Presentation on theme: "Why Don’t We Do a Better Job of Treating Pain? Bryan E. Bledsoe, DO, FACEP Midlothian, TX."— Presentation transcript:
Why Don’t We Do a Better Job of Treating Pain? Bryan E. Bledsoe, DO, FACEP Midlothian, TX
Introduction n Many, if not most, medical conditions cause pain.
Introduction n Pain is a protective mechanism and occurs whenever any tissues of the body are being damaged.
Introduction n Pain occurs whenever the cells or tissues are being damaged— whatever the underlying cause.
Introduction n The reaction to pain may be rapid, as seen when one touches a hot pan.
Introduction n Or slow, as when one has been seated in the same position for an extended period of time.
Introduction n It is for this reason that persons with spinal cord injuries are at risk for developing decubitus ulcers.
Introduction n Because of their injury, they: Cannot sense pain from the pressure area. Cannot move to eliminate the pressure. Or a combination of both.
Introduction n One of the oldest roles of medical practitioners is to help alleviate pain.
Introduction n Analgesia The relief of pain without a loss of consciousness.
Introduction n Analgesia can be provided by: Drugs Surgical Procedures Physical Modalities Other
Introduction n Analgesia: Eliminate the source of the pain. Block or attenuate the pathways that transmit pain impulses to the brain. Combination of the two.
Introduction n Pain elicits a strong emotional response that is often recorded in our memory.
Introduction n “Lest we be like the cat that sits down on a hot stove-lid. She will never sit down on a hot stove-lid again—and that is well; but also she will never sit down on a cold one anymore.”
Problems n Pain appears to be under treated: Failure to assess pain. Failure to quantify pain. Fear of addiction. Legal constraints of utilizing controlled substances. Ignorance
Problems n UCLA Medical Center Study: Hispanic patients with isolated long-bone fractures were twice as likely to receive NO pain medication when compared to their non-Hispanic white counterparts. –Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993;269(10):1537-9
Problems n Grady Memorial Hospital: Black patients with isolated long-bone fractures were less likely to receive adequate analgesia when compared to their white counterparts. –Todd KH, Deaton C, D’Adamo AP, Goe L. Ethnicity and analgesic practice. Ann Emerg Med. 2000;35(1):11-16
Problems n Nationwide survey of burn patients: Only half of burn patients treated in emergency departments received adequate analgesia for their burn pain. –Singer AJ, Thode HC Jr. National analgesia prescribing patterns in emergency department patients with burns. J Burn Care Rehabil. 2002;23(6):361-5
Problems n EMS Study (Pediatrics) Few pediatric patients receive prehospital analgesia, although most ultimately received ED analgesia. –Swor R, McEachin CM, Sequin D. Grall KH. Prehospital pain management in children suffering traumatic injury. Prehospital Emergency Care. 2005;9(1):40-43
Prehospital Pain Management n Pain in the prehospital setting is often: Not identified, Under treated, Both. –Ricard-Hibon A, Leroy N, Magne M, et al. Evaluation of acute pain in prehospital medicine. Ann Fr Anesth Reanim. 1997;16(8):945-9
Prehospital Pain Management n Patients with extremity fractures receive inadequate analgesia. Study of 1,073 patients found only 1.5% received analgesia in the prehospital setting. –White LJ, Cooper LJ, Chambers RM, Gradisek RE. Prehospital use of analgesia for suspected extremity fractures. Prehosp Emerg Care. 2000;4(3):205-8
Prehospital Pain Management n Prehospital patients with lower- extremity fractures (including hip fractures): Only 18.3% of eligible patients received analgesia. –McEachin CC, McDermott JT, Swor R. Few emergency medical services patients with lower extremity fractures receive prehospital analgesia. Prehosp Emerg Care. 2002;6(4):406-410
Prehospital Pain Management n Femoral neck fractures are among the most common orthopedic injuries encountered in prehospital care.
Prehospital Pain Management n Hip fractures: Only a modest proportion of these patients receive prehospital analgesia for this painful and debilitating injury. –Vassiliadis J, Hitos K, Hill CT. Factors influencing prehospital and emergency department analgesia administration to patients with femoral neck fractures. Emerg Med (Fremantle). 2002:14(3):261-6
Prehospital Pain Management n Nothing is more cruel than: Retrieving elderly patient with isolated hip fracture. Tying them to a sheet of plywood or plastic. Wrapping a hard collar around their arthritic neck. Placing them in a 2-ton truck. Driving them to the hospital over rough roads.
