Spotlight
A Lot of Pain (Medications)

• This presentation is based on the September 2014
AHRQ WebM&M Spotlight Case
– See the full article at http://webmm.ahrq.gov
– CME credit is available
• Commentary by: Shoshana J. Herzig, MD, MPH, Division of
General Medicine, Beth Israel Deaconess Medical Center,
Harvard Medical School
– Editor, AHRQ WebM&M: Robert Wachter, MD
– Spotlight Editor: Bradley A. Sharpe, MD
– Managing Editor: Erin Hartman, MS
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Source and Credits

Objectives
At the conclusion of this educational activity, participants
should be able to:
• Appreciate the challenges of managing acute pain in hospitalized
patients on chronic opioids
• Describe the importance of understanding the nature of the acute
pain and its relationship to the chronic pain
• List key principles in safe prescribing of opioids in the hospital
• List patient-related and prescribing-related risk factors for opioid-
related adverse events
• Describe steps to improve prescribing and monitoring of patients
on opioids in the hospital
• Describe the Prescription Drug Monitoring Program (PDMP) and
how it may improve prescribing
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Case: A Lot of Pain
A 58-year-old man was admitted to the hospital
with a non-healing foot ulcer related to severe
peripheral vascular disease. He also had a history
of chronic obstructive disease and chronic pain.
His pain was long-standing and related to multiple
prior neck and back surgeries. For years he had
been treated with long-acting morphine (extended-
release 40 mg twice daily) as well as additional
opioids for breakthrough pain. On admission, he
reported 8/10 pain, despite receiving his home
opioid regimen. After a surgical amputation to treat
the ulcer, his pain worsened to 10/10.
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Background
• Rates of opioid use, and long-term use for
chronic non-cancer pain, have markedly
increased over the last 2–3 decades
– In one study, more than 25% of patients
hospitalized at Veterans Administration Hospitals
were receiving chronic opioid therapy
• Patients receiving chronic opioid therapy
consume a disproportionate share of health
care resources, including more emergency
department visits and days in the hospital
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Background (2)
• Providers frequently have to manage acute pain
in hospitalized patients on chronic opioid therapy
• Achieving adequate pain control in patients on
chronic opioid therapy is challenging
– Patients may need higher doses (dependence)
– Patients may experience great pain with less noxious
stimuli (opioid-induced hyperalgesia)
– Physicians may be reluctant to prescribe higher
doses
• This can result in under-treatment of pain in this
patient population
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Evaluating the Acute Pain
• Understanding the nature or quality of the acute pain and its
relationship to the patient's chronic pain complaint is crucial
– Is acute pain related to an injury or procedure (e.g., post-operative pain after
surgical amputation in this case)?
– Is the chronic pain worse?
• Understanding the pain may allow optimal pharmacologic
treatment
– Inflammatory pain is optimally treated with nonsteroidal anti-inflammatory
drugs (NSAIDs)
– Neuropathic pain may respond well to gabapentin or pregabalin
• The American Society of Anesthesiologists recommends a
multimodal approach to pain management, using at least 2
different classes of analgesics
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Using Opioid Analgesics
• Once a decision is made to use opioid analgesics to
manage acute post-operative pain, it is important to
identify the optimal drug, dose, route, and regimen in
assuring favorable risk-to-benefit ratio
• Guidance on these decisions comes mostly from expert
opinion (see references below)
• Patient's previous long-acting opioid should be continued,
if possible, to deliver the patient's usual baseline analgesia
and avoid precipitating opioid withdrawal
• When adding additional opioids for acute pain, immediate-
release opioids should be used to facilitate dose titration
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Using Opioid Analgesics (2)
• Oral route is preferred to maximize duration
of action
• If pain is severe, intravenous opioids may
initially be required
• If possible, immediate-release opioid chosen
for management of acute pain should be the
