recent acute pain consult

[ear-ache]

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I recently had an interesting (if not humbling) inpatient acute pain consult that I though that you might enjoy.

Mid 60’s y/o gentleman with complex PMHx. HPI is essentially metastatic colon cancer requiring hemipelvectomy complicated by nonhealing sacral & ischial ulcesr. POD #0 for skin flap closure.

Pt’s home pain regimen – Duragesic 350mcg/hr, OxyContin 60mg BID, Oxycodone 60-90 q3h PRN, Pregabalin 150mg TID, Cymbalta (I forget the dose), Ibuprofen 200mg TID (stopped prior to procedure). Baseline pain scores 3-4/10. States he gets n/v with morphine and hydromorphone, that Oxymorphone “doesn’t work”, and prefers fentanyl.

Called by surgical service to assist with intractable 10-out-of-10 pain. Pt is clearly uncomfortable. He is on his home pain medications minus the ibuprofen. Fentanyl Duragesics were in place during surgery, he took his AM and PM dose OxyContin and received 250mcg Fentanyl and 6mg Hydromorphone intraoperatively. He got 450mcg Fentanyl in PACU. Epidural was refused by patient as “it didn’t work for my other surgery”.

Over the next 4 hours I administered a total of 3000mcg fentanyl. I started with 100mcg fentanyl pushes and escalated to 300mcg pushes. I was not at the bedside continuously (I obviously have other call responsibilities), and when I was not present he had a fentanyl PCA that eventually reached 300mcg/10min, which he would lock out. He had no noticeable positive or negative effects from the narcotics, it was like pushing water. On two occasions I pushed Ketamine 20mg with 1mg versed while I tried to “catch up” with opioids. The ketamine would stun him for only 20 minutes. My final attempt with my failing plan was a single push of Oxymorphone 3mg IV – no effect. I wake my attending and he enlightens me.

What is your diagnosis and plan?

 

[ChrisA]

consider a ketamine drip? we use it all the time where I am for acute pain. Its a nice adjunct since you guys are trying everything else....

 

[New2Midwest]

Agree with ketamine drip and try to talk to him at length re: epidural and how you are going to "make it work" this time around... May also want to try some low dose clonidine (0.1 mg po TID) if VS/LOC will tolerate it-sounds like there should be no problem with a little clonidine in this guy...

 

[ear-ache]

consider a ketamine drip? we use it all the time where I am for acute pain. Its a nice adjunct since you guys are trying everything else....

Unfortunately the nurses cannot push/hang ketamine, as it is classified as an induction drug at our institution. And technically, I am not supposed to administer ketamine outside the OR or ICU. Ironically administration has no issues with nurses setting the demand dose of a fentanyl PCA at 300mcg q10 min and walking away.

However, we can order Ketamine infusions on the unit.

 

[fastosprintini]

diagnosis 😳pioid induced hyperalgesia

treatment : wean opioids, provide analgesia with well placed epidural, down the road treat pat with intrathecal morphine pump and /or neurolytic blocks of the dorsal root ganglion using etoh2
fasto

 

[Noyac]

diagnosis 😳pioid induced hyperalgesia

treatment : wean opioids, provide analgesia with well placed epidural, down the road treat pat with intrathecal morphine pump and /or neurolytic blocks of the dorsal root ganglion using etoh2
fasto

WOW Fasto. You sound like a real pain doc.😍

Ear-ache, have you tried Tylenol?

 

[Planktonmd]

Diagnosis: Drug addict.
Treatment: There is no treatment.

 

[Licoricestick]

diagnosis 😳pioid induced hyperalgesia

treatment : wean opioids, provide analgesia with well placed epidural, down the road treat pat with intrathecal morphine pump and /or neurolytic blocks of the dorsal root ganglion using etoh2
fasto

And in the meanwhile if he refuses the epidural still (why is it always the ones that really need them...) go paracetamol/acetaminophen regularly, ketamine infusion, clonidine, and consider putting him back on the NSAIDs or something like a dose of parecoxib?

ear-ache you said it was humbling.... is there something else coming as part of the story?

 

[cchoukal]

an epidural is all well and good, but I suspect even with a surgical anesthetic level of blockade, this guy will still experience 'pain.' The clonidine is a nice touch. We use dexmedetomidine for a day or so as the clonidine is started, and in place of the ketamine, you might try methadone for the NMDA activity. You're in a tough spot and am curious how it all shook out (i had a similarly addicted pt my last night on call).