Prehospital Pain Management n Without adequate analgesia!
What is Pain? n A sensory or emotional experience or discomfort. n Single, most common medical complaint.
Qualities of Pain n Organic versus Psychogenic n Acute versus Chronic n Malignant versus Benign n Continuous versus Episodic
Types of Pain n Acute pain: Pain associate with an acute event n Chronic pain: Pain that persists after an acute event is over Pain that last 6 months or more
Pathophysiology n The generation of pain involves interaction between all parts of the nervous system.
Pathophysiology n Significant strides have been made as to how the body senses and interprets pain over the last 2 decades. n Pain-generation pathways more clearly understood. n Chronic pain better understood.
Pathophysiology n Pain is more than a just a feeling or sensation, but linked to the complex psychosocial factors that surround traumatic events. n Pain is the brain’s interpretation of the painful stimulus.
Pathophysiology n Perceiving pain: Algogenic substances—chemicals released at the site of injury. Nociceptors—Afferent neurons that carry pain messages. Referred pain—pain that is perceived as if it were coming from somewhere else in the body.
Pathophysiology n Nociception Derived from the word noxious meaning harmful or damaging to the tissues. Mechanical event that occurs in tissues undergoing cellular injury.
Pathophysiology n Nociceptive stimulus is detected by free nerve endings in the tissues. n Three type of stimuli excite pain receptors: Mechanical Thermal Chemical
Pathophysiology n Pain fibers principally located in the superficial layers of the skin. n Pain fibers also located in: Periosteum Arterial walls Joint surfaces Falx and tentorium of the cranial vault.
Pathophysiology n Deep structures: Sparsely supplied with pain fibers Widespread tissue damage still causes the slow, chronic, aching-type pain.
Pathophysiology n Visceral Pain: Ischemia Chemical stimuli Spasm of hollow viscus Over distension of a hollow viscous
Pathophysiology n Chemicals that excite pain receptors: Bradykinin Serotonin Histamine Potassium ions Acids Acetylcholine Proteolytic enzymes
Pathophysiology n Chemicals that enhance the sensitivity of pain endings, but do not necessarily excite them: Prostaglandins Substance P
Pathophysiology n Types of pain: Fast Pain: –Felt within 0.1 second after painful stimulus –Also called: sharp pain, pricking pain, electric pain and acute pain. –Felt with needle stick, laceration, burn
Pathophysiology n Types of pain: Slow Pain: –Felt within 1.0 second or more after painful stimulus –Also called: dull pain, aching pain, throbbing pain and chronic pain. –Usually associated with tissue destruction
Pathophysiology n Pain fibers transmit impulse to spinal cord through fast or slow fibers: A-δ (delta) fibers—small myelinated fibers that transmit sharp pain. C fibers—small unmyelinated fibers that transmit dull pain or aching pain.
Pathophysiology n Pain is often a “double” sensation as fast pain is transmitted by the Aδ fibers while a second or so later it is transmitted by the C fiber pathway.
Pathophysiology n Pain impulses enter the spinal cord from the dorsal spinal nerve roots. n Fibers terminate on neurons in the dorsal horns.
n Peripherally-acting agents: Corticosteroids Non-steroidal anti-inflammatory agents (NSAIDs) Local Anesthesia
Pain Management n Peripherally-acting agents: Methylprednisolone Acetaminophen Ibuprofen Aspirin
Pain Management n NSAIDs Effective for pain and inflammation Good side-effect profile Second generation NSAIDs have better side-effect profiles Inhibit prostaglandins and other mediators of pain and inflammation
Ketorolac (Toradol) n Only injectable NSAID in the US n Analgesic, antipyretic and anti-inflammatory properties.
Ketorolac (Toradol) n Used for moderate-severe pain n Orthopedic and soft-tissue injuries n Popular for ureteral colic. n Often used in conjunction with centrally-acting agents such as morphine.
