H-A-L-D-O-L Spells Relief

Transcription

1 No Relevant Financial Disclosures H-A-L-D-O-L Spells Relief Novel Pain Management Strategies Bill Soares MD, MS Assistant Professor of Emergency Medicine UMMS-Baystate Put another way Decreased opioid Rx Not effectively filled the pain management void We may be driving people toward illicit substances 1

2 Goal of this talk Enhance ED based Pain Management: Incorporate Multimodal Pain Algorithms Utilize cutting edge techniques Still limit opioid use Goal of this talk Enhance ED based Pain Management: Multimodal pain algorithm Incorporate cutting edge techniques Continues to limit opioid use...for 3 patients in our remaining 24 minutes (7 patients per hour) 55 year old female who presents with 1 week R upper dental pain. Worse with chewing, swallowing OK Subjective fever, none currently Received Tylenol on prior ED visit, did not help Dental Pain in the ED Exam global poor dentition, multiple caries No facial swelling or e/o abscess Normal posterior oropharynx No trismus 2 million annual visits (1.5% ED visits) Up to 43% have received opioid pain medications On the other hand, 25% receive no outpatient pain prescription. 2

3 Step 1 Dental Block Standard of Care Fast, safe, effective Anesthesia for 8-12 hours Incremental pain relief for 24 hours or more Step 1 Dental Block Supraperiostial Block (single tooth block) Step 1 Dental Block Inferior Alveolar Block (hemi lower jaw block) Tricks of the Trade Appropriate needle Topical Medication Slow injection Distraction Step 2 Appropriate oral medications But I REALLY don t like needles I just want a strong pill 3

4 Step 3 Cutting Edge - Steroids But I really don t like needles and I am allergic to ibuprofen Can be used in isolation as anti-inflammatory medication Decreases post-op pain when take in pre-op setting Can be used to prolong the duration of dental blocks Step 3 Cutting Edge - Steroids Allergy to ibuprofen and has received dental block Single dose oral dexamethasone Allergy to ibuprofen and refuses block 5 day burst of prednisone Treat active infections (Penicillin) Caution in diabetics Summary Dental Pain 1 Dental block Use topical anesthetic, distraction, appropriate needle, slow injection 2 APAP and NSAIDS +/- antibiotics 3 - If unable to tolerate NSAIDS, consider steroids Single dose dexamethasone if block performed 5 day prednisone burst if no block 35 year old man, history of migraines, presents with headache Gradual onset, typical aura Unilateral, pounding headache with vomiting No fever, no neck stiffness. Afebrile No papilledema Normal Neurologic Examination 4

5 Headaches and Migraines 7% of men and up to 15% of women suffer from migraine headache Up to 50% receive parental opioids while in the ED One of the top 10 most common chief complaints to receive a discharge opioid prescription. Step 1: Antidopaminergic Metoclopramide (Reglan) Can give 10mg every 30 minutes up to 3 doses Does not need co-administration of diphenhydramine to prevent akathisia Can combine with NSAID, APAP Prochlorperazine (Compazine) Consider co-administration of benadryl to avoid akathisia. Step 1a: Haldol but I am allergic to Reglan, and I don t like how Compazine makes me feel Butyrophenone (droperidol) Strong Antidopaminergic 5mg IV (2.5mg IV if <70kg) Can be combined with NSAID / APAP Consider prolonged QTc Home medications Be aware of sedation Consider Adjuvants IV fluids APAP IV Maximize NSAIDs Consider Dexamethasone (prevent 1 in 6 recurrence) Consider Magnesium (low quality evidence) but doctor, I still have a headache, isnt there anything else? 5

6 Cutting Edge: Block Cutting Edge: Block Sphenopalentine nasal block Cutting Edge - Propofol cant you give me something to just knock me out? Propofol to achieve moderate sedation. quick response to physical stimuli 30-40mg bolus ( mg/kg) followed by 10-20mg every 3-5 minutes Cutting Edge - Propofol Summary Migraine 1 Antidopaminergic Agents Reglan (multiple doses), or Compazine, or Haldol Augment with other medications (APAP, NSAID, IVF, Dexamethasone, Magnesium. 2 Blocks Sphenopalentine 3 Consider Propofol Sedation goal, responds to commands, stimuli Comparable to sumatriptan, less recurrence. 6

7 44 year old female, history of depression, anxiety, fibromyalgia, gastroparesis with gastric stimulator, migraines, presents with epigastric abdominal pain and vomiting. She was taken off her opioid medications (morphine ER 30mg Q12 hours, percocet prn) by her PCP 1 week ago as they no longer prescribe opioids. Since that time, she has had worsening symptoms. Chronic Abdominal Pain / Gastroparesis PMH: 5 normal CT A/P this year PSH: Diagnostic Ex-Lap unrevealing 2 years ago Allergies: many Exam: normal Vital Signs, abdomen soft all quadrants. Abdominal pain is a top 5 chief complaint for ED patients 10-15% receive ED based opioid prescriptions. Patients with chronic abdominal pain and gastroparesis experience over-testing, frequent hospital admissions and extreme differences in pain management Step 1: Max out freebies Step 2: Consider HALDOL IV antidopaminergic / prokinetic (Reglan) APAP / NSAIDS Topical medications (carafate, maalox, simethicone) IV fluids 7

