Pain in Hospitalized Patients

Tim Lee
Hospitalist, VMMC
 Pain

• Pain is not that simple.

• Multiple factors (biological, psychological, and social)
influencing pain, suffering, and function.
• IASP defines pain as “an unpleasant sensory and
emotional experience associated with actual or
potential tissue damage.”
• Acute pain
• Chronic pain
• Cancer pain (end of life pain)
• Simple vs complex pain
 Acute Pain

Duration: one month or less.

Cause: new tissue injury such as trauma, infection, or
surgery.
Goal: identify cause and treat to expedite healing.
Taper off pain meds over one month.
 Chronic Pain
• Duration: greater than 3 months.
• Cause: difficult to identify, multifactorial.
• Cure of chronic pain is not possible.
• Goal: help patient develop adaptive self-management
strategies to improve health and function.
• Simple pain: clear cause, symptoms correlate,
functioning well despite pain.

• Complex pain: co-morbid psychosocial problems,

functional impairment, poor response to treatment,
high resource utilization, opioid related harm.
 Pain Relief in the United States
NEJM January 2012

• Pain is influenced by physical, psychological, and

social factors.
• A person’s beliefs about pain can substantially affect
outcome.
• Experience can be improved if patients are educated
and enabled to play a more active role in managing
their own pain.
 Pharmacoloic Treatment
• Acetaminophen
• NSAIDS
• Gabapentin
• Lidoderm
• Methacarbamol, cyclobenzaprine
• Opioids
 Opioids

• Evidence is limited: short-term trials (mean 8 wks).

Supports short-term treatment for acute pain.
• No quality studies re safety/efficacy of long-term
opioids.
• Opioid prescribing increasing dramatically in past 2
decades.
• Dramatic rise in opioid related adverse effects, abuse,
and deaths.
Opioid Sales, Admissions for Opioid-Abuse Treatment, and Deaths Due
to Opioid Overdose in the United States, 1999–2010.
 Annals of Internal Medicine January 2014

• Doses of 50mg to 100 mg morphine or MEQ/day:

increase risk of unintentional overdose 2-3 fold.
• Doses greater than 100 mg/d risk increases
dramatically.
 Equianalgesic Table
Opioid IM/IV Oral
(mg) (mg)
Morphine 10 30
Oxycodone Not Available 20
Oxymorphone 1 10
Hydromorphone 1.5 7.5
Fentanyl 0.1 Not Available
Meperidine 75 300
Hydrocodone Not Available 20
Codeine 120 200

Ref.
 Journal of Hospital Medicine, Feb 2014

• More than half of patients on medicine service were

prescribed an opioid
• Average dose 68 mg MEQ/d.
• One-quarter received 100mg MEQ/d or more on at
least one day of their hospitalization.
• Rate of adverse events higher at hospitals with higher
use.
 Opioids
• Pruritus: antihistamine
• Constipation: bowel regimen
• Nausea / Vomiting: antiemetics
• Sedation /increased risk of falls
• Urinary retention
• Gastroparesis
• Delirium
• Respiratory depression: OSA, COPD (Narcan 0.2-0.4mg IVq3min)
• Tolerance
• Hyperalgesia / worsening pain
• Start low.
• Consider scheduled dosing.
• Monitor use daily
• Do not start new long-acting opioids.
 Patients At Risk

IV opioids
Active heroin addiction.
Methadone maintenance.
Long-term opioids (high-dose)
 IV Opioids

• Increased risk of complications

• Associated with longer length of stay
• No better analgesia than oral opioids.
• Cause rapid on - off effects.

• Transition from IV to oral opioids as soon as possible.

• Use oral opioids when a patient is able to take PO.
Opioids – PCA
 Active Heroin Addiction
Urine drug screen on admission.
Assess for opioid withdrawal:
Tachycardia, sweating, restlessness, myalgias, arthralgias,
rhinorrhea, n/v, loose stool, yawning, anxiety, irritability.

