Pain management guidelines - (Can someone offer/link a brief outline for help during rotations)

[lucid_interval]

Hey guys,

Kinda getting slumped by pimp questions on appropriate pain management guidelines.
Can someone please give me a brief idea regarding when to use what, or link me to one?

Eg: Been suggesting toradol when attending thought opiods, been suggesting toradol when attending thought tylenol or vice versa,
This is like the sixth time this has happened.

Thanks in advance!

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[deleted951662]

This is a big question and too much to offer any kind of simple answer. Are you able to provide specific examples?

 

[Zebra Hunter]

There are no pain management guidelines that are universally taught and pain management is probably one of the most variable aspects between physicians of anything in medicine. You will come across some old school attendings that will give every patient with a painful complaint dilaudid or morphine, you will come across younger docs that will prefer opioid sparing analgesia, and you will come across many that are somewhere in between. Don't stress about knowing what analgesia is appropriate, no one cares what a med students analgesia of choice is, just as long as you aren't recommending tylenol for open fractures.

I generally live by these set of rules: Any musculoskeletal complaints when obviously there is no urgent or emergent dx gets NSAIDs (including chronic back pain), most fractures or severe soft tissue injury gets opioids, chest pain gets aspirin and maaaaaybe nitro depending on BP and whether I actually think this is cardiac related, suspected surgical abdominal pain gets opioids, kidney stones get toradol and opioids, suspected minor abdominal pain is variable depending on what I think it is (bentyl for crampy abd pain, maalox and viscous lidocaine for gastritis, NSAIDs for UTI), headaches get compazine/toradol/benadryl, chronic pain patients coming in crying and hyperventilating get haldol, and anything else that obviously sounds emergent and miserable gets opioids. Basically if you think this patient is probably going home without getting any advanced imaging, don't give opioids and if you actually believe that they are having a true emergency causing their pain outside of an MI, give opioids.

 

[MechEDoc]

Hey guys,

Kinda getting slumped by pimp questions on appropriate pain management guidelines.
Can someone please give me a brief idea regarding when to use what, or link me to one?

Eg: Been suggesting toradol when attending thought opiods, been suggesting toradol when attending thought tylenol or vice versa,
This is like the sixth time this has happened.

Thanks in advance!

Good luck with that. Pain management is extremely variable. You can appropriately apply every first-line guideline on management of acute lower back pain and then be criticized for "giving narcotics" versus "not giving narcotics". You're pretty much screwed in any scenario. Just try to figure out what the attending wants, follow that, learn from each different approach and adopt your own when you're able to.

Take for instance renal colic, you can do the following:

• IV lidocaine.
• PO ibuprofen
• Toradol… but wait! Should you give 8 mg, 10 mg, 15 mg, or 30 mg?
• DDAVP
• Morphine, dilaudid, etc.
• Flowmax
• IV fluids, no IV fluids.

Good luck!

 

[theseeker4]

Hey guys,

Kinda getting slumped by pimp questions on appropriate pain management guidelines.
Can someone please give me a brief idea regarding when to use what, or link me to one?

Eg: Been suggesting toradol when attending thought opiods, been suggesting toradol when attending thought tylenol or vice versa,
This is like the sixth time this has happened.

Thanks in advance!

You are never going to be able to know what to suggest, until you work with a particular attending enough to know what they like. This is because it is highly variable between physicians. Some try to avoid opiates if at all possible, some give opiates to almost everyone unless they refuse. Some like tylenol, some like NSAIDS, some like newer/alternative therapy such as ketamine/IV lidocaine. Some are PO only unless they have to be NPO, some will give IV if an IV is in no matter what. Best thing to do is pay attention to what patients get what, and how it seems to work for them. Once you get some experience you can begin to form your own preferences. As long as you aren't giving a particular therapy that is clearly contraindicated, the fact that you suggest something other than a particular attending doesn't mean you are necessarily wrong, it just means you don't know that physician's preferences yet.