 

[fastosprintini]

seriously, i would have a talk with him and find out what his goals are....
most likely his lifeexpectancy is < 6 months so that aggressive therapy is indicated, my choice would be a neurolytic block with alcohol(hypobaric, so the target is up) and the patient has to accept some loss of function (bladder, bowel,sensation dependent on the site)
my $0.02 fasto

 

[Jeff05]

possibly opioid induced hyperalg.
or they just don't work anymore.
possibly a seeker. but, patient has a clear source of pain, so i would give him benefit of doubt.

it's silly to keep pushing the same drug that doesn't work. i mean would you keep pushing labetalol is BP didn't drop after 200mg?

give dilaudid and zofran.
definitely start methadone.
write for plenty of benzos.
c/s interventional for intrathecal pump and pall. care for hospice.

 

[ear-ache]

Thank you for your comments and suggestions

- I agree with continuing/encouraging ketamine for its NMDA antagonism, but there was increasing resistance to its use on the floor secondary to political issues. Oral ketamine was also blocked by nursing administration.
- I agree with starting clonidine, and it was implemented the following day
- Scheduled Tylenol was implemented latter following discussion about OIH. He was initially refusing it as it “doesn’t work”.
- NSAID’s unfortunately were not an option due to plastic’s concern about their flap.
- I would have like to have attempted an epidural, but I agree that sacral coverage may have been problematic
- I agree Jeff05 with trying different opioids, but you need to have cooperation with the patient and he was refusing morphine and hydromorphone. That left me with fentanyl, oxymorphone, and methadone
- Fasto sounds eerily like my attending

The conversation with my attending went something like this (condensed and paraphrased)
Me: I think it is combination of opioid tolerance and tachyphylaxis. I think we should start methadone to see if switching opioids is effective and because it has some NMDA antagonism.
Attending: You’re a ***** (although said very politely). This screams opioid induced hyperalagesia. You are only making things worse by pushing these ridiculous doses of opioids. The ketamine would have been more effective if you had not chased it with opioids. Starting methadone is reasonable for the NMDA activity in modulation of OIH – you would have been right for the wrong reasons.

We started methadone, stopped his oxycodone and OxyContin, and decreased his PCA to a lowly 150mcg/10min. In a few hours his pain was 7-8/10, 24 hours after methadone his pain was 5-6/10 (we also started tapering off his Duragesic at this time), 48 hours latter his pain was 3-4/10 which is better than his baseline. He is now off the Duragesics and his regimen is Methadone 25mg TID with oxycodone for breakthrough. We are having discussions with him concerning intrathecal pumps, nerve stimulators, and neurolytic blocks. There have been some interesting discussions concerning what would be good agents to place in his IT pump.

I found this nice review article after speaking with my attending;
Mitra S. Opioid-induced hyperalgesia: pathophysiology and clinical implications. J Opioid Manag. 2008 May-Jun;4(3):123-30.

Link;
http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

 

[Planktonmd]

That was a great case but unfortunately in the overwhelming majority of patients on high dose Narcotics the notion of narcotic induced hyperalgesia is more of a wishful thinking than reality and any attempt to decrease the dosage or switch to methadone would be faced by extreme resistance from the patient.
You might have found one of the extremely rare cases where the patient is actually not a true drug addict yet but don't count on seeing many of those in the future.

Thank you for your comments and suggestions

- I agree with continuing/encouraging ketamine for its NMDA antagonism, but there was increasing resistance to its use on the floor secondary to political issues. Oral ketamine was also blocked by nursing administration.
- I agree with starting clonidine, and it was implemented the following day
- Scheduled Tylenol was implemented latter following discussion about OIH. He was initially refusing it as it “doesn’t work”.
- NSAID’s unfortunately were not an option due to plastic’s concern about their flap.
- I would have like to have attempted an epidural, but I agree that sacral coverage may have been problematic
- I agree Jeff05 with trying different opioids, but you need to have cooperation with the patient and he was refusing morphine and hydromorphone. That left me with fentanyl, oxymorphone, and methadone
- Fasto sounds eerily like my attending

The conversation with my attending went something like this (condensed and paraphrased)
Me: I think it is combination of opioid tolerance and tachyphylaxis. I think we should start methadone to see if switching opioids is effective and because it has some NMDA antagonism.
Attending: You’re a ***** (although said very politely). This screams opioid induced hyperalagesia. You are only making things worse by pushing these ridiculous doses of opioids. The ketamine would have been more effective if you had not chased it with opioids. Starting methadone is reasonable for the NMDA activity in modulation of OIH – you would have been right for the wrong reasons.

