1. Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center Rajesh Chandra, M.D. Division Chief General Internal Medicine & Geriatrics UH Case Medical Center Todd M. Zeiger, M.D. UH Sharon Center Family Medicine Regional Medical Director UH Sharon and Medina Health Center Mariel Harris, M.D., J.D. Medical Director for Senior Services UH Richmond Medical Center Geriatric Medicine, Hospice & Palliative Care UH Center for Geriatric Medicine David Cogan, M.D. Senior Medical Director UHMP Robin Rowell, RN, CNP VP, Institute and Medical/Surgical Clinical Operations UH Case Medical Center Hildy Pearl, MS, RD, LD Clinical Systems Liaison UH Case Medical Center Debbie Horan, RN, BSN Clinical Systems Liaison UH Case Medical Center Helen C. Foley, MSN, RN Adult Oncology CNS Seidman Cancer Center UH Case Medical Center Kim F. Bixenstine, Esq. Vice President and Deputy General Counsel University Hospitals

2. October 27, 2012University Hospitals Pain – Healing it Without Feeling it According to the Institute of Medicine, the number of Americans who suffer from Chronic Pain is estimated to be: 1.25 million 2.45 million 3.75 million 4.100 million

3. October 27, 2012University Hospitals Objectives Understand the basic principles of pain management Understand the barriers to and myths of pain management Understand regulations regarding prescribing/dispensing pain medications Understand hospital specific resources for pain management October 27, 2012University Hospitals

4. October 27, 2012University Hospitals Case presentation CC: Fell off bicycle HPI: 55yo WM competing in 4 day fundraising bicycle ride who fell off bicycle and now presenting with 10/10, constant, sharp, localized left hip pain. Patient has chronic tingling in hands and legs which is overshadowed by current pain. PMH: OA- shoulders, spine, hips - s/p injections, wears soft cervical collar to sleep; Carpal Tunnel syndrome- wears wrist splints to sleep NKDA October 27, 2012University Hospitals

5. October 27, 2012University Hospitals Case presentation Meds: –Pregabalin 100mg po TID x 2 years –Duloxetine 60mg po daily –Oxycontin 40mg po BID x 2years –Sennosides/ docusate 2 tabs po qhs –Cyclobenzaprine 5mg po qhs prn FamHx: Non-contributory SocHx: interventional radiologist, swims and/or bicycle rides 6 days a week; married to PM&R MD; no known addiction history October 27, 2012University Hospitals

6. October 27, 2012University Hospitals Case presentation ROS: as per HPI, otherwise negative PE: Afebrile, HR- 120, RR- 18, BP- 140/ 75 –Remarkable for externally rotated and shortened L LE with pain on hip flexion Labs: BMP, CBC, INR, LFTs within normal limits Imaging: Left sided intertrochanteric hip fracture Plan in ED: –Ortho consultation –Pain control –Admit October 27, 2012University Hospitals

7. October 27, 2012University Hospitals Question 1 You recognize patient is not opiate naïve. You need to give him something for pain. He is NPO for possible surgery. A reasonable first dose would be: A) Morphine 5mg IV B) Hydromorphone 2mg IV C) Oxycodone 5mg po D) Ketorolac 30mg IV Patient’s Home Meds: Pregabalin 100mg po TID x 2 years Duloxetine 60mg po daily Oxycontin 40mg po BID x 2years Sennosides/ docusate 2 tabs po qhs Cyclobenzaprine 5mg po qhs prn

8. October 27, 2012University Hospitals Best response: A Route of choice Drug of choice Dose of choice –Acute on chronic pain- chronic pain meds are now baseline/ background –Convention in terms of reasonable breakthrough dose- 5-15% of daily long-acting –Must calculate equianalgesic doses A) Morphine 5mg IV B) Hydromorphone 2mg IV C) Oxycodone 5mg po D) Ketorolac 30mg IV October 27, 2012University Hospitals

9. October 27, 2012University Hospitals Equianalgesic Dosing OPIOIDPARENTERAL(mg) ORAL (mg) Morphine1030 Oxycodone20-30 Hydromorphone(Dilaudid)1.57.5 October 27, 2012University Hospitals