same type as that used for chronic pain
– Will minimize chances of adverse effects
– Can facilitate ease of dose calculations
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Titrating Doses of Opioid Analgesics
• To optimally calculate and titrate doses, it’s often
easiest to convert to "oral morphine equivalents"
(convert all opioids to same amount that would be
given in oral morphine)
• Several online or handheld device calculators are
available to help with this conversion
• If using the same type of opioid as used for the chronic
pain, an initial dose of 10%–20% of baseline total daily
dose should be used for acute pain
• This dose should be ordered on an as-needed basis
(PRN), approximately every 4 hours for the oral route
and every 3 hours for the intravenous route
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Using a Different Opioid
• If necessary to change to an opioid that’s
different from that used for the chronic pain,
dose should be adjusted
• Guidelines recommend starting with a total
opioid dose that is 25%–50% lower than
calculated equianalgesic dose
– Can avoid unintentional overdose due to
incomplete cross-tolerance (i.e., patients may be
more sensitive to different opioids)
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Other Considerations in Choosing
• Other key considerations in choosing
alternate opioids
– Morphine and hydromorphone have fewer drug–
drug interactions than other opioids
– Most opioids, including morphine and
hydromorphone, are mainly eliminated in the
urine; may need to adjust dose in setting of renal
failure
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This Case
• The outpatient dose of 40 mg of extended-release
morphine twice daily should be confirmed
• For his acute pain, as his chronic opioid is morphine,
immediate-release morphine would be appropriate
• The recommended dose for the acute pain would be
10%–20% of his baseline of 80 mg/day
– Morphine 8–16 mg orally every 4 hours
– Adjusted based on response
• Give the inflammatory nature of the pain, absent
contraindications, an NSAID could be added
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Case: A Lot of Pain (2)
In addition to post-operative surgical pain and his chronic
pain, he also began having diffuse severe muscle spasms.
Over the next 48 hours he was given increasing doses of
extended-release morphine (up to a dose of morphine 165
mg orally three times a day), as well as intravenous and oral
hydromorphone for breakthrough pain. In the afternoon on
post-operative day 3, he was found to be somnolent, with an
oxygen saturation of 87% on room air. His other vital signs
were unremarkable and his oxygen saturation improved to
92% on 2 liters of oxygen by nasal cannula. His afternoon
dose of extended-release morphine was held by the primary
nurse who notified the surgical resident on duty.
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Case: A Lot of Pain (3)
The patient did well until 3 hours after the dose was held,
when he became more alert, complained of 10/10 pain in his
post-surgical leg, and had tremors and diffuse muscle
spasms. The nurse treated symptoms with hydromorphone 6
mg orally and 1 mg intravenously per the prescribing orders.
The surgical resident evaluated the patient and requested
the extended-release morphine be given for ongoing severe
pain. The nurse, reluctant to administer this medication in
light of the patient's somnolence, attempted to explain this,
but the resident insisted the medication be administered.
Since the patient was writhing in bed with muscle spasms,
the resident prescribed diazepam 5 mg intravenously (a
muscle relaxant the patient had not been previously
prescribed).
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Case: A Lot of Pain (4)
Approximately 5 minutes after diazepam was given, the
patient turned pale, became minimally responsive, and was
found to have a respiratory rate of 5 breaths per minute. A
code blue was called for opioid and benzodiazepine
overdose. The patient responded well to intravenous
naloxone (an agent that acutely reverses effects of opioids)
and increased oxygen by non-rebreather mask. He was
transferred to the ICU for ongoing monitoring and treatment
with naloxone. He was found to have new acute renal
insufficiency, which likely had contributed to a build-up of
opioids, enhancing their effects. He recovered well and was
transferred back to the surgical unit 3 days later. He was
ultimately discharged without any long-term effects.