 

[GeneralVeers]

Hey guys,

Kinda getting slumped by pimp questions on appropriate pain management guidelines.
Can someone please give me a brief idea regarding when to use what, or link me to one?

I disagree with "theseeker4" (appropriate name). There really shouldn't be different styles and practice guidelines. The BEST practice is to avoid narcotics if at all possible. Try alternative strategies first, like NSAIDS, ice, elevate, etc. Only with complete failure of other methods should narcotics be given, and then PO only. The numbers suggest that 1/50 opioid naive people who we prescribe narcotics to will die of an overdose.

This does not apply of course to acute long-bone fractures, kidney stones, or other obviously severely painful diagnoses.

 

[Janders]

^^^^Precisely.

If you learn ANYTHING from this thread, let it be that it is a wonderful thing to keep opioid naive patients naive. As such, opioids are RARELY first line, and even when they are you should probably add some additional agents to give synergy. Reasons to give opioids first line include crazy painful fractures, severe burns, and undifferentiated acute belly pain that appears *real* (this last group is the tough one).

Otherwise--
Tylenol 1gm PO (I suppose IV if your institution carries it)
Ibuprofen 600mg PO or Toradol 15mg IVP or Toradol 15mg IM
Cyclobenzaprine 10mg PO
Lidocaine Patch 5% (the OTC is 4%...), apply directly where it hurts!
Injected Lidocaine/Bupivicaine

... in some combination are really wonderful for so many painful conditions. These are my go-tos. When you send them home, you can add topical Diclofenac, Decadron/Prednisone, topical lidocaine ointments, Gabapentin etc. Sometimes I sub Valium 5mg for the Flexeril.

Educating your patients about the likely outcome (we are going to make you more comfortable, not 100% pain-free).

If I'm giving opioids, I like PO Morphine 15mg x 1.

If I'm giving parenteral opioids, I admit to enjoying the ease of 1mg IVP Dilaudid, though certainly Morphine or Fentanyl may be better choices.

opiates – emupdates has some good stuff.

Migraines are a special category
Renal colic and IV lidocaine are my friends.

IV ketamine its own bag of worms

 

[thegenius]

Good luck with that. Pain management is extremely variable. You can appropriately apply every first-line guideline on management of acute lower back pain and then be criticized for "giving narcotics" versus "not giving narcotics". You're pretty much screwed in any scenario. Just try to figure out what the attending wants, follow that, learn from each different approach and adopt your own when you're able to.

Take for instance renal colic, you can do the following:

• IV lidocaine.
• PO ibuprofen
• Toradol… but wait! Should you give 8 mg, 10 mg, 15 mg, or 30 mg?
• DDAVP
• Morphine, dilaudid, etc.
• Flowmax
• IV fluids, no IV fluids.

Good luck!

DDAVP for renal colic?!?!

 

[MechEDoc]

DDAVP for renal colic?!?!

Low quality studies. Probably temporizes the problem by transiently reducing urine output. I've put that intervention in there along with other dumb things I've done once and probably won't do again. Haven't had much luck with IV lidocaine either, except for freaking out nursing.

Desmopressin effectiveness in renal colic pain management: Systematic review and meta-analysis - PubMed

In conclusion, the results of this systematic review suggest that, according to the present low-quality studies, desmopressin can be used as an adjuvant therapy in renal colic management in combination with opioids.

www.ncbi.nlm.nih.gov

 

[Zebra Hunter]

IV lido doesn't work for renal colic which recent literature has demonstrated. I stick with the tried and true toradol +/- opioids. No need to get unnecessarily fancy.

 

[GeneralVeers]

IV lido doesn't work for renal colic which recent literature has demonstrated. I stick with the tried and true toradol +/- opioids. No need to get unnecessarily fancy.

I can get 80-90% of renal colic patients comfortable, quickly with this approach. I don't waste my time freaking out the nurses with IV lidocaine, ketamine for pain control etc. The stuff may work, but the time it takes to convince the nurses, and deal with inevitable nursing complaints outweighs any benefits.

