Yale 20: Non-Opioid Pain Management

June 12, 2024

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00:00Hi everyone, my name is Julia Joseph.
00:04I'm a current third year internal medicine
00:06resident at Yale New Haven Hospital.
00:08I created this video with the help
00:09of our palliative faculty member,
00:11Doctor Persik in order to
00:13discuss non opioid pain options,
00:15especially from an inpatient perspective.
00:17I remember being an intern,
00:19especially on nights, and not having
00:21an idea of what the options were to
00:23treat pain before reaching for opioids.
00:25So hopefully this will
00:27help build a framework.
00:29We will first start with a case,
00:31then go over basic principles,
00:33dive into the non opioid pain options before
00:37concluding with our case and learning points.
00:39So we'll start off with a familiar situation.
00:42Imagine you're the overnight intern
00:44and you get woken up with a page.
00:46Hey doc patient in room 5 two
00:48O 8 is having a lot of pain.
00:50Can you give him something?
00:52What do you do?
00:55One acronym that can be helpful
00:57to assess pain is OPQRST,
00:59which many of you may have
01:01been taught in medical school.
01:03It will remind you to ask about the onset,
01:05the provoking factors,
01:07the quality of the pain,
01:09whether the pain radiates anywhere,
01:11the severity of the pain,
01:13and the timing and duration of the pain.
01:19As you gather this information,
01:21it's helpful to classify the type of pain.
01:23There are several types of pain syndromes,
01:26but I've included three major types
01:28of syndromes that you may encounter.
01:30No sceptive pain is pain that arises
01:32from the activation of no sceptors due
01:35to a pain impulse that was detected
01:37as demonstrated here. For example,
01:39when you stick your hand on a nail,
01:41the no sceptors transduce the
01:43signal back to your brain which
01:45registers the painful impulse.
01:47Neuropathic pain is actual damage to
01:50the somatosensory nervous system.
01:51You will commonly see this in patients
01:53with long standing diabetes and have
01:55sustained nerve damage in their feet,
01:57for example.
01:58Finally, nosey plastic pain arises
02:01from altered perception of pain.
02:03While there's no evidence of tissue damage
02:05as you might see a nociceptive pain,
02:07they are experiencing pain from
02:10dysregulated sensory processing.
02:12You may see this in conditions
02:15like fibromyalgia.
02:16All right, so let's dive into
02:18our non opioid pain modalities.
02:21So the first medication we'll
02:23discuss is acetaminophen.
02:24Acetaminophen is very effective
02:26for mild to moderate pain,
02:28but can also help with severe
02:30pain when combined with opioids.
02:31It works by inhibiting prostaglandins,
02:34which decreases pain signaling
02:36and tamps down fevers.
02:37IV Tylenol has the same efficacy
02:39as rectal and oral Tylenol,
02:41but works quicker.
02:42It can be hard to get approved
02:44though because of the higher cost.
02:46Rectal and IV administration can
02:48especially be useful for patients
02:51at end of life or patients who
02:53can't take oral Tylenol safely.
02:54The absolute Max that's recommended
02:57is 4G a day,
02:58but for those patients who have a history
03:01of cirrhosis or chronically used Tylenol,
03:03you should really consider a reduced
03:06maximum of two to three grams per day.
03:10You should be careful when keeping
03:12a patient on scheduled acetaminophen
03:14when you want to avoid masking fevers,
03:16such as when you are taking
03:18care of neutropenic patients.
03:19You should also be careful prescribing
03:21too much acetaminophen and patients
03:23who are at risk of accumulating
03:26the toxic metabolite nap Qi.
03:27These include patients with low glutathione
03:30stores like malnourished patients,
03:32patients with ongoing alcohol use,
03:35or patients who are on medications
03:37that are CYP 450 inducers.
03:41Acetaminophen,
03:42as you can see here, gets metabolized
03:44to nap Qi by the CYP 450 enzyme.
03:47So you can imagine that if you
03:49have medications that Rev up the
03:51activity of the CYP 450 enzyme,
03:53you will then accumulate more nap Qi.
03:56You also need glutathione in
03:59order to inactivate nap Qi.
04:00So in patients who are malnourished
04:02or don't have enough glutathione
04:04stores you can imagine then you will
04:06have more accumulated nap Qi that
04:08will lead to toxic liver damage.
04:12ENASAS are the next class of medications
04:15which have anti-inflammatory
04:16properties unlike acetaminophen.
04:18They work by inhibiting Cox enzymes in both
04:21the peripheral and central nervous system.
04:23Toradol is an example of a non selective
04:26NSAID while selecoxib is a Cox two
04:29selective NSAID by inhibiting Cox two.
04:31Selecoxib confers a degree of
04:35gastric protection by only
04:38working on the Cox 2 enzyme.
04:41Unfortunately,
04:41NSAID's overall have an increased risk of
04:44MIS and strokes as well as risk of AKI.
04:47The risk of AKI is particularly
04:49high in the 1st 30 days.
04:51Cox two inhibitors do have more GI
04:54protective effects but unfortunately still
04:55have the other serious side effects noted.
04:58In general,
04:58you should avoid in patients who
05:00are at risk of bleed,
05:01significant cardiac history or
05:03renal impairment.
05:07This is an NSAID reference table that you
05:09can pause if you'd like to learn more.
05:11The ones pointed out are some
05:12common NSAID that you may come
05:14across such as Motrin and Toradol,
05:16which you could see in the hospital,
05:17especially Toradol because it's
05:19a non selective NSAID that comes
05:21in IV or IM formulation. There's
05:23Meloxicam which is a relatively
05:25Cox two selective NSAID,
05:27although it has some Cox one activity.
05:29And then there's Sela Coxib which
05:31is a Cox two selective NSAID.
