Acute Pain in the Setting of Chronic Pain

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

docB

Chronically painful
Moderator Emeritus
Lifetime Donor
20+ Year Member
Joined
Nov 27, 2002
Messages
7,890
Reaction score
752
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.

Members don't see this ad.
 
I don't have to worry about it.
I can't prescribe schedule II in Texas, because I don't have triplicate prescriptions, which are required by DPS.
So if I am sympathetic, I admit them. If I'm not, for whatever reason, I encourage them to follow up with their pain specialist. And that's about it.
We can't fix everything, and chronic opioid tolerance is pretty high on the list of "can't fix".


As with everything else, my answer is usually droperidol.
 
yesterday had a mid-30s F 36wk OB on 100mg methadone who was s/p MVC w/ a distal radius fx. Controlled her pain in the ED, but when she goes to leave she asks repeatedly for something stronger for pain. I told her to follow up with her pain MD. It's probably easier to do that when you don't have to worry as much about patient satisfaction surveys.
 
Members don't see this ad :)
yesterday had a mid-30s F 36wk OB on 100mg methadone who was s/p MVC w/ a distal radius fx. Controlled her pain in the ED, but when she goes to leave she asks repeatedly for something stronger for pain. I told her to follow up with her pain MD. It's probably easier to do that when you don't have to worry as much about patient satisfaction surveys.

That's just the situation I'm talking about (although I don't know what they're going to do with a highly tolerant, addicted neonate). I've given the following speech 10 times in the last month when they ask for "something stronger."

"There isn't anything stronger. You are already on the strongest pain medicines available. You are on so much narcotic that there just isn't anywhere else to go when you hurt yourself. You will just have to suffer with the pain from your arm (or whatever) because you are on so much medicine for your back (or whatever). There's just nothing else we can do for you. And your pain will be worse than normal because your body's pain receptors have been changed by the drugs. I sorry. You need to see your pain doctor and you should work to get off of the long term narcotics so you don't wind up in this situation if you injure yourself in the future."
 
Here's a real question I have that I'm not asking rhetorically: can you max out on opioids?

My understanding is that for all practical purposes you cannot. As I've understood it, people on high-dose chronic opioids have a high tolerance, but even in these people I can titrate their dilaudid or oxycodone such that they get pain relief, get sleepy, completely lose consciousness and go apneic, as the dose increases.

So if that's true, maybe there's a role for even more opiates when these folks break their arms.

(Seriously, 30s F on that much oxy, hydro, and xanax? I'd love to know what went wrong, way back when...)

Will second droperidol. I <3 droperidol.

Would consider peripheral nerve blocks.

These patients are the reason there is such a subspecialty as "pain medicine." Consults are indicated.
 
Here's a real question I have that I'm not asking rhetorically: can you max out on opioids?

My understanding is that for all practical purposes you cannot. As I've understood it, people on high-dose chronic opioids have a high tolerance, but even in these people I can titrate their dilaudid or oxycodone such that they get pain relief, get sleepy, completely lose consciousness and go apneic, as the dose increases.

So if that's true, maybe there's a role for even more opiates when these folks break their arms.

(Seriously, 30s F on that much oxy, hydro, and xanax? I'd love to know what went wrong, way back when...)

Will second droperidol. I <3 droperidol.

Would consider peripheral nerve blocks.

These patients are the reason there is such a subspecialty as "pain medicine." Consults are indicated.

Points taken. I'm not being contrary here but I can't really do any of that. I'm happy to give more narcs but their "sweet spot" of not screaming but still breathing is so narrow they are a management and logistical nightmare.

I have no pain consultants or anesthesia who will see a patient in the ED. I can't send someone home on droperidol. I can give them some slugs of D or MS in the ED and monitor them so they don't go apnic or if they do I can intervene but what then? I can't admit them to the floor with an almost deadly regimen of narcs. I can't send them home like that. I can't intubate them for a pain issue.

I wish these people could know how bad these situations get so they would be motivated to get off, or at least down, on their narcs before they get into an acute pain + chronic pain situation.
 
I don't have to worry about it.
I can't prescribe schedule II in Texas, because I don't have triplicate prescriptions, which are required by DPS.
So if I am sympathetic, I admit them. If I'm not, for whatever reason, I encourage them to follow up with their pain specialist. And that's about it.
We can't fix everything, and chronic opioid tolerance is pretty high on the list of "can't fix".


