How to Order a Pain Regimen

[0:00]So your patient's in pain. What are you going to do about it, doctor? This is a question you're going to get asked all the time, and let's go over the options that are available to you. We're going to be talking about Tylenol, we're going to be talking about Nsaid, lidocaine patches, capsaicin cream, diclofenac gel, opioids, ooh, and neuropathic pain treatments, methadone, ketamine, buprenorphine, and then some miscellaneous stuff. All of that's going to be what we're doing going to discuss today in this video. So when a patient is coming into the hospital, I basically put everybody on 650 milligrams Q4 hours as needed of Tylenol. Or you can do 1,000 milligrams every 6 hours as needed. The max Tylenol or acefin that you can give for patients is 4 grams per day in normal patients. And if they have cirrhosis or they've got liver dysfunction, they can still get Tylenol, but your max is going to be about 2 grams a day instead. You really don't start to see toxicity until you get to about 10 grams of Tylenol in one day, so that's just a good reference for you that even when you're giving them the max amount of 4 grams a day, they're still pretty far from that level that causes toxicity. You will see in the hospital that some people refer to Tylenol as AP, but I think they're crazy. AP is an error prone abbreviation based on this journal article that I read, and basically it causes a lot of confusion for patients. So I think we should stop saying AP and just say Tylenol or acefin. I like that better. For patients who are in a lot of pain, consider scheduled doses instead of PRN doses because they're going to miss their doses if it's all PRN. So it's really useful to have scheduled Tylenol if they're continually having pain and basically using their PRNs all the time. That just makes sure that they're not going to miss any. Oral and rectal Tylenol are good routes. IV is also good, but the hospital doesn't really like you using it too much because it's quite expensive, at least at UC Davis. Your next line of defense is going to be the NSAIDs, but really I try to avoid them because people don't like using them because of the risk of GI bleed or AKI, especially in the hospital. But if you need to, they're definitely available if your patient's not at risk of these two conditions. So Ibuprofen, also known as Motrin or Advil, usually we go for 400 to 600 milligrams orally every 6 to 8 hours. Personally, I like 400 milligrams because the evidence seems to show that it has the same analgesic effect, and as you go higher, you only increase the risk of side effects, but not the benefit of pain control. Naproxen is known as Aleeve, and the main advantage of this one is it can be dosed every 12 hours. But it's got a higher risk of GI bleed, so not something we typically give in the hospital. Ketorolac or Toradol is something you will use in the hospital. It's got IV and IM forms available, which is one of the really key reasons it's so useful, very useful in patients with nausea and that they can't tolerate oral medications. Very, very commonly used in patients with kidney stones. The downside of Toradol is it's got the highest rate of GI bleed. Indomethicin again, something you're probably not going to see too much in the hospital, but it's commonly used in gout. Next, we have Celecoxib or Celebrex, and this was avoided for a very long time because it was shown to have a higher rate of developing cardiovascular events or clots and stuff like that. But newer evidence actually does not show an increased risk of heart attacks or ischemic events, and it may actually have a lower risk of GI bleed compared to the other NSAIDs. So I actually feel like we might start seeing this more going forward, although I've personally never ordered this yet. The next very useful thing to consider is a lidocaine patch. You know, you're going to get patients with musculoskeletal pain all the time, and a lidocaine patch, just slap that bad boy on there. I don't know if it really works, if it's just placebo, but it's a good option to try. So you can give them up to three patches. They're placed and removed every 24 hours. The only thing about them is it's hard to get them as outpatient because there's a lot of insurance coverage issues, but it's very good while they're inpatient. Capsaicin cream, one of my faves. So some patients like it, but others don't like the burning feeling. Basically, what it does is it binds to noseceptors in the skin and causes initial excitation and enhanced sensitivity, but then there's this refractory period where there's reduced sensitivity and persistent desensitization, that's possibly due to the depletion of substance P, okay? This is most effective for osteoarthritis, we use the 0.025% cream for that, and then also for neuropathic pain where we use the stronger concentration of 0.075% cream, which is not available at UC Davis, unfortunately, and then cancer-related pain. There's a couple of trials that I linked here showing the evidence behind capsaicin cream because I was kind of like, you know, some of my patients liked it, but I'm not really sure if the evidence was that strong for it. But in this double-blind trial, 80% of patients with osteoarthritis had reduced pain after two weeks, and then this trial showed that there was efficacy, but it only had moderate to poor efficacy. And then there's high reports of burning and redness, but patients who started on capsaicin cream and even though they had all those side effects, they continued to take it even despite those side effects because they had very significantly decreased neuropathic pain. So, it's a good option to try. Just make sure you warn your patients beforehand that, you know, this might cause some burning. We've got diclofenac gel, which is an Nsaid, but it's just applied topically. So, we do a 1% gel up to four times daily. It's often used in osteoarthritis. The 3% gel is for actinic keratosis and not for pain, so don't order that because I accidentally ordered 3% gel for one of my outpatients and the pharmacist had to contact me about that. And the great thing about this is it's got low systemic absorption, so any of those side effects that you were worried about with your oral Nsaids, not going to have to worry about as much with the diclofenac gel. Now, let's get to the big boys, the opioids, okay? We're going to start with Tramadol here. It's a partial mu and serotonin receptor agonist. The side effect that you really need to be aware of is a lowered seizure threshold, and it's really pretty grossly falling out of favor because patients have very, very variable responses, so you can never predict how well a patient's going to tolerate the drug. It's also got the lowered seizure threshold, so it's just not great overall. A typical dose for this would be 50 milligrams every 4 to 6 hours as needed. Oxycodone, pretty commonly used in the hospital. I like to usually start with a 5 milligram dose while a patient is admitted, but if they're elderly or very small, we'll start with 