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The prescription for pain management

From the April ACP Hospitalist, copyright © 2013 by the American College of Physicians

By Charlotte Huff

Hospitalists often find themselves caught in the pain management crosshairs. Acute and chronic pain are sometimes undertreated, according to a battery of studies, while federal officials continue to ramp up efforts to combat opioid addiction.

Still, physicians can wield considerable influence to ease the suffering of patients in pain, starting with identifying the optimal drug and administering it before pain escalates, according to experts in the field. Depending on the type of discomfort involved, there may be opioid alternatives or supplemental medications, they said.

Illustration by Sarah Ferone.

Illustration by Sarah Ferone.



Even seemingly basic measures, such as how the medication order is written, can help prevent pain, said Amos Bailey, MD, FACP, an internist and oncologist who directs the Safe Harbor Palliative Care Program, which is affiliated with the Birmingham VA Medical Center and the University of Alabama at Birmingham.

“The problem is a health services delivery problem,” he said. “You have the medication and then the health system has to deliver that medication to the right person in the right dose when they need it.”

Dr. Bailey authored a study, published in the November 2012 Journal of Pain and Symptom Management, which assessed pain relief practices for 1,068 patients at VA medical centers during their final weeks of life in 2005.

According to a medical records review, 81.2% of the patients reported pain, but a smaller percentage—64.2%—had an active opioid order at the time of their death. Fewer than half, 47%, received opioids during their final 24 hours of life.

Meanwhile, the abuse and misuse of these drugs has triggered increasing concern. U.S. deaths involving opioid pain relievers now surpass those from heroin and cocaine combined, according to a November 2011 analysis in the Morbidity and Mortality Weekly Report (MMWR). The analysis showed that opioid deaths, related treatment admissions and sales were all on the upswing from 1999 to 2008. The 2008 overdose death rate was nearly four times the rate in 1999.

More recently, federal officials also have highlighted the risks of methadone. Methadone was involved in 39.8% of overdose deaths involving a single opioid in 2009, according to another MMWR analysis published July 6, 2012. Overall, the 2009 methadone-related overdose death rate was 5.5 times what it was in 1999.

Assessing risk

While opioids frequently form the cornerstone of pain relief for hospitalized or postsurgical patients, they shouldn't become the default prescription in all situations, pain and palliative medicine specialists said.

One 2012 Archives of Internal Medicine study involving 391,139 Canadian surgery patients who were classified as opioid-naïve points to the risks of prescribing the drugs for lower-pain procedures. Seven percent of patients were prescribed an opioid after cataract removal, varicose vein stripping, laparoscopic gall bladder removal and transurethral resection of the prostate.

Of those initially prescribed an opioid, more than 10% were still taking the drug one year later, researchers found. Although it's unclear why use persisted, the data raise concerns about unnecessary initiation for surgeries that aren't expected to cause a lot of pain, they wrote.

To assess a patient's addiction risk, it's crucial that hospitalists don't skimp on a detailed medical history, said Timothy E. Quill, MD, FACP, president of the American Academy of Hospice and Palliative Medicine. Along with a personal or family history of substance abuse, mental health diagnoses such as major depression or anxiety disorder should also elevate concern, particularly if those risk factors accumulate, he said.

Clearly, high-risk patients can still require surgery or experience an acute flare of an ongoing chronic pain problem, Dr. Quill said. But he recommends that the hospitalist seek help from a pain or palliative medicine specialist to effectively manage the pain of these more challenging patients, including identifying the best medication regimen and setting the patient's expectations about pain, particularly for after hospital discharge.

“You still have to treat their pain, but you get very conservative about how long you're treating it,” said Dr. Quill, who also directs the palliative care division at the University of Rochester Medical Center in New York. “And the end point can't be zero pain, if they've had significant, chronic pain for a long, long time.”

Sometimes, though, red flags can be misleading, and doctors should guard against jumping to conclusions, said Jeanie Youngwerth, MD, who directs the University of Colorado Hospital's palliative care consult service. Worrisome behaviors, such as watching the clock until the next dose or exaggerating pain symptoms when a clinician approaches, may just be signs of pseudoaddiction, she said.

“Probably the one piece of advice that I give to the doctors that I'm training is that most of the time it's pseudoaddiction, as opposed to the patient being truly addicted,” she said. “The patient's pain is really poorly controlled and those behaviors are in response to that. And if we were better at controlling their pain in the hospital, then we should see those behaviors go away.”

Postsurgical pain

Routine acute pain management, such as following surgery, typically involves a time-limited course of pain drugs, said Darin J. Correll, MD, an anesthesiologist and director of the postoperative pain management service at Brigham and Women's Hospital in Boston. To best support the patient through the immediate postsurgery period, the doctor should determine both the severity and type of pain involved, he said.