As with everything else, my answer is usually droperidol.

Never a truer phrase has been said . . .
 
Here's a real question I have that I'm not asking rhetorically: can you max out on opioids?

My understanding is that for all practical purposes you cannot. As I've understood it, people on high-dose chronic opioids have a high tolerance, but even in these people I can titrate their dilaudid or oxycodone such that they get pain relief, get sleepy, completely lose consciousness and go apneic, as the dose increases.

So if that's true, maybe there's a role for even more opiates when these folks break their arms.

(Seriously, 30s F on that much oxy, hydro, and xanax? I'd love to know what went wrong, way back when...)

Will second droperidol. I <3 droperidol.

Would consider peripheral nerve blocks.

These patients are the reason there is such a subspecialty as "pain medicine." Consults are indicated.

There's no max dose for opioids, and there's no good way of telling when you've completely saturated the mu receptors (and even if you could upregulation is going to ensure you can't maintain saturation with a consistent dose). Treating acute pain is relatively easy in the ED, but docB's point about outpatient management is spot on. I've had people with intrathecal morphine pumps (in addition to both sustained and IR release opioids) come in complaining of worsening pain. Nothing I write is going to even come close to that.

docB's answer of honestly describing the limits of modern medicine is probably the right way to do it, although it hurts our pride to admit we can't help the patient and the patient can come away confused and bitter if their pain doc never instilled in them an understanding that they're going to have pain and the goal is functionality. As a profession we've broken people with our inappropriate treatment of chronic pain (it's a lot easier to get an appointment to a pill mill then to a board-certified doc) and I often wonder if we'd be better off not treating (non-terminal) chronic pain with opioids.
 
Found out our pharmacy doesn't carry droperidol. I was upset when I heard this.

I know on trauma, we dealt with this quite a bit (as I'm sure all of you did). Pain management increased oral meds until they could be taken off the IV meds so they could be discharged. I have never written for so many narcs in my life and I am still not comfortable doing it.

My problem is also this: pt on multiple narcs, benzos, etc for pain management. Comes in complaining of pain, but so gorked they are falling asleep while talking to you and slurring their speech. This is without proof of pain as you mentioned. I refuse to give these people anything but tylenol or motrin (if they aren't already allergic).

There are some with real reason for pain and I figure if they have meds at home they take for PRN breakthrough, then they can take it for breakthrough pain for whatever reason. If they are on oxycodone 5mg PRN, I'll increase it to 10mg if they are still functioning on the 5mg. Anything above 10mg makes me nervous without any history of reason to be nervous.

I also discuss with them about finding ways to wean off what they are on for the next time.
 
Found out our pharmacy doesn't carry droperidol. I was upset when I heard this.

I know on trauma, we dealt with this quite a bit (as I'm sure all of you did). Pain management increased oral meds until they could be taken off the IV meds so they could be discharged. I have never written for so many narcs in my life and I am still not comfortable doing it.

My problem is also this: pt on multiple narcs, benzos, etc for pain management. Comes in complaining of pain, but so gorked they are falling asleep while talking to you and slurring their speech. This is without proof of pain as you mentioned. I refuse to give these people anything but tylenol or motrin (if they aren't already allergic).

There are some with real reason for pain and I figure if they have meds at home they take for PRN breakthrough, then they can take it for breakthrough pain for whatever reason. If they are on oxycodone 5mg PRN, I'll increase it to 10mg if they are still functioning on the 5mg. Anything above 10mg makes me nervous without any history of reason to be nervous.

I also discuss with them about finding ways to wean off what they are on for the next time.

Part of the problem is going to be that people in chronic pain (sicklers being the archetype) lose the sympathetic surge the rest of us have with pain. So they may be in agony and not sweaty, nauseated, hypertensive, or tachycardic. There's no objective way to determine pain in someone with chronic daily pain, which is frustrating.

Now you're thinking to yourself, I see plenty of chronic pain patients that are moaning, sweaty, and vomiting. And I'd argue that you're seeing a mix of acting (they're reconstructing the reactions they used to have because they know we'll ignore them if they don't look in distress) and severe anxiety around not getting their pain relieved. Add in a sprinkle of opioid withdrawal and they look almost exactly like someone in acute pain. Which I think actually does them a disservice because we assume they're scamming us because they don't have the H&Ps we associate with acute pain. Of course I have essentially no ability to help an unresourced patient with chronic pain, so this may be their best bet.
 