We started methadone, stopped his oxycodone and OxyContin, and decreased his PCA to a lowly 150mcg/10min. In a few hours his pain was 7-8/10, 24 hours after methadone his pain was 5-6/10 (we also started tapering off his Duragesic at this time), 48 hours latter his pain was 3-4/10 which is better than his baseline. He is now off the Duragesics and his regimen is Methadone 25mg TID with oxycodone for breakthrough. We are having discussions with him concerning intrathecal pumps, nerve stimulators, and neurolytic blocks. There have been some interesting discussions concerning what would be good agents to place in his IT pump.

I found this nice review article after speaking with my attending;
Mitra S. Opioid-induced hyperalgesia: pathophysiology and clinical implications. J Opioid Manag. 2008 May-Jun;4(3):123-30.

Link;
http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

 

[ear-ache]

That was a great case but unfortunately in the overwhelming majority of patients on high dose Narcotics the notion of narcotic induced hyperalgesia is more of a wishful thinking than reality and any attempt to decrease the dosage or switch to methadone would be faced by extreme resistance from the patient.
You might have found one of the extremely rare cases where the patient is actually not a true drug addict yet but don't count on seeing many of those in the future.

Agreed. Getting him to start methadone required debunking the stereotype that only heroin addicts take methadone

 

[fastosprintini]

nice move with the methadone, most people do not realize that methadone is considered a "broadspectrum" opioid with partial NMDA receptor activity..., keep us posted how things are progressing!
fasto

 

[ChrisA]

Anyone else use methadone in the OR?

I use it alot for long back cases as well, pts do nicely post op.

 

[Noyac]

Give him one of your doobies.

 

[veetz]

Good post, thanks for posting.

 

[dhb]

Intrathecal catheter with HB bupi would have been a good option from the start.

 

[ear-ache]

Intrathecal catheter with HB bupi would have been a good option from the start.

Hmmmm... Anyone have much experience/exposure to IT catheters? I sure haven't. We sometimes use them in OB, but OB pts are typically a young & healthy and their IT or epidural catheters don't stay in long. How long can IT catheters stay post-op?

In the end this gentleman had better pain control and less side effects with Methadone than his Duragesic/OxyContin combination - so he has chosen to hold off on invasive pain procedures at this time.

If he were to someday get an IT pump - any thoughts as to what you would dose it with (given his Hx of OIH)?

 

[powermd]

That was a great case but unfortunately in the overwhelming majority of patients on high dose Narcotics the notion of narcotic induced hyperalgesia is more of a wishful thinking than reality and any attempt to decrease the dosage or switch to methadone would be faced by extreme resistance from the patient.
You might have found one of the extremely rare cases where the patient is actually not a true drug addict yet but don't count on seeing many of those in the future.

I had a similar case about two years ago. Started methadone 25 mg IV tid on a patient previously requiring a gazillion mg of IV dilaudid per hour with 10/10 pain. With the 'done on board was able to drop the dilaudid PCA to reasonable numbers, with excellent pain control. At UC Davis we do a lot of PO ketamine in these cases, I can't say I've personally seen great success with this yet. And when there is success, we use polypharmacy to such a degree it would be difficult to attribute the results to any particular drug.

I agree the majority of these folks are either addicts or chemical copers seeking psychic anesthesia (I love that term). The best thing to do is maximize adjuvants and taper the opioids, however the patient protests. In the setting of acute pain I'm more likely to be willing to push the opioid dosing or rotate to see if you get better pain relief, or side effects/dysfunction. Addicts have pain too and deserve treatment. Sooner or later they go home, and whether or not the opioids can be continued depends on how realistic your risk management plans are. No risk management = no opioids.

 

[radslooking]

i would try lysis of the reticular activating system with PO Etoh