Treatment for opioid withdrawal:

• Clonidine 0.1 to 0.2mg q6h.
• NSAIDs, trazodone, ondansetron, loperamide.
• We can prescribe methadone to treat opiate
withdrawal in patients hospitalized for acute illness.
• Methadone 20 -30mg/d, once daily for withdrawal.
• No opioids dispensed at discharge.
 Heroin addiction with acute pain

• Non-opioid pain meds: NSAID, acetaminophen,

gabapentin, cyclobenzaprine, Lidoderm..
• Higher dose short acting opioid (in addition to
methadone)
• No opioids dispensed at discharge.
 Methadone Maintenance

• Urine drug screen on admission.

• Verify dosing history, last maintenance dose.
• If compliant: give same dose while in hospital.
• If not certain give 30mg daily.
• No methadone dispensed at discharge.
• Methadone can be given IV at half the dose, divided q6h.
 Methadone Maintenance with acute pain

• Non-opioid pain meds

• Higher dose short acting opioid (in addition to
methadone)
• No opioids dispensed at discharge.
• Notify methadone program of opioids given in hospital.
 Buprenorphine (Suboxone)

If patient has acute pain, options are:

• Continue suboxone plus non-opioid pain meds
• Stop and give short acting opioid.
• Stop and give methadone 30mg/d for
maintenance, plus short-acting opioids

No opioids dispensed at discharge.

Patient restarts their Suboxone after discharge.
 Long-term Opioids

• Urine drug testing on admission can be helpful.

• Verify long-term opioid therapy.
• Review clinic notes.
• Continue same dose(if safe) in hospital without increase.
• Long-term opioids managed by outpatient prescriber at
discharge.
 Long-term Opioids and acute pain

• Chronic pain exacerbations ≠ acute pain.

• Long-term opioids not expected to help with acute
pain
• Add additional short acting opioids for acute pain.
• At discharge, short-acting opioids, one week
supply, about #30 pills.
 Definitions
• Tolerance: increase dose to maintain effect.
• Physical dependence: withdrawal when stop.
• Abuse: using for non-prescribed effects.
• Dependence (Addiction): compulsive use
resulting in harm and continued use despite that
harm.
• DSM V "opioid dependence" has been removed
as a diagnosis. DSM V does not use the word
"addiction." The new diagnostic term is opioid
use disorder and when using this diagnosis list
severity (mild, moderate or severe) based on
criteria met and specify the status of remission.
Drug Related Aberrant Behavior

• Worsening health and function on opioids

• Appearing sedated
• Early refill requests, reports of lost/stolen meds
• Self dose escalations
• Obtaining opioids from other sources.
• Unexpected urine drug screen findings
 Many Factors worsen Pain, Suffering and Function

Emotional:
Anxiety ↑ pain intensity.
Depression ↑ risk of chronic pain.
Depression negatively impacts outcome.
Treating depression ↓ pain.
PTSD, poor sleep, substance abuse can worsen pain.
Cognitive behavioral:
Catastrophic thoughts, disabling beliefs: “This is bad.” “hurt = harm” “I can’t function with pain.”
belief in oneself as disabled by pain, belief one has no control over pain.
Fear-avoidance behavior.
Physical:
Inactivity, poor pacing
Disuse syndrome ↑ pain, hyperalgesia
Attention:
Focusing on pain. no outside interests, valued activities, goals.
 Pain Modulation

Modulation in spinal cord before reaching brain. Rubbing

activates touch fibers.
Modulation in thalamus, insular, anterior cingulate, and
somatosensory areas.
 Sensitization
Pain amplification

Central

stimulus

Peripheral

stimulus

Hyperalgesia (heightened sensitivity to pain)

Allodynia ( non-noxious stimuli can be painful)
 Social Isolation
Anterior cingulate activation with physical pain and with social rejection.

• ↓ Social network ↑ pain

• Social rejection ↑ pain
 Distraction

Attention to music, maze task, virtual reality game ↓pain and

activation in pain processing areas on fMRI.
 VEMA
• Validation. listen, normalize their experience, believe
their pain, acknowledge their struggle.
• Education. share assessment findings, help them
understand how they can help themselves. Address
disabling beliefs, avoidance behaviors, self-
management. reinforce realistic expectations from
opioids
• Motivation. responsibility for change lies within the
patient.
• Activation. activity despite pain. paced activity.
 Deficiencies

• Rushed practitioners, lack of time.

• Lack of care coordination, follow-up.
• Patients inadequately trained to manage their
illnesses.