Non-opiod alternatives:
Low-dose ketamine
IV lidocaine

Obviously no PO equivalent, but some of the time just terminating the acute episode gives you a window to discharge.

But, yeah, I'm defeated by these sorts of patients, too.
 
Do you think there is a use for short-course steroids or a shot of dexamethasone in some of the cases above (radiculopathy, fracture), as an anti-inflammatory and so that the patient feels that you at least tried something to bridge them to their pain provider? Is there some obvious contraindication I'm missing or would it just do nothing?
 
Do you think there is a use for short-course steroids or a shot of dexamethasone in some of the cases above (radiculopathy, fracture), as an anti-inflammatory and so that the patient feels that you at least tried something to bridge them to their pain provider? Is there some obvious contraindication I'm missing or would it just do nothing?

Radiculopathy, sure. We give Medrol paks for them all the time. I tend to think that it wouldn't help fracture pain though.
 
Members don't see this ad :)
"If I am sympathetic, I admit them"
"Low dose ketamine"

These are both absolute non-starters in the non-Texas community ED. Period. I also don't have droperidol. Lidocaine IV? I shall freely tell you that my experience with lidocaine IV is old-school ACLS - not for pain relief. If I tried that in my community ED, I would not get a scoffing look - I would simply get a "no".

In other words, people are giving nearly inapplicable advice.

I have asked - more than once - about droperidol and ketamine. It is a black letter "no". Hell, I get pushback for admitting hypoxic patients. Pain? You gotta be completely kidding me.

I mean, it would be like saying "just prescribe some medical marijuana". Well, if you're not on the west coast or in Hawai'i, the value of that advice is nil.

The best piece of information in this thread is docB's speech, concerning upregulation of pain receptors and max opiate usage, although I also got a chuckle out of his typo of omission with "I sorry".
 
if they have a pain doc, i call them. most of the folks on those types of doses have one. if they don't, they need one.

feel fortunate to be able to give droperidol - the more seasoned nurses about jump for joy b/c they know that the q2 min bell-pushing is about to stop. fantastic drug even at VERY low doses compared to those associated w/ qt prolongation.

i will add that a benzo added to pain meds will often help, or adding a sleep med like ambien or trazodone. obviously, start low and have the pt follow up soon...
 
Had a guy like this the other day on ungodly amounts of opioids with a broken ulna who tried to lecture me when I said "wow, these are some pretty high doses." about how I'm stigmatizing him and whatever... I called his private pain doc and got him an appt - I know not an option everywhere, did some quick reading and did an US-guided regional block of the elbow to give him at least some relief, put him in a loose splint with a sling, gave him (and documented) some really good discharge instructions about what to watch for compartment syndrome and discharged him really satisfied.

Not sure if I took any kind of undue risk by doing it that way, but the attending was cool with it and I was really satisfied with the results
 
Had a guy like this the other day on ungodly amounts of opioids with a broken ulna who tried to lecture me when I said "wow, these are some pretty high doses." about how I'm stigmatizing him and whatever... I called his private pain doc and got him an appt - I know not an option everywhere, did some quick reading and did an US-guided regional block of the elbow to give him at least some relief, put him in a loose splint with a sling, gave him (and documented) some really good discharge instructions about what to watch for compartment syndrome and discharged him really satisfied.

Not sure if I took any kind of undue risk by doing it that way, but the attending was cool with it and I was really satisfied with the results

I think that guy came to my ER 5 minutes later bitching about how that other doc wouldn't give him any pain meds
 
Had a guy like this the other day on ungodly amounts of opioids with a broken ulna who tried to lecture me when I said "wow, these are some pretty high doses." about how I'm stigmatizing him and whatever... I called his private pain doc and got him an appt - I know not an option everywhere, did some quick reading and did an US-guided regional block of the elbow to give him at least some relief, put him in a loose splint with a sling, gave him (and documented) some really good discharge instructions about what to watch for compartment syndrome and discharged him really satisfied.

Not sure if I took any kind of undue risk by doing it that way, but the attending was cool with it and I was really satisfied with the results

There's no way I'd block someone at risk for compartment syndrome. The upside isn't worth it. I also don't think I'd respond well to his lecture, but that's another issue. In regards to Apollyon, low-dose ketamine doesn't fly in my Texas community ED (it runs afoul of procedural sedation guidelines even at sub-disassociative doses) although I am able to admit trauma patients for pain control. All traumas go to the surgeon on call for the first 24 hrs so I bypass the medicine doc whining about admission criteria.
 