10. October 27, 2012University Hospitals Question 2 He is admitted with plans for surgery the next day. You need to control his pain overnight. The most reasonable option is: A) Morphine 5mg IV q4h prn B) Continue Oxycontin and Pregabalin and add Morphine 5mg IV q4h prn C) Continue Oxycontin and Pregabalin and add Morphine PCA

11. October 27, 2012University Hospitals Best response: C Practical aspects of choosing prn pain meds Is patient going to be able to ask? Will patient ask? Is RN going to be able to get to patient in a timely manner? Do we need to do some dose finding? Pharmocokinetics A) Morphine 5mg IV q4h prn B) Continue Oxycontin and Pregabalin and add Morphine 5mg IV q4h prn C) Continue Oxycontin and Pregabalin and add Morphine PCA October 27, 2012University Hospitals

12. October 27, 2012University Hospitals Best response: C Practical aspects of choosing to use a PCA Is patient going to be able to safely use PCA? (not delirious, using opiates appropriately) Do we need to do some dose finding? We use less opiate with PCA than without Continuous aspect of PCA- is equivalent to long-acting opiate How to do PCA dosing - continuous, patient push and RN bolus A) Morphine 5mg IV q4h prn B) Continue Oxycontin and Pregabalin and add Morphine 5mg IV q4h prn C) Continue Oxycontin and Pregabalin and add Morphine PCA October 27, 2012University Hospitals

13. October 27, 2012University Hospitals Best response: C Takes more medicine to get pain under control than to keep it under control Delirium in hip fractures more often from pain than opiates* * Relationship between Pain and Opioid Analgesics on the Development of Delirium Following Hip Fracture. Morrison et. al, Journal of Gerontology : Medical Sciences 2003, Vol. 58A, No. 1, 76-81. A) Morphine 5mg IV q4h prn B) Continue Oxycontin and Pregabalin and add Morphine 5mg IV q4h prn C) Continue Oxycontin and Pregabalin and add Morphine PCA October 27, 2012University Hospitals

14. October 27, 2012University Hospitals Question 3 Patient is now post-op. Continues to use PCA. He has fallen asleep. Nurse is concerned that his cell phone rings and he sleeps right through it. The nurse notifies you of this. You should: A) Give all the Narcan you can find on the floor B) Discontinue all opiates C) Hold opiates and restart at lower dose D) Assess patient and develop a ddx for the patient’s sedation

15. October 27, 2012University Hospitals Best responses: C & D There is no set amount of opiate associated with sedation, respiratory arrest/ death You get sedation first- safety of PCA with no continuous dosing (see graph) RR drops slowly- not abrupt cessation of breathing Catching up on sleep A) Give all the Narcan you can find on the floor B) Discontinue all opiates C) Hold opiates and restart at lower dose D) Assess patient and develop a ddx for the patient’s sedation October 27, 2012University Hospitals

16. October 27, 2012University Hospitals Safety mechanism of PCAs with NO CONTINUOUS DOSE October 27, 2012University Hospitals

17. October 27, 2012University Hospitals Best responses: C & D Don’t want to get behind on pain which will happen if holding long-acting med --- liken this to other scheduled meds (e.g. beta blockers) Abbey Pain Scale or other for assessing pain in non- communicative patient A) Give all the Narcan you can find on the floor B) Discontinue all opiates C) Hold opiates and restart at lower dose D) Assess patient and develop a ddx for the patient’s sedation October 27, 2012University Hospitals

18. October 27, 2012University Hospitals Assessing Pain in Patients Who Can’t Communicate - Abbey Pain Scale October 27, 2012University Hospitals

19. October 27, 2012University Hospitals Question 4 Hospital day 3 Patient’s pain is well controlled. He is doing well with PT and is going to be discharged home with home PT. He has had no BM since admission. What do we need to think of before he goes home? A) Which intern is responsible for d/c summary B) What his opiate dose will be C) What adjuvants he should be on D) What resources are available to him and you as you continue to manage his pain E) Who do we need to give a handoff to F) Fixing his constipation G) All of the above

