I know we all deal with this all the time. I've just had a bunch of tough cases packed into the last few weeks.
How do you deal with patients who have a real, acute injury like a fracture but are on big doses of chronic pain meds at baseline?
Just recently I had the following:
50s F with acute lower extremity fracture on methadone 100mg qd and Nucenta at baseline.
40s F with acute cervical radiculopathy but on Lyrica and SSRI. Had past hx of addiction to oxycodone and can't tolerate hydrocodone.
60s F with humerus fx, MSContin 30 bid with roxinol for breakthrough at baseline.
30s F with postconcussive HA, real, big toma, +LOC but no fx or ICB. On Oxycodone 30 mg q6h with Norco 10s PRN and Xanax.
And so on.
These are difficult patients but they have real painful conditions. If they're conscious, i.e. if you haven't put them in and almost anesthetized state they are screaming. They don't really merit admission and no inpt doc wants them but there's nothing I can give them as an outpatient because they're already maxed out.
The Bird's Word
(just the opinion of some random guy who doesn't know much)
This is a very difficult and complicated issue. Lets start with some
quick and dirty opiate calculations so we know what we're dealing with:
Patient #1-Methadone 100mg per day (throw out the nucynta for symplicity) = 125mg of IV morphine per 24 hour around the clock =
20mg IV morphine q 4 hr around the clock 24/7
Patient #2-(no dose given)
Patient #3-Morphine 140mg po per day (assuming morphine ER 30 mg BID + roxinol/morphine 20 mg QID) = 46 mg of IV morphine per 24 hr around the clock =
7 mg IV morphine q 4 hr around the clock 24/7
Patient #4-oxycodone 30 mg q 6 and norco (assuming 10mg hydrocodone q 6) = 73 mg of IV morphine per 24 hr =
12 mg IV morphine q 4 hr around the clock 24/7
Someone above mentioned
intrathecal pumps. Note that 5 mg of morphine (per 24 hr) in an intrathecal pump is roughly equal to 500 mg IV per 24 hr =
morphine 83 mg IV q 4 hr 24/7 (multiply intrathecal dose times 100 to get IV dose).
You are not going to get this person out of pain.
Take patient #1: you could give that patient 40 mg of IV morphine (I'm not suggesting you do) and it might,
might just start to touch their pain, considering their basal dose. Clearly this is well out of the range that most Emergency Physicians, nurses, or hospitalists are going to be comfortable giving. Certainly you can give your normal opiate doses and titrate, but most aren't going to be comfortable going up to 40 mg IV in a couple of hours even if the patient is wide awake and still complaining of pain (though you could). For the intrathecal pump, "fuggettaboutit!" That being said, what do you do with such patients?..............
The answer is not easy.
1) A lot of this will depend on your community standard. If you have an academic pain department (fellowship, etc)
consult, consult, consult. Don't even attempt to be a hero with such doses. You have the luxury of having a Pain fellow/resident on call. Wake them up.
2) Know that in the Pain community there is tremendous controversy right now about the role and dosing of opiates in chronic non-cancer pain. It's worth
lurking in the pain forum once in a while. Prior to the 1990's there was relative "opiophobia" where pain undertreatment was the norm (oligoanalgesia) then the pendulum swung hugely in the other direction with cancer pain dosing being recommended in non-cancer pain patients. The standard became "pain as the fifth vital sign" and no ceiling on doses for anyone based on the theory addiction risk of <1%. This was a number cited without any data, and even those who started citing it, now admit they.........made it up. Yes,
MADE IT UP
Now we have 15,000 patients dying of Rx overdose per year (
CDC) and the founding fathers of this theory
renouncing it publicly and the
senate investigating.
The end result is that you have a whole generation of physicians and patients schooled on the theory that addiction is rare (based on a made-up number) and that opiate doses with no ceiling are the standard. You have the old school Pain people that still believe in this and another school trying to push the pendulum back in
the other direction.
