Intern Bootcamp 2019: PAIN & POOOOOOOP Doug Hutcheon, MD July, 2019

A Few Disclaimers This is not a comprehensive lecture on pain management Some of this is science, some of this is opinion I like to tell stories Y’all tell ME what YOU want to talk about

Remember: Being a (Good) Doctor is Hard . . . And that’s a good thing You are having lunch in the cafeteria when you get a page from a nurse who says Mrs. Philips in 7A102 is complaining of abdominal pain. So you . . . . . . Order a Norco and get back to that sweet sweet burrito from Twisted Chili

GREAT GOOD

Go Back to the Bedside . . . and BE HONEST

(Just a few of) The Meds at Your Disposal NSAIDs IBU, acetaminophen (yes, there is IV acetaminophen and it works great. . . just not here) IV ketorolac* gabapentin HUUUUUUGE maximum daily dose Opioids *Doug’s favorite

Non-Opioids Management of acute pain in the acute setting Go big or go home IBU 600mg po q4hrs prn or 800mg po TID acetaminophen 975mg or 1000mg po TID prn ketorolac (Toradol) 15mg or 30mg greater side effect profile  short duration Consider scheduling . . . in certain circumstances gabapentin always scheduled 100mg po qd start it, ramp it up 600mg po BID or 900mg po BID Working? Yes  GREAT! keep going No  STOP

NO TWO PATIENTS ARE THE SAME, SO: DEVELOP A PLAN WITH YOUR PATIENT TRY IT OUT ASSESS IT RE-WORK IT *Doug’s favorite

Alright . . . Lets Talk About Opioids Doug’s first 3 rules about opioids: Don’t use them

Using Opioids Cancer-related pain Again . . . TALK TO YOUR PATIENT Set expectations If the gut works . . . USE IT

Using Opioids Efficacy vs potency ALWAYS start with short acting morphine vs hydromorphone exception: renal dysfunction ALWAYS start with short acting Doug’s “go-to” morphine 3mg po q3hrs prn breakthrough BUUUUUT I make a unique decision for each patient!!!!

Assessing Your Plan Set yourself up for SUCCESS . . . TALK TO YOUR PATIENT Set expectations!! PRN . . . what the heck does that mean anyway?!? Theoretical World (Order) vs Real World (MAR Summary) Talk to your nurses 2 parameters  2 questions

STOP!!!!! CODE BROWN!!!

Constipation is the Enemy From this day forward you will ALWAYS prescribe a SCHEDULED bowel regimen EVERY time you order opioids Doug’s go to starting: senna 17.2gm (that’s 2 tabs) po qhs Miralax (polyethylene glycol) 17gm (one packet) po qd

Constipation is the Enemy ALWAYS easier to back off than UNPLUG Doug’s rule of 3 (days) . . . Time to go from below Some other meds: docusate (Colace) bisacodyl: PO or PR magnesium citrate lactulose I don’t like using PO GREAT enema

Parting Thoughts TALK. TO. YOUR. PATIENTS. Set expectations (In their language) Set expectations Come up with a plan, try it out, assess it, tweak it Opioids and bowel regimen are bonded in holy matrimony