Ketorolac (Toradol) n Onset of action: < 30 minutes IV n Peak effects: 45-60 minutes n Duration: 4-6 hours n Typical IV dose: 30 mg
Pain Management n Centrally-acting agents: Opiates Anesthetic gasses used in analgesic quantities Atypical agents (ketamine)
Opiates n Mainstay of analgesic practice n Originally derived from the opium poppy plant n Many now synthetically manufactured
Opiate Receptors n Μu (μ ) receptors n Kappa (κ) receptors n Delta (δ) receptors n Actions: Inhibit pain Cause sedation Respiratory depression Cardiovascular depression
Opiates n Actions: Act on CNS and organs containing smooth muscle Analgesia without loss of consciousness
Opiates n Effects: Analgesia Suppresses cough reflex Respiratory depression Mental clouding Mood changes Euphoria Dysphoria Nausea and vomiting
Opiates n Effects: Meiosis Decreased gastric, biliary and pancreatic secretions Reduce gastric motility Delay digestion of food in the small bowel Decreases peristalsis in the colon (constipation)
Opiates n Effects: Certain opiates (morphine) cause an increase in biliary tract pressure Certain opiates (morphine) cause peripheral vasodiation Histamine release (red eyes, pruritis, flushing)
Fentanyl n Synthetic opiate—chemically unrelated to morphine n Initially an anesthetic induction agent n Short-acting n Pharmacological effects similar to that of morphine n Better side-effect profile because of short duration of action.
Fentanyl n Less histamine release than morphine Sivilotti ML, Ducharme J. Randomized, double- blind study on sedatives and hemodynamics during rapid-sequence intubation in the emergency department: The SHRED Study. Ann Emerg Med. 1998;31(3):125-6.
Fentanyl n Now routinely used in emergency medicine and, to a lesser degree, in EMS –Chudnofsky CR, Wright SW, Dronen SC, et al. The safety of fentanyl in the emergency department. Ann Emerg Med. 1989;18(6):839- 40.
Fentanyl n Used in multiple trauma patients because of hemodynamic profile. –Walsh M, Smith GA, Yount RA, et al. Continuous intravenous infusion for sedation and analgesia of the multiple trauma patient. Ann Emerg Med. 1991;20(8):913-5.
Fentanyl n Proven effective in the prehospital (air medical) treatment of pediatric trauma patients. n No untoward effects during 5 years of prehospital use –Devellis P, Thomas SH, Wedel SK, et al. Prehospital fentanyl analgesia in air- transported pediatric trauma patients. Pediatr Emerg Care. 1998;14(5):321-3.
Fentanyl n Onset of action: Immediate IV n Peak effects: 3-5 minutes n Duration: 30-60 minutes n Typical IV dose: 25-100 μgs
Opiates n Synthetic opiate agonists / antagonists Nalbuphine Butorphanol
Synthetic Mixed Opiates n Sub-class of opiates with both agonistic and antagonistic property n Activate some opiate receptors while blocking others n Reportedly decreases the likelihood of abuse and respiratory depression n Not controlled in many states
Nalbuphine n Most common mixed agent used in prehospital care n Antagonistic properties decrease the potential for abuse.
Nalbuphine n Initial studies indicated it was an effective alternative to morphine. –Chambers JA, Guly HR. Prehospital intravenous nalbuphine administered by paramedics. Resuscitation. 1994;27-153-8. –Stene JK, Stofberg L, MacDonald G, et al. Nalbuphine analgesia in the prehospital setting. Am J Emerg Med. 1988;6(6):634-9.
Nalbuphine n Subsequent studies seem to suggest not as effective as once thought. n English study found it offered poor pain control to a high proportion of patients in the prehospital setting. –Wollard M, Jones T, Vetter N. Hitting them where it hurts? Low dose nalbuphine therapy. Emerg Med J 2002;19:565-570.
Nalbuphine n Because of antagonistic properties, prehospital nalbuphine usage appears to be responsible for increased opiate requirements once patients arrive in the ED. –Houlihan KPG, Mitchell RG, Flapan AD, et al. Excessive morphine requirements after prehospital nalbuphine analgesia. J Accid Emerg Med 1999;16:29-31
Nalbuphine n Also appears to interfere with general anesthesia and maintenance. –Robinson N, Burrow N. Excessive morphine requirements after pre-hospital nalbuphine analgesia. J Accid Emerg Med. 1999;16:123- 7.
Nalbuphine n Probably should have a limited role in emergency medicine and EMS.
Nalbuphine n Onset of action: 2-3 minutes IV n Peak effects: < 30 minutes n Duration of effect: 3-6 hours n Typical IV dose: 5-20 mg
Synthetic Mixed Opiates n Butorphanol (Stadol)
Butorphanol n Used by a few EMS systems n Similar properties to nalbuphine n Role in EMS has not been widely studied n Probably should have a limited role in EMS
Butorphanol n Thought to be non-addictive. n Stadol NS resulted in significant addictions
Butorphanol n Onset of action: < 1 minute IV n Peak effects: 3-5 minutes n Duration: 2-4 hours n Typical IV dose: 0.5-2.0 mg
Gasses n Nitrous Oxide (N 2 O): Anesthetic at high concentrations Analgesic at low concentrations Initially used in dentistry and obstetrics Introduced into EMS in the 1970s. Effective in treating virtually all types of pain.
