Pain Management in the Acute Setting 2012 MN Affiliate of NACNS Conference Debra Drew, MS, RN-BC, ACNS-BC Sara Hall, MS, RN-BC, ACNS-BC University of MN Medical Center, Fairview Objectives • Compare and contrast characteristics of acute and chronic pain. • Identify multimodal analgesics in acute pain management. Acute vs • Acute pain due to surgery, trauma, injury, medical process (MI, kidney stone, ischemic, etc) • Usually known cause • Expected timeline with beginning, middle and end (less than 3 months) • Decreases with healing Chronic Pain • May be elicited by injury or disease but sometimes cause is unknown • Environmental, emotional, and cognitive factors will contribute to persistence of pain and associated illness behaviors • Persists for a long period of time : months, years… • Low level of underlying pathology that does not explain presence or extent of pain • Fishman et al, 2010. Pathophysiology of Acute Pain • Sources: Nociceptive, neuropathic, muscle, bone • Basic Process of Normal Pain Transmission Transduction: Damaged cells release sensitizing substances to initiate action potential Transmission: Action potential from injury site ascends to brain Perception: Conscious experience pain Modulation: Inhibition of nociceptive impulses • Different than chronic pain McCaffery & Pasero, 1999 Importance of treating acute pain? • Uncontrolled acute pain triggers a physiologic stress response involving multiple systems • Adequate control leads to earlier mobilization and less complications from surgery • Prevent persistent postsurgical chronic pain-incidence between 20-50% following major surgery • May lead to shorter hospital LOS=reduced health care costs • Increase patient satisfaction Kahlet, 2006 UMMC Preoperative Pain Consult (POPC) • Identification of complex patients with a high risk for a poor response to traditional post-operative pain management protocols. • Provision of a pain management assessment 1-2 weeks prior to surgery. Population Studied Elective Lower Extremity Inpatient Procedures: March 2011-March 2012 Average Length of Stay in Days Severity of Illness 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 6.00 6% 40% 4.88 5.00 77% 75% 4.00 60% 4.38 3.53 3.00 Test Minor 19% 23% Control Similar Control Dissimilar Moderate Major 2.00 1.00 0.00 Treatment Control A Control B Financial Analysis POTENTIAL SYSTEM SAVINGS: 20% of approximately 3500 patients x(Test-Similar Control) Case Cost $5.83 Million savings* *while preserving the same contribution margin as the healthier 80% of the population! Central Sensitization After long-lasting nociceptive stimulation: • Primary afferents terminating in spinal cord sprout new connections between neurons • Inhibitory interneurons die from excessive activation of NMDA receptors • Clinically, one sees hyperalgesia +/- allodynia Van Wilgen & Keizer, 2012 Hierarchy of Pain Assessment In Order of Most Reliable to Least Reliable Measures 1. 2. 3. 4. 5. Patient’s self-report is the most valid and reliable measure of pain existence and intensity. Pathologic conditions or procedures that usually cause pain Observe Behaviors (e.g. facial expression, body movements, crying) Proxy ratings. Report of pain from parent/family/others close to patient. Physiologic measures: Least sensitive measure of pain existence and intensity. Conclusion: inappropriate to rely solely on physiologic data to measure pain. Herr et al, 2011 Self Reported Elements of a Pain Assessment Location: where, more than one location? Duration: when did it start? Intensity: how much does it hurt? Description: what does it feel like? Aggravating/relieving factors : what helps/or doesn’t help? Selected Pain Assessment Tools Numerical Rating Scale (NRS) 0 – 10 where 0 is no pain and 10 is the worst pain imaginable Word Scale: “no pain, mild, moderate, severe” Faces Scale Visual depiction of pain severity Used with younger children FLACC Behavioral assessment based on facial expression, leg and arm movements, cry, and consolability Preverbal children and infants Unable to self-report FLACC Scale Functional Assessment Evaluate impact of pain on physical function, quality of life and ability to perform ADLs • Self care abilities • Rehab activities • Physical therapy • Occupational therapy • ADLs Comorbidities of Substance Abuse or Mental Illness • Acute care setting is not the environment to successfully treat substance abuse or mental illness • Patients with acute pain and disease of addiction should be given appropriate multimodal analgesics which may include opioids. • Severe depression and anxiety must be treated for successful pain management. Drew & St. Marie, 2011 Preemptive Analgesia for Post op Pain • Use of medications prior to surgery to reduce post op pain • Help reduce central sensitization • NSAIDs, gabapentinoids, NMDA receptor antagonists, opioids • Literature is non-conclusive, however clinically see a difference Moiniche, 2002 Perioperative Medications • Use Multi-modal Analgesia-using two or more analgesic agents with different mechanisms of action • Have a synergistic effect leading to better analgesia • • • • Opioids-multiple formulations Nonopioid analgesics (NSAIDs, acetaminophen) Coanalgesics/adjuvant analgesics Need to adjust for age (neonate to elderly), renal and hepatic impairment, individual responses, other comorbidities, potential drug interactions Pasero, 2012 Opioids • MUST use an equianalgesic conversion guide that is trustworthy • American Pain Society-Principles of Analgesic Use in Treatment of Acute Pain and Cancer Pain (6’th edition) • Account for