Opioid tolerance complicates treatment of acute pain, but hospitalists have to know how to ameliorate acute pain in patients who are already on opioids, Molly A. Feely, MD, FACP, told attendees at the Internal Medicine Meeting 2019 hospital medicine precourse.
“Patients with chronic pain need appropriate pain management, too,” she said. Dr. Feely, who is an assistant professor of medicine and program director of the hospice and palliative medicine fellowship at Mayo Clinic in Rochester, Minn., noted that her “Pearls for Pain Management in the Opioid-Tolerant Population” apply only to chronic pain patients whose acute pain is expected to resolve, not to cancer patients with progressive pain.
The first challenge in treating these patients' pain is evaluating it. “How many of you are frustrated by pain scores?” she said to laughter from the audience.
Pain scores are not designed to be compared across patients, but they can be helpful to assess patients' current pain in light of their previous reports. “When you look at individual patients, their pain scores have consistency over time,” said Dr. Feely. “How many of you have patients who are at 8, 9, or 10 all the time? I have lots of those patients. I think ‘Great!’ [if] today's an 8. That's a good pain score day for that patient.”
This understanding should also guide pain goals, which can be based on patient perspectives but must also be realistic. “If he tells me that he's hoping for a 3, but he's only been at an 8 for a year and a half, we need to set expectations,” she said. “Our inpatient goal should be consistent with that which we have achieved in the outpatient setting.”
To add some objectivity to a patient's pain scale report, use functional assessment. “Our assessments of people's pain should be both subjective and objective, and functional assessment is the primary objective source we use to help us form an opinion about how we're doing managing someone's pain,” said Dr. Feely. “Is he able to get out of bed? Is he able to walk the hallways? Those are clues that we should be looking for.”
Don't assume that a patient's pain is controlled based on her normal vital signs. “The presence of the chronic pain over time blunts their sympathetic response to pain,” she said. “They may not mount a tachycardia response; they may not mount a hypertensive response; they may not mount a sweating response to acute severe pain.”
To treat pain once it's been assessed, consider patient-controlled analgesia (PCA). “Believe it or not, for the majority of patients who have chronic pain, PCAs are actually a pretty good way to manage acute pain problems in the hospital,” said Dr. Feely. “It gives them some control and avoids some of the battles between patients and nursing staff on whether or not they truly have pain or not.”
There are also a number of alternative pain treatments that can potentially reduce the need for opioids. Although gabapentin may be useful, particularly for chronic abdominal pain, there are limitations. “The problem with gabapentin is you really do have to start low and you have to go up slow because they can get side effects, predominantly somnolence. . . . You're not going to have enough time for gabapentin to get to the therapeutic range before his acute pain is gone,” said Dr. Feely.
Pregabalin may be a better option, because it works the same way gabapentin does but with fewer side effects. “You can uptitrate it much more quickly than you can gabapentin,” she said. “I tend to double it every day. I tend to start at 25 b.i.d., then 50 the next day.”
Cognitive behavioral therapy is another effective pain treatment that has too slow an onset to control inpatient pain. “The skills require practice. By the time the patient has a good grasp of the skills involved in cognitive behavioral therapy, their acute pain is probably gone,” said Dr. Feely.
“However, there are lots of other things you can utilize your clinical nurse specialists for,” she added. Acute pain can be reduced by relaxation techniques, music therapy, or massage, among other options. “I'm probably the only person in the room who can actually get acupuncture in a hospitalized patient, but if you can get it, it's also helpful for managing acute pain,” Dr. Feely said.
Finally, don't forget acetaminophen and NSAIDs in their various forms. Both drug classes “actually decrease the use of opioids if they're used consistently and continuously,” she said. “Schedule them.”
Acetaminophen can be dosed in an IV, but very expensively. A more useful alternative route may be topical NSAIDs, provided there are no contraindications. “They come as a gel and patch formulations. I tend to use the patch almost all the time because the gel has to be massaged in for a minute to two minutes for it to be effective,” said Dr. Feely.
When patients have been treated and it's time for discharge, the goal for most should be to go home on the same regimens they came in on, if possible, she advised.
“When they're having an acute issue in the hospital is not the time you want to go about changing around their chronic pain regimen, even if you don't entirely agree with their chronic pain regimen, provided it is safe,” said Dr. Feely. “There's no need to switch them around to a bunch of different opioids.”
Some patients will, of course, have ongoing acute pain, and in those cases, the hospitalist should prepare them for later weaning. “For example, ‘You've just had hip fracture surgery. We expect in two weeks for your pain to be significantly improved. When you follow up with your primary care provider, they're going to start the weaning process of getting you back on your normal regimen,’” said Dr. Feely. “You're setting the outpatient providers up for success.”