I think that guy came to my ER 5 minutes later bitching about how that other doc wouldn't give him any pain meds


Hey man, your problem now.

/buffed and turfed
 
Nothing to add much to the current discussion, but at least for headaches, even traumatic ones (at least w/o skull fx/bleed), they seem to go down the same pain pathway, and don't normally require narcotics to control. I'm unfortunately stuck w/o droperidol and compazine, but fioricet, high dose solumedrol, IV depakote, and just once IV keppra seem to work. The only exceptions i've encountered so far was a really bad pseudotumor, whose headache wasn't relieved until a second therapeutic tap was performed (thankfully not my pt).
 
I like how the Chronic painers assume that just because they are in the ER for ANY reason they think they can get a shot, even if they aren't there for a painful complaint.

I'll have people complaining of cough, or vague neuro symptoms, and inevitably the nurse will come ask me: "Doctor he wants a shot for his pain"

me: "What pain? He's here for cough"

Nurse: "For his chronic back pain".

Me: "He isn't here for back pain, so don't give him anything".

A little bit later....

Nurse: "Patient has left, doctor."

Me: "Good"
 
There's no way I'd block someone at risk for compartment syndrome. The upside isn't worth it. I also don't think I'd respond well to his lecture, but that's another issue. In regards to Apollyon, low-dose ketamine doesn't fly in my Texas community ED (it runs afoul of procedural sedation guidelines even at sub-disassociative doses) although I am able to admit trauma patients for pain control. All traumas go to the surgeon on call for the first 24 hrs so I bypass the medicine doc whining about admission criteria.

I'm not saying it with my usual snarky disdain. I really feel helpless. Is there any better info you can suggest for these situations?
 
"...call their pain doc..."

I have NEVER been able to get in touch with one. Got a nurse at best. Now, vegas is a medical hell hole in general, so that may play into it.

Also, I honestly cannot remember the last time one came in for either acute on chronic or chronic during their pain docs office hours!!! Pretty smart eh??

They always say, "we thought we'd tough it out"...oh, til just after 5 and their pain doc does not take calls!
 
me: "What pain?

Ha! If I had a nickel for every time I've uttered those precise words, in those precise circumstances, I could feed myself at Starbucks for a month.

I'm not saying it with my usual snarky disdain. I really feel helpless. Is there any better info you can suggest for these situations?

I certainly can't. I also feel pretty helpless. Kind of like when kids with bronchiolitis come in, only completely different.

I think your speech to the pts about chronic narcs is a good one.
 
"If I am sympathetic, I admit them"
"Low dose ketamine"

These are both absolute non-starters in the non-Texas community ED. Period. I also don't have droperidol. Lidocaine IV? I shall freely tell you that my experience with lidocaine IV is old-school ACLS - not for pain relief. If I tried that in my community ED, I would not get a scoffing look - I would simply get a "no".

In other words, people are giving nearly inapplicable advice.

I don't know that droperidol in inapplicable. As with most "rules" at hospitals, when you ask to see it written, you find that it isn't a policy, just learned behavior. If it isn't available, that's another thing.

Sympathetic means cancer patients with bony mets. I don't soft admit the end stage fibromyalgia. I don't have a sickle cell population anymore, thank god.
But the cancer patients you can usually find a reason to admit them for intractable pain.

I agree that ketamine is tough unless you've got a hospital with a forward thinking pain policy. And if it doesn't, this is the great place to make a change. I mean, if you're having one of these patients per month, changing the policy might not help. But it sounds like DocB has a more frequent problem, and it might be worthwhile to talk to P&T or someone about this.

If the nurses are telling you "no" after an order, then your community ED has bigger problems.
 
my favorite is when back pain patients whine that they have METAL in their BACK!!!... and therefore should be given narcotics when and how requested...
i say: "me too!"
pt's jaw drops....

if the pt goes to our hospital's affiliate pain practice, they do call back. eventually... usually less than an hr. i wish their notes were in our system, but arghhh... esp for those they've "fired".
 
Sympathetic means cancer patients with bony mets.

A great hospice doc taught me that nothing treats bony met pain better than decadron and with my small N I have to say I agree with her
 
I'm not saying it with my usual snarky disdain. I really feel helpless. Is there any better info you can suggest for these situations?