 

[GonnaBeADoc2222]

I can get 80-90% of renal colic patients comfortable, quickly with this approach. I don't waste my time freaking out the nurses with IV lidocaine, ketamine for pain control etc. The stuff may work, but the time it takes to convince the nurses, and deal with inevitable nursing complaints outweighs any benefits.

Agree. I do love ketamine for takedowns however, and will use this despite any nursing objections.

 

[GeneralVeers]

Agree. I do love ketamine for takedowns however, and will use this despite any nursing objections.

Actually ketamine for takedowns is one area where I have complete nursing buy-in. Nurses who have used it actively request it.

 

[Janders]

IV lidocaine hasn't shown superiority to Morphine, but certainly some of the studies have shown equivalence.

Purely anecdotally here is my experience with renal colic since I started using it:

1st Line = toradol IV---> probably 2/3 of patients have incredible, massive, rapid relief. These people literally want to kiss me the next time I walk in the room.
2nd Line = IV lidocaine--> Probably 1/2 of the remaining get significant relief. Probably 1/3 find it instant and total.
3rd Line = opioids--> Usually these sort out the remaining people, if not... woof. Call urology.

I'm pulling out all the patients who have "renal colic" who then have imaging NOT showing ureteral stones. Oddly(?!) they respond... differently.

Anyway, I don't think its a godsend, but I find it useful and it has lowered my opioid usage. It is especially pleasant for the couple stone patients with true allergy to NSAIDs who orbit near our shop, and people with significant concomitant medical renal disease.

Lastly we have at least two patients with recurrent renal colic and SIGNIFICANT prior opioid habits, now on suboxone and doing wonderful vis-a-vis recovery / jobs / life... who come out of their way to come to our shop and get IV lidocaine because it gives them relief without the temptation of opioids. This was pretty much all the evidence I needed...

 

[theseeker4]

I disagree with "theseeker4" (appropriate name). There really shouldn't be different styles and practice guidelines. The BEST practice is to avoid narcotics if at all possible. Try alternative strategies first, like NSAIDS, ice, elevate, etc. Only with complete failure of other methods should narcotics be given, and then PO only. The numbers suggest that 1/50 opioid naive people who we prescribe narcotics to will die of an overdose.

This does not apply of course to acute long-bone fractures, kidney stones, or other obviously severely painful diagnoses.

I agree with that you say about narcotics. Perhaps I didn't phrase it properly, but what I was trying to say is as a resident, it will be difficult to predict the various attending styles without experience. I personally think narcotics should be avoided in most circumstances, especially as an RX, but there are lots of doctors who disagree.

 

[deleted109597]

You're better off writing down and keeping a list of what each attending wants. There are people out there that still are unaware that opioids kill people (or seem not to care). They get mad at you for not giving narcotics to sprains or corneal abrasions. No amount of explaining will correct this.
There are people out there that give narcotics for headaches.
There are people out there that give narcotics for low back pain on people who you show them the database demonstrates doctor shopping and abuse or diversion patterns.
Practice how you want to practice.

 

[Groove]

We have a non narcotic policy which has made it incredibly easy to get rid of most of our drug seekers. That being said, it's ultimately up to the physician. I still write some narcs on occasion depending on what's going on though it's pretty rare these days. The pendulum has swung towards non opioid modalities in all things painful which I find incredibly humorous since most of my junk heads are buying heroin and fentanyl on the streets and I suspect our "opioid" crisis has much more to do with illicit drugs and abuse than prescription narcotics. Even though I hate opioid addicted pt's, I feel bad (kinda) for the people that have been on these mega morphine equivalents for years only to have it all discontinued 2/2 physician prescribing restrictions.