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Adverse Events With Opioids
• Opioids are among the top causes
of drug-related adverse outcomes
in hospitalized patients
• Opioid overdose (the most serious
adverse events) may occur in
0.2%–4% of those exposed to
opioids in the inpatient setting
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Predictors of Opioid-Related Adverse Events
• Patient-related factors
– Age
– Obesity
– Renal or hepatic failure
– Sleep apnea
– Chronic obstructive pulmonary disease
• Prescribing-related factors
– High doses (in particular > 100 mg oral morphine
equivalents per day)
– Co-prescribing of other sedating medications
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This Case
• This patient had several risk factors placing
him at risk for an adverse events
– Opioid doses in excess of 100 mg of morphine
equivalents
– Use of multiple opioid drugs
– Co-prescription of other sedating medications
(diazepam)
– Renal failure
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Opioid Overdose
• The prescribing phase of the medication-use
process contributes most to opioid overdose
• Improper monitoring is the second most
common contributor
• This would suggest multi-modal initiatives
aimed at improving prescribing and
monitoring may have the highest yield
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Joint Commission Recommendations
• In 2012, The Joint Commission issued
recommendations for safe use of opioids in
hospitals
• For prescribing, they recommend a
combination of education, use of information
technology, and oversight and consultation
with pain specialists
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Use of Information Technology
• Information technology can be harnessed
in a number of important ways:
– Support desired prescribing practices
– Build alerts for unsafe prescribing
– Provide conversion support to ensure the
calculation of correct doses
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Pain Management Specialists/Pharmacists
• Consultation with pain management specialists or
pharmacists is recommended when:
– Converting from one opioid to another
– Changing route of administration (i.e., from oral to intravenous or
oral to transdermal)
– Using high-risk opioids such as methadone, fentanyl, and
intravenous hydromorphone
• Other scenarios should prompt consideration of consultation
with an expert:
– Uncertainty about prescribing decisions
– Difficulty achieving adequate analgesia
– Suspected addiction
– Managing opioids in a patient with risk factor for an adverse event
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Prescription Drug Monitoring Program
• The Prescription Drug Monitoring Program (PDMP) is an
additional resource that can improve opioid prescribing by
doing the following:
– Assisting with outpatient opioid dose confirmation
– Identification of potential addiction/misuse/diversion
• PDMPs are state-run databases that track all pharmacy
dispensing of controlled substances
• Studies have shown that PDMPs can influence prescribing
in primary care and the emergency department
• Hospitals should work toward linking PDMPs to electronic
health records so the information is easily available
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Monitoring Patients
• To improve monitoring, The Joint Commission
recommends serial assessments of
respiration and depth of sedation
• Institutions should also use pulse oximetry
when indicated to monitor oxygen saturation
– Should be considered when increasing the dose,
changing from one opioid to another, or in
patients with risk factors for adverse events
– Although it should be noted that oxygen
saturation can be falsely normal if patients are
receiving supplemental oxygen
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This Case
• The case illustrates many common errors in opioid
prescribing for acute pain in a hospitalized patient on
chronic opioids
– A distinction should have been made between his chronic pain
and the acute pain
– Using hydromorphone instead of morphine likely contributed
– Doses should have been reduced in the setting of renal failure
– Benzodiazepines should generally be avoided in patients on
opioids
– Consultation with a pain management specialist may have
prevented these prescribing errors and the adverse event
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Take-Home Points
• Taking a thorough history regarding the nature of the pain,
and differentiating acute from chronic pain, is crucial in
directing optimal treatment and monitoring of response
• Always combine opioid and non-opioid analgesics to
maximize analgesia and reduce opioid requirements. For
acute pain, use immediate-release opioids to allow dose
titration, preferably via the oral route, starting at a dose of
approximately 10%–20% of the patient's total baseline opioid
requirement. If changing to a different opioid, use a dose
25%–50% lower than the calculated equianalgesic dose
• Most opioids, with the exception of fentanyl, need to be dose
reduced in the setting of renal failure
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Take-Home Points (2)
• Avoid co-prescription of other medications with sedating
properties—particularly benzodiazepines
• Consider consultation with a pain management specialist for
patients at high risk of an opioid-related adverse event, or in
situations of uncertainty or suspected addiction
• Hospitals should work toward integrating Prescription Drug
Monitoring Program information into physician workflow when
prescribing opioids
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