1. Acute Pain Management Solomon Liao, M.D.
Associate Clinical Professor
Director of Palliative Care Services
Hospitalist Program

2. PRACTICAL Objectives Use opioids with comfort in an inpatient setting
By the end of this session, participants will be able to:
Use opioids with comfort in an inpatient setting
Address side-effects
Master opioid conversions
Choose the appropriate opioid
PRACTICAL

3. WHO pyramid Severe Pain Pure opioids: Morphine Moderate Pain
Mild opioids: Codeine, Vicodin
Mild Pain
Non-opioids: Tylenol, NSAIDS

4. Back Pain 56 yo chronic back pain
Pain well controlled with Oxycontin 20 mg bid
Developed dysphagia
Unable to swallow pills
Now admitted in severe pain
How do you write admit pain med?

5. Conversion Oxycodone 1 mg = 1.5 mg Morphine
40 mg Oxycodone/day = 60 mg PO Morphine/day
1 mg IV Morphine = 3 mg PO Morphine
60 mg PO Morphine = 20 mg IV Morphine
20 mg IV Morphine/24 hrs = 1 mg/hr

6. Epigastric Pain 46 yo Admit from ER for severe acute epigastric pain
Radiates to back
Curled up in a fetal position
Amylase and lipase elevated
What pain medication would you use?
How would you give it to her?

7. DEMEROL

8. Demerol Side-effects Partial mu agonist, most kappa effects
Most addictive
short acting
high peaking
Lowers seizure threshold
active metabolite - normeperidine
Anticholingeric - not for elderly

9. PCA Titration Better pain control Less medication, less side effects
Titration Principle
Smaller dose, more frequent
Matches pain curve
Anticipatory pain effect
PRN match continuous rate
2 mg/hr & 0.5 mg q 15 min PRN

10. Trauma 76 yo Adm to trauma Svc, s/p MVA Pulmonary contusion, rib Fx
Delirious - confused
Pulling off O2, hard collar on, 4 point restraints, pulling at foley
Given MS PCA by surgery team
What is wrong with the picture?

11. Titration Short acting agent (fast route)
For opioid naïve – start 2 mg IVP q 1-2 hr
Can safely increase by % q day
No ceiling (Max. dose) for pure opioids
Add PRN to standing dose

12. Morphine Pharmacokinetics

13. Fentanyl Case
Geriatric Fellow called by NP: nursing home patient with pain
Fentanyl patch applied
Next day patient still in pain
Another Fentanyl patch added
2 days later Pt obtunded

14. Opioid Choices Morphine - IV, SQ, IM, PO, PR, SL
Dilaudid - IV, SQ, IM, PO, SL
Oxycodone - PO, SL
Fentanyl - IV, transQ, transmucosal
Levorphanol - IV
Methadone – PO, SL, IV, SQ
Hydrocodone - PO

15. Discharge to Outpatient
Around the Clock
“An ounce of prevention is worth a pound of cure”
Rules of thumb
Rescue dose = 10% of 24 hr dose PRN q 4 hrs
Call if use more than 2 PRN dose or use more than 2 days

16. Narcan? 87 yo small Japanese lady S/p TAH/BSO, POD # 2
Allergy to morphine
MD orders Dilaudid 0.5 mg q 2 hrs
RN gives in error Dilaudid 5 mg IVP
RR 10, Pt sleeping – arousable
What should the RN do?

17. Side-effects Acute Chronic - constipation All resolve within 3-5 days
Respiratory depression (rare) - hours
Sedation – 1-2 days
Nausea/vomiting (33%) – 3-5 days
Chronic - constipation
“The hand that writes the opioid, writes the laxative”

18. Indications for Narcan
Not for mental status change
Just hold – let wear off
Cause significant acute withdraw pain
RR < 6
Oxygen saturation <90%
If respond then
Narcan drip & transfer to ICU
Because duration <2 hrs

19. Summary Titration NO DEMEROL Monitor side-effects PCA best
short acting
convert to long acting
NO DEMEROL
Monitor side-effects