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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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
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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.
Types of Pain
Nociceptive pain – dull aching, throbbing type pain. This is pain arising from direct tissue damage.
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.
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).
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
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).
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.
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.
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.
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.
Make sure to treat a patient’s underlying opioid use disorder in addition to their acute pain.
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.
Listeners will develop an approach to managing acute pain in the hospitalized patient.
After listening to this episode listeners will…
Dr Weimer reports a relevant financial relationship, serving as a consultant for Path CCM. The Curbsiders report no relevant financial disclosures.
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.
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