As a side note it's a similar situation to the patients with symptomatic cholelithiasis. Yes it's painful. Yes it will come back. Yes it could become dangerous. But no I can't just admit you and get a surgeon to take it out now. They just won't do it. You have to follow up as an outpatient. Sorry. My hands are tied.

But it sounds like DocB has a more frequent problem, and it might be worthwhile to talk to P&T or someone about this.

I should talk to my hospital's P&T representative. Oh wait. That's me.

I can't see us doing it. We only just recently had to fight off one of those silly "only anesthesiologists should give propofol" pushes again.
 
One of our pain docs says treat exactly as you otherwise would. Distal radius? Percocet on top of their usual chronic meds because (as we all know) even the chronic meds don't work all that well and you're sort of peeing into the ocean. Risk of overdose (according to him) was par assuming they're awake on their usual stuff and not stoned. The patients aren't thrilled to still have any pain, but its all we've got as far is know.
 
Part of the problem is going to be that people in chronic pain (sicklers being the archetype) lose the sympathetic surge the rest of us have with pain. So they may be in agony and not sweaty, nauseated, hypertensive, or tachycardic. There's no objective way to determine pain in someone with chronic daily pain, which is frustrating.

Now you're thinking to yourself, I see plenty of chronic pain patients that are moaning, sweaty, and vomiting. And I'd argue that you're seeing a mix of acting (they're reconstructing the reactions they used to have because they know we'll ignore them if they don't look in distress) and severe anxiety around not getting their pain relieved. Add in a sprinkle of opioid withdrawal and they look almost exactly like someone in acute pain. Which I think actually does them a disservice because we assume they're scamming us because they don't have the H&Ps we associate with acute pain. Of course I have essentially no ability to help an unresourced patient with chronic pain, so this may be their best bet.

First paragraph I do agree with you. They often come in in withdrawal and I'll give them a handful of whatever drug to get them to their doctor the next day.

The second paragraph is where I do have difficulties with patients. Hard to tell if they are acting or not. Those I know and I see on a regular basis I do know the difference. Those I don't know I give them what they need until I have no proven source. After that is where I have difficulty. Do you prescribe more at that point?

If a person has a fracture / obvious source for pain and functioning, like I said, I'll increase the dose to a certain point. If they are huge and have no neck, I look at increased risk for apnea with narcs. If they are skinny, I look at increased risk of easier OD, so increase by less.

If they are on oxycontin and oxycodone, I seem to be more comfortable adjusting. Methadone - I have no idea. That's when I would write for some oxycodone for them to take and follow up with their pain management doc to have everything adjusted.
 
What practical advice do have, then? Sure, multimodal pain control is beyond the scope of many ED settings...so what do you do? Snow 'em and street 'em?

I DON'T have the practical advice. Then again, I'm not the one saying ketamine and lidocaine. If I did indeed have anything to give, versus what I am doing (asking for/taking advice), I would. What do I do? I do what, just like several others have said in this thread, is flounder, with my hands figuratively up in the air.

I don't know that droperidol in inapplicable. As with most "rules" at hospitals, when you ask to see it written, you find that it isn't a policy, just learned behavior. If it isn't available, that's another thing.

Sympathetic means cancer patients with bony mets. I don't soft admit the end stage fibromyalgia. I don't have a sickle cell population anymore, thank god.
But the cancer patients you can usually find a reason to admit them for intractable pain.

I agree that ketamine is tough unless you've got a hospital with a forward thinking pain policy. And if it doesn't, this is the great place to make a change. I mean, if you're having one of these patients per month, changing the policy might not help. But it sounds like DocB has a more frequent problem, and it might be worthwhile to talk to P&T or someone about this.

If the nurses are telling you "no" after an order, then your community ED has bigger problems.

What I have been told about droperidol is we don't have it on formulary. I don't know about the anesthesia dudes, but, what I was told was that, even if I could get it from the pharmacy, it would be in the same class, as far as nursing, as ketamine - continuous cardiac and respiratory monitoring, on a procedural sedation level. I don't have enough juice at the place yet, though, to challenge this.

I get you on the cancer mets pain - the way it was originally worded, I was thinking about the whining, total body dolor, on methadone and oxy CR and Fentanyl patch and Dilaudid PO regimen, and still "12/10", with the only dx being the dual PTSD and fibromyalgia.