20. October 27, 2012University Hospitals Best response: G Opiate dosing –Long-acting is 50-75% of total daily Oral Morphine Equivalent varies for incident pain, expected changes to pain –Short-acting dose Convention in terms of reasonable breakthrough dose - 5-15% of daily long- acting A) Which intern is responsible for d/c summary B) What his opiate dose will be C) What adjuvants he should be on D) What resources are available to him and you as you continue to manage his pain E) Who do we need to give a handoff to F) Fixing his constipation G) all of the above October 27, 2012University Hospitals

21. October 27, 2012University Hospitals Basic Principles of Opiate Prescribing Make it simple: oral route, one drug Prescribe an adequate dose Do the math! Use equianalgesic conversion table Use a correct dosing interval Prescribe around-the-clock (long-acting opiate) - when warranted Provide a breakthrough dose (short-acting opiate) Treat common opiate side effects Use appropriate adjuvants October 27, 2012University Hospitals

22. October 27, 2012University Hospitals Do the math! Calculate 24 hour oral morphine equivalent (OME) Consider adequacy of pain control –Calculate - expected total oral morphine equivalent –Increase current 24 hr OME by 25-50% for moderate pain control –Increase current 24 hr OME by 50-100% for poor pain control Determine the opiate that will be given Use equianalgesic conversion table Correct for incomplete cross-tolerance when rotating to different opiate –Reduce dose by 25 – 50 % Calculate short and long-acting doses October 27, 2012University Hospitals

23. October 27, 2012University Hospitals Equianalgesic Dosing OPIOIDPARENTERAL(mg) ORAL (mg) Morphine1030 Oxycodone20-30 Oxymorphone110 Hydromorphone(Dilaudid)1.57.5 Fentanyl0.1 Hydrocodone30 October 27, 2012University Hospitals

24. October 27, 2012University Hospitals Best response: G ADJUVANTS – Inflammation/ post-op - NSAIDS/ steroids – Neuropathic – TCA, anti-epileptics, SNRI, anesthetics – Complementary therapies - heat/ice, massage, physical therapy, acupuncture etc. A) Which intern is responsible for d/c summary B) What his opiate dose will be C) what adjuvants he should be on D) What resources are available to him and you as you continue to manage his pain E) Who do we need to give a handoff to F) Fixing his constipation G) all of the above October 27, 2012University Hospitals

25. October 27, 2012University Hospitals Best response: G –Talk to Team assuming care - re: course and plan for meds and what is being written for at d/c A) Which intern is responsible for d/c summary B) What his opiate dose will be C) What adjuvants he should be on D) What resources are available to him and you as you continue to manage his pain E) Who do we need to give a handoff to F) Fixing his constipation G) all of the above October 27, 2012University Hospitals

26. October 27, 2012University Hospitals Guidelines for Dictating Pain Management History Describe pain syndromes patient suffered For each complaint, describe: –Type of pain and severity reported –Provoking factors –Relieving factors –Procedures completed/ attempted and result –Medications tried, what worked and at what dose –Medications tried that were ineffective –Medications with adverse reactions, how treated (remember to distinguish intolerance, such as nausea or sedation, from true allergy)

27. October 27, 2012University Hospitals Guidelines for Dictating Pain Management History Detailed description of –Discussion with patient and family on how to manage analgesics after discharge –Prescriptions given, including # of pills of each Rx and whether any refills were authorized –What doctor or doctors will be responsible for follow-up –If appropriate, what OARRS or pharmacy investigation was done –If appropriate, what REMS information was given to patient and whether a contract was or should be made for use of long-acting opiates in chronic non-cancer pain syndromes

28. October 27, 2012University HospitalsOctober 27, 2012University Hospitals Definition of Terms Katz NP, et al. Clin J Pain. 2007;23:648-660. Misuse Use of a medication (for a medical purpose) other than as directed or as indicated, whether willful or unintentional, and whether harm results or not Abuse Any use of an illegal drug The intentional self administration of a medication for a nonmedical purpose such as altering one’s state of consciousness, eg, getting high Addiction A primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations Behavioral characteristics include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, craving Pseudoaddiction Syndrome of abnormal behavior resulting from undertreatment of pain that is misidentified by the clinician as inappropriate drug-seeking behavior Behavior ceases when adequate pain relief is provided Not a diagnosis; rather, a description of the clinical intention