The 10-point pain scale is useful, but sometimes a more interactive approach can work better, given that two patients might rate the same discomfort as a 2 versus a 7, Dr. Correll said. Because perception matters the most, he often lobs an open-ended question walking into a patient's room: “I'm Dr. Correll and I'm from the pain management service. How are you doing today?’

The patient's response can tell him a lot about what type of medication is needed. A sharp or stabbing sensation is more likely to be related to the surgical incision or related internal organ manipulation, he said. But other sorts of pain may not be relieved by opioids.

Surgery can trigger an acute muscle spasm—perhaps described by the patient as a charley horse—that requires a muscle relaxant like oral baclofen. An opioid would only leave the patient sleepy and still frustrated by unrelieved pain, Dr. Correll said. Pain described as a burning or electric shock feeling indicates nerve-related pain. One good option for that might be an intravenous ketamine infusion, he said.

And don't forget the basics, Dr. Correll said. Postsurgical patients also should be started on acetaminophen or a non- steroidal anti-inflammatory drug immediately following surgery to help combat inflammation, unless the drugs are contraindicated due to underlying kidney or liver damage.

Another postsurgical challenge, particularly given abbreviated hospital stays, is how best to calculate the optimal dose for the first days after the patient leaves the hospital, said Jason Eldrige, MD, associate director of inpatient pain medicine at the Mayo Clinic in Rochester, Minn. His advice: Closely monitor the intravenous dose the patient requires the second or third day, and use that to calculate an oral regimen following discharge.

To convert an intravenous dose to a pill dosage, Dr. Eldrige suggests the following approach: First convert the patient's 24-hour intravenous opioid dose to its equivalent for intravenous morphine. Then take that dose and calculate an equivalent daily oral morphine equivalency dose (DOME). If opioid classes are switched in the process—say from hydromorphone to morphine—that final oral dose should be reduced by 30% to 45% to compensate for incomplete cross-tolerance between classes, he said, thus providing an increased safety margin. (See sidebar.)

Ideally, patients should receive a few oral doses prior to hospital discharge, Dr. Eldrige said. He suggested a longer stretch of monitoring, at least 12 hours, if a long-acting opioid is prescribed as part of the oral dose. Four to eight hours typically would be reasonable if the patient were only taking a short-acting opioid, he said.

Opioid selection

When the patient is still hospitalized, and once acute pain has been addressed, providing medication through patient-controlled analgesia (PCA) is typically preferred by the patient and provides benefits in terms of stabilizing pain control, Dr. Eldrige said.

As for the specific opioid class, Dr. Eldrige recommends that hospitalists consider hydromorphone for acute pain as an alternative to the long-standing drug morphine. “It has fivefold more potent effects but with a much cleaner metabolism and possibly fewer side effects,” he said. Since morphine contains clinically significant active metabolites that can accumulate, it poses a higher risk of side effects, including respiratory depression and neuroexcitation, especially in patients with impaired kidney function, he said.

Morphine, though, retains some advantages for end-of-life patients, as it can be delivered in more forms than hydromorphone, including a concentrated liquid that can provide relief with just a few drops on the tongue, Dr. Bailey said. That alternative is crucial for patients no longer able to swallow a pill or operate a PCA, he said.

The research evidence also is stronger that morphine exhibits an additional benefit, easing patient difficulties with shortness of breath, Dr. Bailey said. It's likely that hydromorphone has a similar effect, but it's not as well documented, he said.

Like the other experts, Dr. Bailey emphasized that methadone as an opioid option should be used with extreme care. If a hospitalized patient has acute pain issues and is already taking methadone, Dr. Youngwerth suggested that the pain or palliative care service be consulted, as the titration and dosing differ from other opioids, she said.

Since the drug has a more delayed effect, any sedative effects can also be delayed compared with other opioids, potentially kicking in unexpectedly or even after the patient has been discharged, she said. Methadone “has its own set of rules,” she said. “If you're not familiar with it, the big problem with it is oversedation and possible death.”

Careful monitoring

Given the risk of excessive sedation and respiratory depression with any opioid, close monitoring is crucial, particularly in the early hours after a hospitalized patient starts the drug, according to pain medicine specialists.

But don't become over-reliant on continuous pulse oximetry, Dr. Correll said. If a patient is also getting supplemental oxygen, a common measure in the hospital, it's far more difficult to identify respiratory changes until they become more severe. “It's likely better [to use pulse oximetry] than not, except that I think it can sometimes give a false sense of security,” he said.