8 Step 2: Consider HALDOL I still have PAIN!!!! Help me! Help me! Nobody is listening to me!!! HELP!! HELP!! I want something to EAT! Euphoria Steady State Withdrawal Steady State No Opioids 8

9 Our Goal Dilaudid IV Dilaudid IV For patients on chronic opioids but cant take them due to vomiting Providing stabilization to allow them to take their home medications again. For patients experiencing withdrawal off opioids with opioid use disorder and pain, consider buprenorphine in place of IV opioid agonists (dilaudid / morphine). Cutting Edge: Buprenorphine Why Buprenorphine 1. You have come to a point where you are going to give some kind of opioid 2. It is a partial opioid agonist less respiratory depression 3. Ceiling effect - less euphoria than IV fentanyl, dilaudid, morphine 4. No DEA waiver if ordered for pain in ED. Cutting Edge: Buprenorphine Buprenorphine IV 0.3mg or 300 micrograms (equals 10mg Morphine) Peaks in 5 minutes, lasts 6-8 hours Sublingual start 4mg SL (equals 6mg Morphine) Peaks in 30 minutes, lasts 6-8 hours 9

10 Caution: Buprenorphine Must ensure last dose of any other opioid was long enough ago to avoid precipitating withdrawal. Short acting Opioids or heroin (6 hours) Avoid if patient taking methadone. In these patients, I will give back their methadone. Summary Chronic AP / Gastroparesis 1 Max out Freebies Reglan, IVF, APAP, NSAIDS, oral medications. 2 Haldol for gastroparesis Beware home medications that prolong QTc With vomiting, consider ECG 3 For patient with history of opioid use, address the opioid withdrawal Try to restart home opioids Consider buprenorphine instead of IV dilaudid Language I have used Addicts Drug seeking behavior Starts with D Histrionic Dramatic Frequent fliers Terminal Fibromyalgia 55 year old female who presents with 1 week R upper dental pain. Worse with chewing, swallowing OK Subjective fever, none currently Received Tylenol on prior ED visit, did not help 10

11 Returned to the ED twice that week, continued pain R upper dental, worse with chewing, subjective fever, each time received appropriate therapy (APAP/NSAID, block) and discharged with a diagnosis of dental pain. I saw her 1 week later on her 3 rd visit. She presented with continued dental pain. I saw her 1 week later on her 3 rd visit. She presented with continued dental pain. but also loss of vision in her right eye Ddx: Temporal Arteritis Pain as a Red Flag New, worse or very difficult to treat pain is a red flag Be aware of the bias and anchoring both that we have and that we project to our staff when treating difficult patients 11

12 To Review Standard of Care Dental Blocks for Dental Pain Multiple Dose Reglan for Headaches Maxing out Freebies for chronic pain prior to opioid medications To Review Innovative Pain management Dexamethasone to augment blocks Haldol for Pain Management (headaches, gastroparesis) Propofol sedation for status migrainosis Buprenorphine (IV, SL) for pain control in place of IV morphine and dilaudid References Binfalah, M., Alghawi, E., Shosha, E., Alhilly, A., & Bakhiet, M. (2018). Sphenopalatine ganglion block for the treatment of acute migraine headache. Pain Research and Treatment, 2018, doi: /2018/ Colman, I., Rothney, A., Wright, S. C., Zilkalns, B., & Rowe, B. H. (2004). Use of narcotic analgesics in the emergency department treatment of migraine headache. Neurology, 62(10), Friedman, B. W. (2017). Managing migraine. Annals of Emergency Medicine, 69(2), doi: /j.annemergmed Hoppe, J. A., Nelson, L. S., Perrone, J., Weiner, S. G., & Prescribing Opioids Safely in the Emergency Department POSED Study Investigators. (2015). Opioid prescribing in a cross section of US emergency departments. Annals of Emergency Medicine, 66(3), e1. doi: /j.annemergmed Maizels, M., Scott, B., Cohen, W., & Chen, W. (1996). Intranasal lidocaine for treatment of migraine: A randomized, double-blind, controlled trial. JAMA, 276(4), Moore, P. A., & Hersh, E. V. (2013). Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: Translating clinical research to dental practice. Journal of the American Dental Association (1939), 144(8), Moshtaghion, H., Heiranizadeh, N., Rahimdel, A., Esmaeili, A., Hashemian, H., & Hekmatimoghaddam, S. (2015). The efficacy of propofol vs. Subcutaneous sumatriptan for treatment of acute migraine headaches in the emergency department: A double-blinded clinical trial. Pain Practice : The Official Journal of World Institute of Pain, 15(8), doi: /papr Okunseri, C., Okunseri, E., Xiang, Q., Thorpe, J. M., & Szabo, A. (2014). Prescription of opioid and nonopioid analgesics for dental care in emergency departments: Findings from the national hospital ambulatory medical care survey. Journal of Public Health Dentistry, 74(4), doi: /jphd THANK YOU 12