29. October 27, 2012University HospitalsOctober 27, 2012University Hospitals Definition of Terms Katz NP, et al. Clin J Pain. 2007;23:648-660. Dependence A physiological state of neuro-adaptation which is characterized by WITHDRAWAL if…The drug is stopped, the drug is decreased abruptly, an antagonist is administered Tolerance The need to increase the dose of opioids to achieve the same level of analgesia

30. October 27, 2012University Hospitals FDA – REMS (Risk Evaluation and Mitigation Strategy) Are regulatory requirements on medications that have a high threshold potential for harm The FDA mandates that the Drug manufacturer develop a REMS program in order to continue sale of those medications REMS programs may include any of the 4 following components: –Medication Guide –Communication Plan –Elements to Assure Safe Use (ETASU) –Implementation System ETASU requires practitioners to complete one or all of the following: Prescriber Certification: Register and obtain/renew by completing drug company online training Medication Guide: Must be provided to all inpatients as well as outpatients prior to receiving the first dose Register the Patient Patient informed consent: Must be signed prior to administration of the drug October 27, 2012University Hospitals

31. October 27, 2012University Hospitals FDA – REMS (Risk Evaluation and Mitigation Strategy) Some commonly used ETASU drugs Oxycontin (soon to be all extended release narcotics) Epogen/Procrit (ESA non- ESRD use) Aranesp (ESA non-ESRD use) Avandia Zyprexa Relprevv Entereg Revlimid Lumizyme Tikosyn

32. October 27, 2012University Hospitals FDA – REMS October 27, 2012University Hospitals

33. October 27, 2012University Hospitals WHERE TO FIND UH OPIOID GUIDELINES, ED OPIOID GUIDELINES and PAIN MANAGEMENT AGREEMENT

34. October 27, 2012University Hospitals Pain Management Referral Resources General: Fast Facts- http://www.eperc.mcw.edu/EPERC/FastFactsandConceptshttp://www.eperc.mcw.edu/EPERC/FastFactsandConcepts UH System Referral Resources October 27, 2012University Hospitals University Hospitals Case Medical CenterPalliative care consult service, Pager 35614 Pain consult service, Pager 35879 Seidman Cancer Center Symptom Management and Supportive Care clinic 216-844-3951 Option 1 Roger Goomber, M.D. 216-844-7335 Salim Hayek, M.D. 216-844-3771 Ali-Amin Khalil, MD 216-844-3552 Binit Shah, M.D. 216-844-3771 Henry Vucetic, M.D. 216-844-7335 UH Ahuja Medical CenterJoshua Goldner, M.D. 216-844-3771 Patrick McIntyre, M.D. 216-844-3771 UH Richmond Medical CenterAl-Amin Khalil, M.D. 216-844-2552 Sami Moufawad, M.D. 440-786-9885 UH Bedford Medical CenterSami Moufawad, M.D. 440-786-9885 UH Conneaut Medical Center UH Geneva Medical Center Arpan Desai, M.D. 440-593-0203 (Interventional only) UH Geauga Medical CenterHenry Vucetic, M.D. 216-844-7335 UH Conner Integrative Medicine NetworkFrancoise Adan, M.D. 216-285-4070 St. John Medical CenterAbdallah Kabbara 440-827-5058 Southwest General Health CenterDavid Sfeir, M.D. 440-816-8990

35. October 27, 2012University HospitalsOctober 27, 2012University Hospitals Thank You. References: American Academy of Pain – Facts and Figures on Pain http://www.painmed.org/patientcenter/facts_on_pain.aspx Relationship between Pain and Opioid Analgesics on the Development of Delirium Following Hip Fracture, Morrison et al. Journal of Gerontology Medical Sciences 2003, Vol. 58A, No. 1, 76-81. The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia, Abbey et al. Int Journal of Palliat Nurs 2004 Jan;10(1):6-13 Definition of Terms, Katz NP, et al. Clin J Pain. 2007;23:648-660