As far as the lidocaine, though, that is something I could try. However, I need a LOT more guidance. "Low dose" I thought was like 0.1 or 0.25mg/kg - but what is it for pain? 0.4-0.8mg/kg/hr, for 1 hour, or what?

You (not McNinja, the general "you") can rightly insult me for not being on the bleeding edge of research and the literature, but, to say "low dose lidocaine", and leave it like that, gives me no help, because it needs a LOT more detail, like a written protocol that at least lays down a framework. With data, I can tell my nurses (who, to be quite sanguine and honest, are the best group with whom I've ever worked in my entire career - no department-crushing personality disorders, only one nurse with the prototypical "me vs you, and I'll throw you under the bus" mentality, and she's per diem, and reasonable, adult people) that they won't be lethally injecting any of the patients. However, with my luck, the first patient will be the one that has perioral numbness or projectile vomiting or seizes, then that will end that.

But any substantive advice, I'll listen.
 
I'm not saying it with my usual snarky disdain. I really feel helpless. Is there any better info you can suggest for these situations?

I honestly think you're initial approach of admitting helplessness and having pt f/u with whoever is prescribing the narcs is currently the right one. I'd consider whatever non-narcotics the patient isn't allergic to and emphasize the non-pharmacologic things that can be done for the pain. If they have acute pain I treat it in the ED until it's minimal using frequent boluses of IV opioids and hope that interrupting the pain cycle may allow their current meds to work better. I wish I had a better answer in terms of at home regimen, but until someone figures out a fast-acting drug that targets the non-mu receptor portion of pain I think that's the best we can do.
 
I wish I had a better answer in terms of at home regimen, but until someone figures out a fast-acting drug that targets the non-mu receptor portion of pain I think that's the best we can do.

The drug you describe is ketamine, except for the home-use part...

I also agree that nerve-blocking and then giving compartment syndrome precautions is a risky move.
 
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&#8230;&#8230;

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.
 
regional block under bedside ultrasound could be reasonable...did a femoral nerve block on a class 4 asa pt who screwed up his whole leg and had successful pain control but he was being admitted.
 
i had no idea how little i knew about chronic pain until i WAS (and thankfully no longer am) a chronic pain patient. thankfully also, i never liked narcs and wasn't on them other than a rare prn, even after an anterior lumbar spine surgery. my TENS unit was my best friend for MONTHS, and my PT and massage therapists a close 2nd and 3rd...

i still don't pretend to be an expert, but my eyes were opened to the world as a doc and as a pt.

also my experience afforded me a glimpse of how pain is managed in Europe... NOT with mega-doses of long acting chronic narcs... we have to change this mindset that everyone should have 0/10 pain (or even 2) now that we know the consequences.
 
Certainly another well-written and thought-provoking post by BirdStrike, but it leaves me back where I started. In the community, without any pain management docs within 75 miles (literally), with patients on heroically (or *****ically) high doses of opiates, and now in acute on chronic pain, he recommends wholly against things like ketamine and lidocaine.

I, personally, am always as compassionate as I can be, until someone doesn't deserve it. So, telling me to be compassionate is like saying "don't fall" - no one goes out of their way to fall down. That is advice that doesn't say anything. If I am not going to do something new, then what do I do? What do I do? Telling the person "I'm sorry, but I can't help you", again (figuratively) throwing my hands in the air, or being sheepish and apologetic, what do I do? "Most of all, do the right thing." The "right thing" would be to transfer these people to any of the tertiary care centers that are, again, the closest being 75 miles away. Who is going to accept that patient for transfer?

Mine are honest questions.
 
Mine are honest questions.

Unfortunately, sometimes there aren't good answers. You'd be hard pressed to find someone to accept the transfer. You'd be harder pressed to get one of the local guys to admit.
When your hands are tied though, you're left with very few options.
Increase their opiates, or
Add non opiates, or
Do nothing.
And that's the sad truth. Just like junkies wanting their next fix, we have a whole class of patients that the only way to "help" them is to potentially kill them.
Not ideal by any stretch, but I don't think there are a lot of other answers out there.
 
See, that's what I tell them now - "I can't do any more for you, because you are already on higher doses regularly than I could ever give you as a one time thing".

So this is EM in the US now. I wish the President would address real issues, instead of the showboating gun thing, which won't do a thing.
 
