Sanju Eswaran Blue 8- Year 6 Internal Medicine PAIN MANAGEMENT: ASSIGNMENT Joel Appel, D.O.?Director Ambulatory and Subinternship Programs Wayne StateUniversity School of Medicine Specific Learning Objectives Knowledge: Consider pathophysiology in theetiology of pain?Describe nociceptiveversus neuropathic pain syndromes Understand WHO analgesic ladder for use ofopioid therapy Use adjuvant (non-opiate) therapy when indicated?Manage or prevent complications of pain medications Skills: Perform a history and physicaldirected at manifestations of pain Utilize pain assessment tools?Calculate equianalgesic doses of opiates Psychosocial: Use of empathy and compassionin dialogue with patient in pain Understand impact of pain on patient as awhole Case 1: A 55-year-old female isadmitted directly to the hospital from her primary care physician’s office witha history of progressive onset of pain. The chart review indicates a history ofinvasive ductal cancer of the right breast 3 years earlier. A lumpectomy wasperformed. She had received adjuvant chemotherapy for 16 weeks after thediagnosis.
She then received chest irradiation. She had no other active medicalproblems. What would be essentialinformation you would need to elicit in the history? Information that would be important to elicit in the history wouldinclude be the onset of pain, location of pain, duration of pain, timing ofpain (i.e. time of day), characteristics of pain, alleviating and aggravatingfactors of pain, other associated symptoms (review of symptoms), radiation ofpain, and severity of pain.
Other factors that are important to address if anymedications were taken for the pain, if she had this pain before, how the painhas changed over time, and how the pain affects her daily living. What would be essentialinformation you would need to elicit on physical examination? Since cancer can be acomplicated and complex diagnosis and can present in numerous ways, it isimportant and vital to do a full and complete head-to-toe physical exam. Forexample, beginning by inspecting the skin and body for obvious deformities orvisible masses can be a good initial step. Then palpating for masses ortenderness can be important, whether in the lymph nodes or thoracic/abdominalcavities. Since several cancers can metastasize to boney structures, it isimportant to evaluate the extremities and spine as well for tenderness. Ascancer can commonly metastasize to the lungs, it is imperative to do a full andcomprehensive lung exam. Another common location for cancers to metastasize isthe neurologic system, both centrally and peripherally; assessing cranialnerves as well as peripheral nerves/extremities is important.
Lastly, it isimportant to look at vitals including blood pressure, heart rate, temperature,and respiratory rate as pain associated with cancer can impact all of thesereadings. Your MS III has accompanied you at the bedside. You initiate aparenteral short acting analgesic, and the patient appears at least transientlymore comfortable and can elaborate further. She had noted discomfort in herback and hips that began 5- 6 weeks earlier. She initially thought that she mayhave been overactive with her exercise regimen. She took non-steroidalanti-inflammatory medication with initial relief, but the pain becameprogressively worse. On this day, she describes it as 9 on a 0-10 scale. It ispresent in the mid-back and both hips, the right greater than the left.
Shedescribes it as a deep, boring ache that is worse with activity and alleviatedsomewhat by rest. It is continuous. You would like your student to ask furtherquestions to assess the psychosocial implications of this pain. What featureswould you expect her to cover?Psychosocial implications of pain are important to address, especially inthe setting of cancer. Some examples of items to address to cover psychosocialassociations include the following: understanding what the patient thinks hercause of pain is and how the pain is produced in her case, assessing what the patientbelieves will help her pain, how the pain is dealing with pain now, and how thepain is affecting her wellbeing, mood, activities of daily living, work, andfamily/social life.
In the context of psychosocial implications, it is alsoimportant to assess the patient’s cultural understanding of pain and causes ofpain/illness, evaluate for depression and anxiety (using SIGECAPS and GAD-7scoring systems), the patient’s fears, patient’s priorities, approaching death,support system, and family history. Lastly, it is important to appraise thepatient’s access to resources such as housing, insurance, financial issues, spiritualresources, the ability to get medications and access facilities, hospitals, andthe healthcare system. Your student asks youabout the clinical manifestations of nociceptive pain versus neuropathic pain.How would you contrast these two syndromes? Neuropathic pain and nociceptive pain are the two importantpathophysiologic classifications of pain. Neuropathic pain results from theinjury of nerves, whether it be in the central or peripheral nervous system.The pain that results from nerve injury can be described as stabbing, sharp, orburning in nature; it can additionally be described as pulsatile or “shock-like”.On the other hand, nociceptive pain is pain that results from noxious stimuli,including thermal, mechanical, and chemical insults, which can include bothsomatic and visceral pain. The pain is typically described as dull and achy innature if it is visceral and sharp and cramping if it is somatic in nature.
Additionally,the location the pain originates from differs in visceral and somatic pain asvisceral pain originates from abdominal and thoracic organs versus somatic painthat originates from skin, muscle, and bones. What would be the most likely etiology of her pain syndrome? In this patient, the most likely cause of her pain is nociceptive somaticpain as a result of metastases to the bone. Given the above information, how would you approach this patientpharmacologically? Pharmacologically, I would approach thepatient’s moderate to severe pain initially with short-acting opiates morphine,hydromorphone/hydrocodone, oxycodone, or fentanyl. Since the patient’s pain hasbecome more severe and is unresponsive to NSAIDs, I think the use of narcoticagents can be warranted, whether it may be alone or in combination withnon-narcotic analgesics, such as Tylenol, aspirin, or NSAIDs. You initiate therapy with Morphine Sulfate at 10 mg IV q 3 hoursas needed.
Your patient has requested this 6 times over the next 24 hours. Whatwould be an appropriate oral dose to convert this patient to? 10 mg IV * 6 times= 60 mg IV/day à 180 mg/day ORAL Morphine Sulfate She is discharged on the above dose. An outpatient PET/CT scan washighly suggestive of bone metastases. One week later, when you happen to be onan ambulatory block in this physician’s office, she states that while she wasdoing well, in the last few days, she was requiring the medication at anincreased frequency, now averaging 30mg MSIR q 3 hours. What would bepharmacologic opiate options in this setting? Scheduled fentanyl patches (Duragesic patches), sustained/controlledrelease preparations of both morphine and oxycodone be used including, or methadonecan be used to treat the increasingly severe pain this patient has.
This can besupplemented with short-acting agents (for breakthrough pain). What additional non-opiate strategies might you employ? There are several non-opiate strategies that can be employed to helprelieve this patient’s pain including non-narcotic analgesics, such as NSAIDs,Tylenol, aspirin, or lidocaine patches. Other treatments for this patient’sbone metastases includes chemotherapy or radiation therapy. Additionally, sincethis patient is on an intense opiate/narcotic regimen, it is important toimplement a bowel regimen, such as daily Miralax. What additional psychosocial support might be useful? Psychosocial support is veryimportant to use for patients with pain, especially in the setting ofmetastases or poor prognoses.
Grief counseling or meeting with a psychiatristor psychologist can be helpful as the rate of psychiatric comorbidities is veryhigh in patients with cancer. Support groups or family meetings can also behelpful for patients with cancer. Some adjuvant types of support include socialworker/financial support to get access to medications and healthcare,transportation services, and spiritual/religious support.