To guard against missing early signs of respiratory depression, a doctor shouldn't write an order that automatically increases a patient's oxygen when the pulse oximeter saturation drops without checking for other causes, including opioids, Dr. Eldrige said. Careful nurse monitoring also is key.

Nurses should conduct a respiratory evaluation before they take the patient's vital signs, Dr. Correll said. That approach will provide a better sense of the respiratory rate before the patient becomes more aroused, he said.

Pay close attention to even subtle trends, such as a slight decline in the respiratory rate over a series of evaluations, he said. For helpful guidance on more effective monitoring, Dr. Correll suggested consulting the 2011 guidelines developed by the American Society for Pain Management Nursing.

For most end-of-life patients, the most pressing problem is adequate pain relief, which is impeded in part by the bureaucratic nature of hospitals, Dr. Bailey said. Compared with home-based hospice, where pain medication can be kept handy, access understandably has to be more controlled in a hospital setting, he said. “On the other hand, there are so many layers involved [in distributing the dose], that the patient's ability to receive pain medication is going to be impaired.”

To prevent breakthroughs in pain, encourage family members to stay nearby, as patients can become too ill to talk or push a PCA button, he said. His Archives study found that family involvement increased a patient's chances of having an active opioid order.

It also helps if the drugs can be easily administered, such as under the tongue or through a subcutaneous injection, Dr. Bailey said. Doctors also should verify that the medication order is current, so it doesn't expire in the middle of the night.

One strategy to encourage regular pain monitoring is for the doctor to write the order as “offer, may refuse,” Dr. Bailey said. Then the nurse will regularly check on the patient but can opt to withhold the medication if the patient appears comfortable, he said.

In situations where the patient's prognosis is terminal, there's no longer the concern about long-term dependency, and thus more inherent latitude in prescribing, Dr. Quill said. But he echoed other doctors, who expressed the ongoing challenge of finding a middle ground between relieving patient suffering without amplifying addiction risk.

“Probably there's a risk that the pendulum is going to swing too far in the other direction and we will go back to being afraid and we'll undertreat everybody's pain again. And there is still some pain that's undertreated,” Dr. Quill said. “But I think it is clear that in the enthusiasm to recognize and treat pain, there was an under-recognition of the genuine risks of these medications.”

Charlotte Huff is a freelance writer in Fort Worth, Texas.

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Converting from intravenous to oral regimen

  • Calculate at 24-hour requirement for morphine (daily oral morphine equivalents = DOME)
  • 60% of medicine should be given in long-acting form, on a scheduled basis
  • 40% of medicine should be given in immediate-release form, on an as-needed basis
  • Adjust for incomplete cross-tolerance (40%-50%)

Courtesy of Jason Eldrige, MD, Mayo Clinic, Rochester, Minn.


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Sample conversion from IV hydromorphone to oral morphine

The patient used 10 mg of intravenous hydromorphone hydrochloride (brand name: Dilaudid) on patient-controlled analgesia over the previous 24 hours. To convert to oral morphine, keep in mind:

  • 10 mg intravenous (IV) Dilaudid = 50 mg IV morphine equivalent
  • 50 mg IV morphine = 150 mg oral morphine
  • 150 mg daily oral morphine equivalents (DOME) × incomplete cross-tolerance = 100 mg
  • Long acting = 30 mg twice a day of morphine sulfate controlled-release. Total dose = 60 mg
  • Short acting = 5 mg of morphine sulfate immediate release, every four hours as needed
  • Plan on weaning at 2-3 weeks postop as the patient heals
  • Consider rapid decline in opioid need with recovery

Courtesy of Jason Eldrige, MD, Mayo Clinic, Rochester, Minn.


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Pain resources

Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med. 2012;172:425-30. [PMID: 22412106]

Bailey FA, Williams BR, Goode PS, Woodby LL, Redden DT, Johnson TM 2nd, et al. Opioid pain medication orders and administration in the last days of life. J Pain Symptom Manage. 2012;44:681-91. [PMID: 22765968]

Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011;60:1487-92. [PMID: 22048730]

Centers for Disease Control and Prevention (CDC). Vital signs: risk for overdose from methadone used for pain relief—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2012;61:493-7. [PMID: 22763888]

Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, et al; American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10:113-30. [PMID:19187889]

Jarzyna D, Jungquist CR, Pasero C, Willens JS, Nisbet A, Oakes L, et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011;12:118-145.e10. [PMID:21893302]

Swarm R, Abernethy A, Anghelescu A, Boston B, Cleeland C, Coyle N, et al; National Comprehensive Cancer Network Adult Cancer Pain Panel Members. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Adult Cancer Pain. 2011.

World Health Organization. Pain ladder for cancer pain relief.

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