prior to admission doses of opioids in post op requirements • Pt was taking 12 tablets of oxycodone/acetaminophen (5/325) on a daily basis prior to admission. This would be converted into hydromorphone basal rate of 0.2 mg/hr. Equianalgesic Conversions Opioid-Induced Hyperalgesia • Opioids can cause an increase in sensitivity to painful stimuli • Seems paradoxical • Hallmarks: Increased pain intensity and spread of pain beyond initial area • Treatment: Reduction of opioid by tapering down or rotating, NMDA-Receptor Antagonists, alpha-2 agonists • Use of dexmedetomidine to “reboot” opioid tolerance • Seen with intraoperative administration of remifentanil in humans Koppert, 2007 Nonopioid Analgesics • New: Intravenous acetaminophen –approved in Nov 2011 by FDA for both adults and pediatrics (Ofirmev®) Useful when pt is NPO or nauseated from surgery Quicker onset of action compared to oral • NSAIDs (ketorolac, ibuprofen, naproxen, celecoxib) • Have an opioid dose-sparing effect • Do not produce respiratory depression • Do not impair GI motility Pasero, 2012 Coanalgesics • Anticonvulsants • Antidepressants • Steroids • Muscle Relaxants • NMDA receptor antagonists-Ketamine • Dexmedetomidine-Opioid-Induced Hyperalgesia • Antihistamines • IV Lidocaine-start intraop and infuse for 24 hours following. Most effective for abdominal surgery. McCarthy, 2010 Methadone: used in two different ways 1. Methadone-maintenance: used to maintain sobriety from other opioid-like drugs (eg heroin, opioids). Dosed once daily by methadone maintenance clinic. Continue during hospitalization. PO or IV. 2. Analgesia: pain management. Dosed BID to QID. Buprenorphine • May be used for substance dependency, similar to methadone maintenance therapy • Need a special certification to prescribe for dependency • Suboxone® (buprenorphine/naloxone) or Subutex® (buprenorphine) • Mixed opiate receptor agonist-antagonist: Partial µ agonist and ĸ-receptor antagonist • High affinity for the µ receptor • Less respiratory depression than regular opioids Buprenorphine • Can last 48-72 hours, ceiling effect, 32 mg/day • Restarting maintenance therapy, need to be off all pure µ agonists for 1-2 days, have mild withdrawal before restarting. If start too soon, will have severe opioid withdrawal symptoms. • Routes: sublingual, intravenous, transdermal, others in Europe • What does that mean for clinicians? • Need to have a solid plan in place for pt on discharge Alford, 2006 Spinal and Local Analgesia • Regional Analgesia: – Neuraxial (Intraspinal) Infusions • Epidural • Intrathecal • Single injections – Continuous Nerve Infusions • Paravertebral, Intrascalene, Transabdominus Plane (TAP) • Local Analgesia: – Continuous infusions into subcutaneous tissue (wound or incisional bed) Anatomy of Epidural and Intrathecal Spaces Topicals • Morphine 0.1% weight to weight in Intrasite® gel. Used in open painful wounds. • Gabapentin 8% in PLO® gel. • NSAIDS: Ketoprofen 10% in PLO® gel. Diclofenac (Flector® patch) • Lidocaine patch (Lidoderm®) Nonpharmacological Measures Cognitive Behavioral Therapies: Hypnosis, distraction, imagery, humor Music Therapy Cutaneous Stimulation TENS Massage Energy Therapies Acupuncture, acupressure Healing Touch, Reiki therapy Aromatherapy Summary “The problems within pain management care in our health care system can no longer be viewed as problems to be solved. Instead, they must be viewed as opportunities to change perspectives and further understanding of humanity, the environment, and the world.” St.Marie,2010 References • Alford, D.P., Compton, P., & Samet, J.H. (2006). Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy. Annals of Internal Medicine, 144, 127-134. • American Pain Society (APS) (2008). Principles of analgesic use in the treatment of acute pain and cancer pain, (6’th ed.) Glenview, IL: APS. • Drew, D.J. & St. Marie, B.J. (2011) Pain in critically ill patients with substance use disorder or long-term opioid use for chronic pain. Advanced Critical Care, 22(3), 238-254. • Fishman, S.M., Ballantyne, J.C., & Rathmell, J.P. (2009). Bonica’s Management of Pain. (4th ed.) Lippincott Williams & Wilkins. • Herr, K., Coyne P.J., McCaffery, M., Manworren, R., & Merkel, S. (2011) Pain assessment in the patient unable to self-report: Position statement with clinical practice recommendations. Pain Management Nursing,12(4),230250. References • Kehlet, H., Jensen T.S., & Woolf, C. (2006). Persistent postsurgical pain: Risk factors and prevention. The Lancet, 367(9522), 1618-1625. • Koppert, W. & Schmelz, M. (2007). The impact of opioid-induced hyperalgesia for postoperative pain. Best Practice & Research Clinical Anesthesiology, 21(1), 65-83. • McCaffery,M., & Pasero, C. (1999). Pain: Clinical Manual.(2nd ed.) Mosby: St. Louis, MO. • McCarthy, G.C., Megalla, S.A., & Habib, A.S. (2010). Impact of Intravenous Lidocaine Infusion on Postoperative Analgesia and Recovery from Surgery. Drugs , 70(9), 1149-1163. • Moiniche, S., Kahlet, H., & Dahl, J.B. (2002). A Qualitative and Quantitative Systematic Review of Preemptive Analgesia for Postoperative Pain Relief. Anesthesiology, 96, 725-741. • Pasero, C. & Stannard, D. (2012). The Role of Intravenous Acetaminophen in Acute Pain Management: A Case-Illustrated Review. Pain Management Nursing, 13(2), 107-124. References • St.Marie, B. (2010) Core Curriculum for Pain Management Nursing. 2nd ed. Kendall Hunt Professional. • Van Wilgen, C.P., & Keizer, D. (2012). The sensitization model to explain how chronic pain exists without tissue damage. Pain Management Nursing, 13, (1), 60-65.