Nitrous Oxide n Supplied as two- cylinder device (Nitronox) that feeds gases into a blender at 50:50 concentration n Self-administered through modified demand valve.
Nitrous Oxide n Proven effective in numerous types of pain encountered in the prehospital setting. –Stewart RD, Paris PM, Stoy WA, Cannon G. Patient-controlled inhalation analgesia in prehospital care: a study of side-effects and feasibility. Crit Care Med. 1983;11(11):851-5. –Pons PT. Nitrous oxide analgesia. Emerg Med Clin North Am. 1988;6(4):777-82,
Nitrous Oxide n Effective for painful procedures such as transcutaneous pacing. –Kaplan RM, Heller MB, McPherson J, Paris PM. An evaluation of nitrous oxide analgesia during transcutaneous pacing. Prehosp Disaster Med. 1990;5(2):145-9.
Nitrous Oxide n NAEMSP has issued a detailed position statement regarding it’s use. –National Association of EMS Physicians. Use of nitrous oxide:oxygen mixtures in prehospital emergency care. Prehosp Disaster Med. 1990;5(3):273-4.
Nitrous Oxide n Probably underutilized for several reasons: Cost Bulky delivery system Storage issues Lack of understanding regarding efficacy
MYTH #1: If I give my patient narcotics, they will not be competent enough to consent for surgery later.
Myths of Pain Management n Myth # 1: FALSE Concern about rendering patient incompetent is unfounded. Withholding analgesia can be looked upon as a form of “coercion” to sign consent for surgery. –Gabbay DS, Dickenson ET. Refusal of base station physicians to authorize narcotic analgesia. Prehosp Emerg Care. 2001;3(5):293-5.
Myths of Pain Management n MYTH #2: If I give my patient narcotics for abdominal pain, it will change the physical examination findings, making diagnosis difficult.
Myths of Pain Management n Myth # 2: False The dogma of withholding analgesia for fear that it will alter an abdominal examination stems from the 1921 book by Dr. Zachary Cope entitled Early Diagnosis of the Acute Abdomen that stated, “If morphine be given, it is possible for a patient to die happy in the belief that he is on the road to recovery, and in some cases the medical attendant may for a time be induced to share the elusive hope.”
Myths of Pain Management n Myth # 2: False Several researchers have examined this question: –Patients with abdominal pain randomly assigned to receive either IV morphine or saline. –Patients were assessed before and after the morphine or saline was administered, and then assessed later by a surgeon if indicated. –The presence of peritoneal signs did not change in the group that received morphine and the accuracy of diagnosis did not differ between the two groups of patients as well as between the emergency physicians and the surgeons. –In fact, there was also a trend that the examination may be more reliable after treatment with morphine. – Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad. Emerg. Med. 1996;3:1086–1092
Myths of Pain Management n Myth # 2: False 108 children with abdominal pain. –52 morphine –56 placebo (saline) Groups well matched. Morphine effectively reduces the intensity of [ain and does not seem to impede the diagnosis of appendicitis. –Green R. et al. Early analgesia for children with acute abdominal pain. Pediatrics. 2005;116:978- 983.
Myths of Pain Management n MYTH #3: If I give my patient narcotics, they will develop respiratory arrest.
Myths of Pain Management n Myth # 3: False Respiratory depressant effects often offset by sympathetic stimulation in the pain patient. Different than from respiratory depression in pain-free opiate addicts. Key is to use correct analgesic dose
Myths of Pain Management n MYTH #4: If I give my patient narcotics, they will abuse narcotics
Myths of Pain Management n Myth # 4: False Because a few patients malinger and drug-seek is no reason to withhold from legitimate pain patients. Addicts need analgesia on occasion too. Most people who become addicted to pain killers have underlying addictive tendencies.
Myths of Pain Management n Myth # 4: False In a 5-year review, the medical use of opiates increased while the incidence of opiate abuse actually decreased. –Joranson DE, Ryan KM, Gilson AM, Dahl JL. Trends in medical use and abuse of opioid analgesics. JAMA. 2000;283(13):1710-4.
n 3 mL of methoxyflurane are placed onto the wick of the inhaler n Device gently shaken and any excess wiped off n Inhaler given to patient to self administer n Supplemental oxygen can be provided.