Watch, I predict we'll see more of these long term opioid/pain pt's committing suicide (which makes for great headlines) d/t lack of pain relief and being cut off from their narcs and then doctors will start getting blamed for these rash suicides because we're not addressing pain well enough and in 10 years we'll be right back where we started full circle.

 

[Groove]

I still haven't gotten on board the whole ketamine craze for analgesia. I still view it as using artillery shells to take out mosquitoes. All it does is alter the sensorium and discombobulate the pt to the point where they can't complain of pain anymore making disposition easier, which I guess is the whole point. I really don't find myself having to use it that much. I imagine it would be much like standing there slamming them in the head with a sledgehammer going "rate your pain now!"...SMACK!.."c'mon rate your pain!"....SMACK!... Sooner or later their going to shake their head and go "What pain? Where am I? Who am I?" at which point the doc writes "Pain is now a zero and pain relief has been so profound that the pt is almost amnestic to their original chief complaint. Discharged!"

 

[TooMuchResearch]

I still haven't gotten on board the whole ketamine craze for analgesia. I still view it as using artillery shells to take out mosquitoes. All it does is alter the sensorium and discombobulate the pt to the point where they can't complain of pain anymore making disposition easier, which I guess is the whole point. I really don't find myself having to use it that much. I imagine it would be much like standing there slamming them in the head with a sledgehammer going "rate your pain now!"...SMACK!.."c'mon rate your pain!"....SMACK!... Sooner or later their going to shake their head and go "What pain? Where am I? Who am I?" at which point the doc writes "Pain is now a zero and pain relief has been so profound that the pt is almost amnestic to their original chief complaint. Discharged!"

Tried it a bit in residency. Doesn't seem to work better than NSAIDs, Tylenol, narcotics. Yes, I am willing to use oral or IV narcotics for seemingly painful conditions during the ED workup. No, I don't send negative workup belly pain home with narcotics.

 

[southerndoc]

The only time I've used ketamine for analgesia was when a guy slipped in a restaurant kitchen and plunged his hand/wrist/distal forearm into a deep fryer that was on. He was in excruciating pain that hydromorphone wasn't touching. I eventually gave him ketamine and it helped tremendously. Never have used it any other time for pain. Use it like candy for acute psychosis/excited delirium.

 

[TheComebacKid]

I really don't understand the aversion to treating patients with opiates in the ED. Emphasis on the phrase iN THE ED.

I make an assessment on the patient. Either A) they are drug seeking as confirmed by chart review, statewide database etc or B) they have a reason to be in pain.

If I determine they are drug seeking, they go home. If at any point they have a reason to be in pain (cancer, severe abdominal pain, fracture, etc) they get pain meds. While I obviously do not give everyone narcs, I have low threshold to give it to people if I don't feel like NSAIDs/tylenol will work for them.

I give all critically ill patients fentanyl because of how short acting it is and the minimal effect on hemodynamics. Any respiratory depression is very short lived. Morphine is obviously an option as well. I usually reserve dilaudid for last because there definitely is some euphoric effect to it, but again, if there pain is not being controlled, I give it to them.

There is virtually zero evidence IMO that treating patients IN the ED with IV opiates leads to increase risk of addiction. Sending patients home with narcotics is a whole different ball game.

My rules on sending patients home with PO narcotics (usually percocet/vicodin) are usually fairly rigid. If you have an acute fracture, you get roughly 12 vicodin/percs. You don't get anything for dental pain, lacerations, abdominal pain etc. If your PMD prescribes you pain medicine for something and you ran out, I will call them. If I can't get a hold of them, too bad, you will have to call them and get it filled in their clinic.

Oh, and cancer patients get whatever the hell they want.

 

[Birdstrike]

If a patient has an acute, painful emergency, document that and use an opiate, if needed. If they don't have an acute pain emergency, or you feel the risks of an opiate outweigh the gains, document that and then don't use an opiate. It's that simple.

And remember, opiates aren't oxygen.