I wish the President would address real issues, instead of the showboating gun thing, which won't do a thing.

Oy.

The President has a lot more important things to do than to focus on the plight of emergency docs without good options for acute-on-chronic pain patients.

I'd be shocked if there was a "magic bullet" piece of advice out there that will make this problem go away. I can only say what I do in this common situation. It's as optimal as I can get given the situation. Then I move on to the poor schlub dying of heart failure or exsanguinating from a collision with a truck. Life's tough.
 
Oy.

The President has a lot more important things to do than to focus on the plight of emergency docs without good options for acute-on-chronic pain patients.

My point was as a microcosm of the bigger picture of things that matter.

I'll have to see the numbers - if more patients are overdosing than being killed by guns, then our plight would have more objective providence. Even if they are close, there should be more equivalence. That's all I am saying.
 
My point was as a microcosm of the bigger picture of things that matter.

I'll have to see the numbers - if more patients are overdosing than being killed by guns, then our plight would have more objective providence. Even if they are close, there should be more equivalence. That's all I am saying.

well, i don't think you need objective evidence honestly, just go OD a roomful of kindegarteners and you'll be set with your subjective evidence.
 
My point was as a microcosm of the bigger picture of things that matter.

I'll have to see the numbers - if more patients are overdosing than being killed by guns, then our plight would have more objective providence. Even if they are close, there should be more equivalence. That's all I am saying.

They're actually pretty close.
http://forums.studentdoctor.net/showthread.php?p=13435813
The CDC said:
Firearm—In 2008, 31,593 persons died from firearm injuries in the
United States (Tables 18 and 19), accounting for 17.4 percent of all
injury deaths that year. The two major component causes of all firearm
injury deaths in 2008 were suicide at 57.7 percent and homicide at
38.5 percent. Even though the year-to-year observed difference in
age-adjusted death rate for firearm injury (all intents) was not statis*
tically significant, notable changes took place in firearm mortality
according to intent: The age-adjusted death rate for firearm suicide
increased by 3.6 percent from 2007, while the death rate for firearm
homicide decreased by 4.8 percent in 2008 from 2007.

Drug-induced mortality
In 2008, a total of 38,649 persons died of drug-induced causes
in the United States (Tables 10, 12, and 13). This category includes
not only deaths from poisoning and medical conditions caused by
dependent and nondependent use of legal or illegal drugs, but also
poisoning from medically prescribed and other drugs. It excludes
unintentional injuries, homicides, and other causes indirectly related
to drug use, as well as newborn deaths due to the mother’s drug use.
(For a list of drug-induced causes, see ‘‘Technical Notes.’’ See also
the discussion of poisoning mortality that uses the more narrow
definition of poisoning as an injury in
http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_10.pdf
 
tripled_rates_graph_600w.png
 
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.
Since I don't even start medical school until August, I'm afraid I can't offer any meaningful assistance regarding your specific question about how to medically manage cases of obvious, severe acute pain among the population of chronic pain patients on longstanding mega-opiate/narcotic therapy.

But from my work experience as a psychotherapist in a psychiatric hospital for the past several years, I am quite familiar with the challenging cohort of patients you describe. I too have often been perplexed, hypothetically, about the exact circumstances which you have proposed in your question. I would also be interested to know: How on earth would you treat a MVC trauma victim, perhaps presenting with multiple skeletal fractures, if their baseline outpatient pain management already consisted of one of the many inconceivable cocktails I encounter everyday (e.g., Oxycontin 80mg BID, Oxycodone 30mg QID, Xanax 1mg BID, Valium 10mg QHS, Ambien CR 12.5 mg QHS, Soma 350mg Daily... etc., etc., etc.... you get my drift). Because these patients have essentially been shuffling around in a semi-conscious, anesthetized state on a daily basis for years prior to their acute injury, I cannot fathom how their traumatic pain could possibly be controlled.

In fact, whenever I have the opportunity to meet a budding pain management patient, in an earlier stage of their downward spiral into chronic abuse of narcotic pain meds, I always take a moment to paint this grim picture for them. Many genuinely admit that they had never considered the possibility of such a terrible outcome, and at the very least, I hope it causes them to think, reflect, and do some serious soul searching. Perhaps for a few of them, it will prompt a serious conversation with their physician about holistic, integrated, and hopefully healthier methods to manage their pain and thereby move forward with a higher quality of life.
 
Top