira, 2019). 

Note: Consider IV acetaminophen if it is available at your institution (Pasero, 2012). Clonidine transdermal patch may also be helpful in certain scenarios for acute post-op pain (Ball, 2006).

Consider Opioid Initiation if Necessary

Choosing a Starting Dose of an Opioid: Determine if the patient is opioid naive vs. has opioid tolerance. If the individual is opioid naive, start at the lowest dose available and titrate the medication based on their response.

Delivery: IV and SC opioids have a rapid rise in plasma levels but levels decrease quickly. Oral opioids have a much longer duration and help minimize the peaks and valleys of the medication plasma concentration. The goal is to keep the plasma concentration within the therapeutic range of  analgesia for as long as possible, which is more readily achieved with PO opioids. Dr. Weimer recommends transitioning an individual to oral opioid medications as soon as a patient can tolerate PO meds.

Frequency: Oral opioids only have a duration of 3-4 hours, in the setting of acute or severe pain consider dosing immediate release only at Q3-4H PRN

Kashlak Pearl: It’s important to transition to oral opioids instead of IV as soon as possible. Oral opioid provide longer analgesic relief than IV or SC delivery routes

Counsel on Opioid Initiation for Analgesia: Counsel a patient at the time of  initiation of an opioid. Let them know we are using an opioid to treat a pain, and it’s important to ALSO use other analgesic modalities as opioids can have harmful  side effects (e.g. ileus, obstruction). Dr. Weimer recommends using standing acetaminophen and/or NSAIDs in addition to opioids for severe breakthrough pain.  Discuss with the patient a need for  continued observation and assessment, and as the pain improves, the opioids should be titrated down.

Opioid Dependence vs. Opioid Use Disorder. Dependence is a side effect of utilizing an opioid for a period of time, and can occur in some people in as short as one week if taking a sufficient enough dose.  This is a physical dependence where cessation of the opioids results in symptoms of withdrawal (e.g. nausea, diarrhea, muscle cramps). In contrast, opioid use disorder requires an individual to meet at least 2 of 11 DSM-V criteria (DSM-V, 2013). Presence of any of the 4 Cs (compulsion, craving, negative consequences, impaired control) may suggest addiction (AAPM, 2001).

Everyone who is leaving the hospital with an opioid prescription should receive naloxone on discharge. 

Opioid Exit Strategy

Dr. Weimer recommends looking  at the individual’s pattern of opioid use and their other multimodal analgesia. Dr. Weimer recommends creating an opioid taper plan with the patient and writing it out explicitly. Consider changes to dose and frequency. Partner with a patient’s provider at the next facility or outpatient provider to help ensure a safe taper. 

Post-Op Pain Management

Gabapentin 

Evidence is mixed for the use of gabapentin in the perioperative period (Verret, 2020; Arumugan, 2016) . In Dr. Weimer’s expert opinion:  she often tries to start gabapentin preoperatively if she thinks the case may be a challenging pain management scenario. Dr. Weimer does find it helpful at times, particularly in patients who have exhausted other analgesic options. 

Ketamine and Cool Stuff from our Anesthesia Colleagues

Consider using IV ketamine (NMDA antagonist) for patients with acute pain and a high opioid tolerance; consult your anesthesiology colleagues to consider using this medication. 

Check out the Management of Post-op Pain: Clinical Practice Guidelines, for more detailed information on intraoperative strategies for acute pain management and more. Consider asking your anesthesia colleagues for regional, neuraxial, or peripheral nerve blocks for acute pain as needed. Ask as well about their Enhanced Recovery After Surgery (ERAS) multimodal approach to perioperative care (Ljungqvist, 2017). Multimodal pain management is key to the best pain outcomes. 

PCA – Patient Controlled Analgesia

Evidence shows this has greater effectiveness and patient satisfaction. Per the clinical practice guidelines of post-op pain management (Chou, 2016): ”Use i.v. PCA when parenteral route needed for more than a few hours and patients have adequate cognitive function to understand the device and safety limitations.” Some contraindications to PCA include: cognitive impairment and severe OSA.

PCA Principal: There are peaks/valleys of opioid plasma concentrations as well as rapid on/off of IV analgesia with this mode of delivery. A PCA will result in more frequent dosing, and deliver smaller doses of opioids per each dose. This will help keep the plasma concentration of opioids in the analgesic range while minimizing the time spent in the “peaks” and “valleys” of IV opioid administration. 

Managing Acute Pain in Opioid Use Disorder (OUD)

Make sure to treat a patient’s underlying opioid use disorder in addition to their acute pain.

• Individuals already receiving full opioid agonist: Dr. Weimer recommends to offer methadone as treatment for their OUD. If methadone is not accessible in the community where you practice, offer connection to care and initiation of buprenorphine-naloxone once they are tapered off full opioid agonists.
• Individuals who have NOT received a full opioid agonist: Offer initiation of buprenorphine-naloxone or methadone.
• Individuals already on a medication for OUD (buprenorphine-naloxone or methadone): Continue the dose of their home medications, and add full opioid agonists in addition to their MOUD. Do not stop their methadone or bup/naloxone (Alford, 2006)

Note:  Individuals with opioid use disorder will require higher doses of opioids for acute pain management due to their opioid tolerance.

Hospital based low-dose initiation of  buprenorphine, read more on Dr. Weimer’s work: (Weimer, 2020). 

Kashlak Pearl: Treat the opioid use disorder with methadone or buprenorphine-naloxone AND acute pain using full agonists opioids if needed.

Take Home Points

1. For acute pain, individuals need a multimodal care plan to provide adequate analgesia
2. Utilize and engage your anesthesia colleagues when you have a patient that may have a challenging post-op course
3. Don’t use Tramadol  (Tramadon’t)

Links

1. The Chair (Netflix series)
2. Chair Cushion – why not be more comfortable?
3. Any Standing Desk
4. NPR listen on a bioethicist’s difficulty quitting opioids
5. Buprenorphine Mini-Course: Building on Federal Prescribing Guidance

Goal

Listeners will develop an approach to managing acute pain in the hospitalized patient.

Learning objectives

After listening to this episode listeners will…  

1. Develop an approach to the management of acute post-op pain.
2. Describe the pharmacology of PO, IV and SC delivered opioids for analgesia. 
3. Develop a multi-modal care plan for the management of acute pain. 
4. Counsel a patient on an “opioid exit” strategy for post-op patients being discharged with opioids.

Disclosures

Dr Weimer reports a relevant financial relationship, serving as a consultant for Path CCM. The Curbsiders report no relevant financial disclosures. 

Citation

Chan, CA, Weimer M. Jyang E. O’Glasser A., Okamoto E, Watto MF. “299 Acute Pain Management for the Hospitalist”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list. Final Publishing date October 11, 2021.