Methoxyflurane n Pain relief usually begins in 8-10 breaths n Lasts for 25-30 minutes n Allows time for IV access and morphine n Should be used in well ventilated area.
Methoxyflurane n Why don’t we have it? Methoxyflurane limited to animal use in US. Reported liver and kidney toxicity (in anesthetic doses—not analgesic doses) US manufacturer quit making Metofane Commonwealth of Australia considers the drug safe for analgesic usage
Intranasal Fentanyl n Australian study has shown intranasal fentanyl safe and effective in treating trauma pain in children between 3-12 years of age. n Children 3-7: 20 μg IN n Children 8-12: 40 μg IN n Additional 20 μg doses q 5 minutes
Intranasal Fentanyl n Allowed for early and significant reduction in pain. n Shows great promise for emergency medicine and EMS –Borland ML, Jacobs I, Geelhoed G. Intranasal fentanyl reduces acute pain in children in the emergency department: a safety and efficacy study. Emerg Med (Fremantle). 2002;14(3):275-80
Alfentanil (Alfenta) n Chemical analogue of fentanyl (shorter acting) n Less side-effects than morphine
Alfentanil (Alfenta) n Faster, more effective pain relief when compared to morphine. n No hemodynamic or respiratory side- effects occurred. –Silfvast T, Saarnivaara. Comparison of alfentanil and morphine in the prehospital treatment of patients with acute ischaemic- type chest pain. Eur J Emerg Med. 2001;8(4):275-8.
Tramadol n Synthetic analogue of codeine. n Has weak opioid agonistic properties. n Slight abuse potential n Non-controlled
Tramadol n Parenteral form not yet available in US n 1/10 as potent as morphine n Onset of action: 1-5 minutes IV n Peak effects: 15-45 minutes n Duration:4.5 hours n Typical IV dose: 100 mg
Tramadol n Analgesia and side-effects similar to morphine. n Concluded tramadol is an effective alternative to morphine in the prehospital setting. –Vergnion M, Desgesves S, Garcey L, Magotteaux V. Tramadol, an Alternative to Morphine for Treating Posttraumatic Pain in the Prehospital Situation. Anest Analg. 2001;92:1543-6.
Entonox n Single-cylinder pre-mixed 50:50 nitrous oxide oxygen mixture. n Available everywhere but the US. n Gasses tend to separate ~ 26° F (but remix with inversion of cylinder) n Cheaper, less bulky,
n Study compared 2-cylinder to 1- cylinder system. n Nitronox safer in cold weather n No significant clinical differences overall –McKinnon KD. Prehospital analgesia with nitrous oxide/oxygen. Can Med Assoc J. 1981;125:836-840
Entonox n Entonox preferred over Nitronox by prehospital personnel involved in study.
Non-Pharmacological n Interesting Austrian study for victims of minor trauma using acupressure. n Patients randomly assigned to receive acupressure at “true points,” at “sham points” or “no acupressure.” n Different values measured before and after treatment.
Acupressure n At the end of transport, patients who received acupressure at “true points” had less pain, less anxiety, a slower heart rate, and greater satisfaction with the care provided. n They concluded that acupressure is an effective and easy-to-learn treatment of pain in prehospital care. –Kober A, ScheckT, Greher M et al. Prehospital analgesia with acupressure in victims of minor trauma: a prospective, randomized, double- blinded trial. Anest Analg. 2002;95(3):723-7.
Summary n How can we improve prehospital pain control? All personnel should assess for the presence and severity of pain. Use objective pain measures Medical directors need to become more aggressive in pain management
Summary n Move prehospital pain management decisions for most conditions from on-line medical control to standing orders. n Time to morphine administration decreased by 2.3 minutes when this change made. –Fullerton-Gleason L, Crandall C, Sklar DP. Prehospital administration of morphine for isolated extremity injuries: a change in protocol reduces time to medication. Prehosp Emerg Care. 2002;6(4):411-6
Summary n Liberalization of prehospital pain protocols resulted in increased usage with no apparent safety or misuse issues. –Pointer JA, Harlan K. Impact of liberalization of protocols for the use of morphine sulfate in an urban EMS system. Prehospital Emergency Care. 2005;9(4):377-381
Summary n Field personnel, EMS physicians, administrators, and representatives from receiving hospitals should organize a comprehensive plan to assure that we are providing adequate analgesia in the prehospital setting. n EMS is a compassionate profession and compassion begins with the relief of pain and suffering