05:33Next, let's talk about some topical options.
05:36Diclofenac is a topical NSAID that
05:38can be used up to four times a day.
05:40You can use 2G for each upper extremity
05:42joint and 4G for each lower extremity joint.
05:45You should not use more
05:46than 32 grams in one day.
05:48The systemic exposure from gel form
05:50is on average 6% of the oral form.
05:53It carries the same risk profiles oral
05:55NSAID's, but it overall is better tolerated.
05:58Capsaicin cream is derived from
05:59Hot Chili Peppers and works by
06:01desensitizing no seceptive fibers.
06:03It can also be useful in neuropathic pain.
06:05You can dose up to four times a day,
06:07but it may take several weeks
06:08before you see an effect.
06:10Stinging and burning at the site of
06:12application has also been reported.
06:14Finally, lidocaine is an anaesthetic
06:16agent that comes in several forms.
06:18You can dose 3 patches of 5% lidocaine
06:21in one setting with a 12 hour on
06:23period and 12 hour off period.
06:25Systemic exposure is approximately
06:27less than 5% with this regimen,
06:29so systemic side effects are
06:31overall relatively rare.
06:34Gabapentinoids are the next class of
06:36medications that we'll talk about.
06:38They were initially developed as
06:40anti seizure agents because they
06:41suppress neuronal excitability by
06:43working on voltage gated calcium
06:45channels as shown in this diagram.
06:47They can also be used to
06:50treat neuropathic pain.
06:51These are both commonly used gabapentinoids.
06:54Pregabalin is more potent and more
06:57predictably absorbed than gabapentin.
06:59Peak blood concentration occurs
07:01within an hour of taking pregabalin,
07:03but can take approximately
07:053 hours with gabapentin.
07:07Due to being a scheduled
07:09class 5 controlled substance,
07:10Pregabalin is not as easy to
07:14prescribe as gabapentin.
07:15When prescribing pregabalin,
07:16you can start at 50 to 150 milligrams a day,
07:20usually in two to three divided doses.
07:23From there,
07:24you can up titrate every week
07:25to a maximum of 300 to 600
07:28milligrams per day in two to three
07:30divided doses to reach effect.
07:32With gabapentin,
07:33you can start at 300 milligrams every day,
07:36usually in three divided doses.
07:38You can up titrate to a maximum of 3600
07:42milligrams every day to reach effect
07:46CNS. Depression is a common
07:49problem with gabapentinoids,
07:50especially when used alongside opioids.
07:53Toxicity can especially be seen
07:55in patients with renal impairment,
07:57so be cautious in those with Akis or
07:59history of CKD if stopped suddenly.
08:02Withdrawal syndromes have been
08:03described with gabapentinoids similar
08:05to alcohol and benzo withdrawal,
08:07including seizures.
08:08So in admitting a patient on
08:10high doses of these medications,
08:12be careful not to stop them immediately
08:15to avoid precipitating withdrawal,
08:16which can occur within 12 hours to
08:19seven days after discontinuing.
08:22The last
08:23non opioid medication we will discuss
08:26is duloxetine, a type of SNRI.
08:29Of all antidepressants,
08:30duloxetine has the largest evidence
08:32base to support its use in pain relief.
08:35It has been FDA approved for several
08:37types of pain syndromes but unfortunately
08:39comes with several noted side effects.
08:41As listed here.
08:42You can start duloxetine at 20 to 30
08:45milligrams a day for one week and then
08:47from their up titrate until receiving
08:49a maximum of 60 to 120 milligrams.
08:51You should see pain improvement as early
08:54as the first week of implementation.
08:56You can especially consider SNR is
08:58like duloxetine for those patients
09:00who have comorbid depression and pain.
09:05Easy measures that can be implemented
09:07and that are often forgotten in the
09:09inpatient setting include using heater ice,
09:11physical therapy to help with mobility,
09:14and using foam support or
09:16pillows to help with elevation.
09:18Now let's get back to our case.
09:20You were the overnight intern
09:22paged about a patient's pain.
09:24You do a quick chart review and note
09:26your patient has a history of type 2
09:27diabetes and is on a blood thinner.
09:29Their labs are otherwise unremarkable.
09:32Your sign out says that he
09:34responds to Oxy at bedside.
09:35Your patient tells you that he is
09:37having burning pain in his feet that
09:39is making it hard for him to sleep.
09:41He already received 650
09:42milligrams of acetaminophen.
09:44That didn't seem to help.
09:46So what can you do?
09:48You determine that this is a
09:50neuropathic pain syndrome based
09:51on the patient's description.
09:52You can give additional acetaminophen
09:55or trial topical agents,
09:57but given that this is likely
09:59underlying peripheral neuropathy,
10:00you could consider trialing a low dose
10:02gabapentinoid or switching to duloxetine,
10:04especially if he's already on an SSRI.
10:07In this case you should avoid ENSAES,
10:09especially because he's on a blood
10:11thinner and opioids would not be
10:14first line in this pain syndrome.
10:16So to summarize,
10:17we discussed 3 pain syndromes
10:20including nociceptive,
10:21neuropathic and NOC plastic pain.
10:24OPQRST is an approach to assess pain.
10:27Acetaminophen should cautiously be used
10:29in patients with low glutathione stores
10:32and if they're taking CYP 450 inducers.
10:36NSAID's can be non selective
10:38or Cox two selective,
10:39but overall their use can still be
10:41limited by several side effects.
10:43Topical options that we talked
10:45through include diclofenac,
10:46capsaicin and lidocaine.
10:47Gabapentinoids including
10:48pregabalin and gabapentin can
10:51be useful for neuropathic pain,
10:53and duloxetine is an SNRI that
10:56also has pain relieving properties.
10:59And if you're interested,
11:00here are the many sources
11:02that I used for this talk.