2.5 milligrams. The onset occurs within 10 to 30 minutes and it lasts 3 to 6 hours. And then there's an extended release version called OxyContin, which lasts for 12 hours. Next, we move on to the big D, the dilaudid, okay? Hydromorphone. This is the one that patients are going to request all the time, and the reasons they like it, it's it's got a more rapid onset of analgesia, which can produce more euphoria. So, dilaudid makes people feel good, and that's why they request it. The main thing you need to know for this one is it's metabolized by the liver, so don't give this in patients with liver dysfunction. The next option is morphine, which is good for air hunger, good for decreasing anxiety. Typically, we see this a lot in patients that are going on hospice or going on comfort care. That's primarily where you're going to see morphine being used. There's a liquid version called roxanol, there's an extended release version called MS Contin. And this one is metabolized by the kidney, so don't give this in patients with kidney dysfunction. Then we've got meperidine or Demerol. This is useful in patients with pancreatitis because it's thought to have decreased spasms of the sphincter of Odd, which allows, you know, all that pancreatic inflammation to drain out. This is also something that's useful in patients with rigors. Common outpatient meds you'll see patients coming in with and which you can continue while they're inpatient if this is something they're using pretty frequently include hydrocodone, acetaminophen, which is Norco, oxycodone, acetaminophen, which is Percocet or Vicodin. Those are some pretty common medications you're going to see. Make sure that everybody on opioids has an opioid overdose order set, which includes naloxone or Narcan for reversal if needed. Make sure everyone on opioids has a solid, solid bowel regimen, at least Miralax and Senna, okay? Constipation is very common. And then finally, I like to go on Google and look on this conversion chart to see dosing equivalents when I'm switching from hydrocodone to oxycodone or oxycodone to morphine or oxycodone to dilaudid. That's a very common one that we do. Just go on Google, look for opioid conversion charts, and that will help you figure out what the equivalent doses are between each of the different opioids. Next, we're going to talk about some neuropathic pain treatments. You've got patients with tingling sensations everywhere or burning pain, stuff like that. You got to remember, there's two main different types of pain, you've got neuropathic pain and nociceptive pain. And the neuropathic pain that's burning and tingling and shooting down their leg does not respond well to opioids. Your options for this include some of the SNRIS like duloxetine and venlafaxine. You've also got gabapentin or Neurontin, and then you've also got tricyclic antidepressants. Typically, if somebody's having pain while inpatient, the first one people reach for is gabapentin, but I think the evidence for the SNRIS might actually be better. TCAs, typically not something you're going to start while somebody's inpatient. Too many side effects, just too dirty of a drug, but gabapentin and the SNRIS definitely something to think about in patients with neuropathic pain. Methadone is a drug that's used in patients who are trying to wean off of opioids, long-acting. The things you need to know about it is that IV methadone has QT prolongation, whereas the oral version does not have QT prolongation. Ketamine, consult pain pharmacy, you crazy person, which on that note, if anybody's having a very, very complicated pain regimen and, you know, it's just very hard to control their pain, always good to put a pain pharmacy consult in because they will help you out a lot. Ketamine is gaining popularity as an opioid-sparing pain medication. And then we've got buprenorphine, which is also gaining popularity. It's a partial agonist of the mu receptor, meaning it acts as an agonist when there's no opioid around, and then when there is an opioid around, it becomes an antagonist. So, you use some illegal opioids, bam, you're blocked, okay? You're not using anything, okay, we'll give you a little bit of that, like, pain control, that kind of comforting feeling, but you use something illegal, you're getting blocked, and that's that's why this is so great. And that's why it's getting so much popularity. It also reportedly has a lower risk of respiratory depression compared to traditional opioids. So something I'm still not super familiar with the dosing, and usually I'd probably contact pain pharmacy for, but I think this is something we're definitely going to be seeing more as we move forward. And then finally, I've just got a bunch of little, quick, little miscellaneous things you can try, you know, we've got a lot of patients on chemo and they've got mouth pain, they've got ulcers, try the lidocaine swish and swallow. For painful foleys, you've got this Eurojet, which is a lidocaine gel that they can coat around the foley, and that might help out a little bit. For pain related to localized swelling, always good to try a warm compress or a K-pad, which is how it, you know, it'll show up in the epic EMR. Muscle relaxants, let's talk about those really quickly. So, that includes baclofen, cyclobenzaprine, tizanidine, they all basically work just by making you sedated and sleepy. At least from what I've heard, I'm sure they do have some muscle relaxing effects, but basically it just knock people out, and that's why they feel better. Baclofen, I've learned, is something you should really only use for central spastic disease. So, they have like a brain lesion that's causing them to have like muscle spasms. It's really not a great drug. Also, a big thing while patients are admitted is you should look out for baclofen withdrawal, which really looks like alcohol withdrawal, has a risk of seizures, etcetera. And on that note, also look out for gabapentin withdrawals, too. And then finally, like I mentioned before, don't forget to make use of consult services, pain pharmacy consult and wound care consult, especially if there's like some sacral wound that's consistently causing pain, you know, just getting some better wound care can often really improve patient's pain. All right, so that's my approach to pain while patients are in the hospital. I hope that gave you some brand new ideas that you can try out. I hope you slap on that capsaicin cream on everybody. Next, we're going to be talking about how to approach headaches while patients are admitted to the hospital. Wait, I forgot. If you liked the video and it was found it helpful, then like, comment, and subscribe. Now you can go and click on that headache video. We're going to talk about how to deal with patients' headaches because a lot of times you're going to get page by headaches, and you'll be like, I don't know what to give other than Tylenol. What can I give this person for their headache? So, let's go talk about that. Click on this video right here, and I'll see you in that next video. Peace.