Yes, some people need opiates but there is no concensus in the Pain community about who, how much and for how long:
http://www.nytimes.com/roomfordebat...tion-drug-abuse/opioids-are-rarely-the-answer
http://supportprop.org/news/SupportPROP_ManagingPain_508.pdf
3) Know that some of these patients who seem to be exaggerating their pain while on huge doses of opiates may in fact have severe pain not necessarily due to withdrawal, malingering, or
in spite of the high dose opiates, but
because of the opiates. It's called
Opiod Induced Hyperalgesia. Yes, chronic high dose opiates in some patients can paradoxically make the pain
worse. The patient may be as puzzled as you as to why their pain
really is 10 out of 10, on a dose 50 times greater than where they started. Hmm......It's worth spending 5 minutes reading about it.
4) Intrathecal pumps = call Pain. They get infected. They stop working. They can get masses at the tip that can be a rare cause of spinal cord compression (catheter tip granuloma = awesome "out of the blue" board question if I was writing them, which I'm not). Call Pain. It's their baby; don't try to nurse it yourself.
5) Most of all=
Be an ER doctor, don't lose focus, get distracted or let bias cloud your judgment.
Rule out the emergencies! Period. Stay focused. Chronic pain doesn't mean you can't have an acute epidural abscess, spinal mets, AAA, or ruptured berry aneursym. Be an ER doctor. You know how to treat acute pain, but don't try to be a Pain specialist.
6) You don't know who is treating this patient, IF ANYONE. Is this person treated by a Board Certified Pain physician? Is this person treated by a self-titled, untrained "pain guy"? Is an internist or FP treating the patient? PA, or NP? Pill mill? Self treating from meds off the street? Were they discharged from their Pain practice today for active substance abuse, refusing addiction treatment, or selling?
You may not be able to know at 3 am on a Saturday morning. Do what you think is right. As much as we need to be compasionate and treat pain, no one ever died of pain. People have died of prescription opiate overdose (~15,000 most recent year's data) and they have died of addiction. Be compasionate, treat the
acute pain, but don't be stupid.
7) As far as Ketamine drips or Lidocaine drips for Pain in the ED?
Don't do it. Just don't do it. Before you are going down the "lidocaine drip" part of the arrythmia pathway, you've long since call cardiology. Why would Pain be any different? Most Pain physicians in the community aren't going to admit a patient for a Ketamine and/or lidocaine drip. Why would you? If they are, likely it's at a tertiary center with a strong Pain presence, fellows, residents, etc, to tweak the drip all night. Wake up the fellow. These drips require a continuous monitored setting. I thinks it's out of the scope for EM. Definitely. Of course if you titrate enough opiate, benzo, ketamine, lidocaine or propofol, you'll get someone out of Pain - it's called General Anesthesia, RSI. Just because you
can do it, doesn't mean you should. Treat people's pain, but stay within your scope.
So getting back to docB's original cases……
You give them what you feel comfortable with, and anything beyond that, call a consultant like you would any other difficult case. If you are in a community where Pain is titrating oral opiates up to the levels noted above, they need to deal with the tolerance, the opiate induced hyperalgesia and specialized drips. In many communities, you won't see these doses or drips.
Don't be a hero and do a ketamine/lidocaine drip for chronic pain. Don't trouble-shoot a pain pump. Don't start long acting opiates (including patches).
Don't mess with methadone. (It has a unique and unpredicatable pharmacology unlike any other opiate, not mention prolonging QTc). If you treat them with something on the strong end of what you
feel comfortable with, it's additive to what their basal maintenance meds are anyways and should help, some. Treat the acute pain and get the patient through until 8am so they can call their Pain doctor. If they don't have one, or don't have one
anymore......there might be a good reason (lost insurance) or a not-so-good reason (active addiction, failed drug screen, refused substance abuse referral, selling or discharge from clinic).
I think docB's take on this is pretty stark and unfortunate, but pretty realistic and astute based on the situations presented and the setting (ED with no 24 hr Pain call).
Again, remember, not everyone is the Pain community is advocating or believes in opiate mega-doses for chronic non-cancer Pain (anymore). With the current Opiate prescription overdose epidemic, you are likely to see the pendulum swing very much in the anti-opiate direction.
ALso, remember, opiates aren't the only treatment for pain (injections, nerve blocks, stimulators, nerve ablations, NSAIDS, anti-epileptics, PT, massage, acupuncture, topicals, surgery, TENS units, bio-feedback/pain coping, etc, etc, etc).
Have compasion. Use your best judgement. Don't forget to rule out the "bad stuff." And most of all, do the right thing.