 

[GonnaBeADoc2222]

If a patient has an acute, painful emergency, document that and use an opiate, if needed. If they don't have an acute pain emergency, or you feel the risks of an opiate outweigh the gains, document that and then don't use an opiate. It's that simple.

And remember, opiates aren't oxygen.

But the painnnnnnnnnnn

 

[Birdstrike]

But the painnnnnnnnnnn

Again, if you have an acute pain emergency and opiates are needed, by all means use opiates. That's the one thing they are proven to work for. But there's a common misconception that if you don't treat pain with opiates (particularly chronic pain) you haven't "treated the pain." That's false. There are many ways to treat pain, particularly chronic pain, without opiates, such as neuraxial (spine) injections, nerve ablations, physical therapy, chiropractic treatments, nsaids, non-opiate analgesics, TCA medications, anti-neuropathic medications, TENS units, cognitive behavioral therapy, spinal cord stimulators, acupuncture, gel injections, botox injections, to name only a few).

In 2017, there were 47,600 deaths from opiates in the USA, per CDC. The death count from opiopenia remains zero.

 

[deleted109597]

Nobody has died from pain ever. And data shows treating pain with opioids increases mortality in some diseases (specifically MI, where you would think it would decrease cardiac oxygen demand if they weren't having sympathetic overload).
People die of pain meds.

 

[rbnsafsadgf]

The death count from opiopenia remains zero.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/add.13512 ( https://onlinelibrary.wiley.com/doi/full/10.1111/add.13512 )

Dying alone: A jail inmate's health spiraled for 7 days and no one stopped it

Madaline Pitkin, 26, died on April 24, 2014, on the floor of her cell at the Washington County Jail. An investigation by The Oregonian/OregonLive found Pitkin had made four written pleas for help that medical staff mostly discounted or mishandled.

www.oregonlive.com

 

[MechEDoc]

https://onlinelibrary.wiley.com/doi/pdf/10.1111/add.13512 ( https://onlinelibrary.wiley.com/doi/full/10.1111/add.13512 )

Dying alone: A jail inmate's health spiraled for 7 days and no one stopped it

Madaline Pitkin, 26, died on April 24, 2014, on the floor of her cell at the Washington County Jail. An investigation by The Oregonian/OregonLive found Pitkin had made four written pleas for help that medical staff mostly discounted or mishandled.

www.oregonlive.com

Opiate withdraw doesn't kill. Missed serious illness, dehydration, and electrolyte abnormalities do. What's the point of a lay press article that likely misses many important points?

 

[Birdstrike]

47

https://onlinelibrary.wiley.com/doi/pdf/10.1111/add.13512 ( https://onlinelibrary.wiley.com/doi/full/10.1111/add.13512 )

Dying alone: A jail inmate's health spiraled for 7 days and no one stopped it

Madaline Pitkin, 26, died on April 24, 2014, on the floor of her cell at the Washington County Jail. An investigation by The Oregonian/OregonLive found Pitkin had made four written pleas for help that medical staff mostly discounted or mishandled.

www.oregonlive.com

10 reported deaths, questionably linked to opiate withdrawal, but more likely due to prison neglect of easily treatable diarrhea & dehydration, versus 47,000 deaths from opiates every year. So, according to that, opiates are a least (but probably more than) 4,700 times more deadly than a lack of opiates.

But don't be surprised if the pushback against curbing opiates gets stronger, which it will. The pressure has already caused the FDA buckle a little bit, issuing a statement to doctors saying: Careful. If you stop opiates, your patients might have hurt feelings and kill themselves.

 

[Birdstrike]

PS: Most opiate deaths currently are not from prescribed opiates. They're from illicit fentanyl, in power form mixed into heroin or pressed into pill form, coming from China:

They make it in China and ship it through the mail to the USA (or Mexico and then truck it here). In fact, until just a few weeks ago, it was completely legal in China to do so. Whether any such ban on the surface results in any less fentanyl production and importing, remains to be seen. Hopefully it will, but there are no guarantees.