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

2. 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

3. 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

4. GREAT
GOOD

5. Go Back to the Bedside . . . and BE HONEST

6. (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

7. 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

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

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

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

11. 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!!!!

12. 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

13. STOP!!!!!
CODE BROWN!!!

14. 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

15. 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

16. 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