Partnership for Patients: NJ HEN 2.0 ADE Webinar Series

Alternatives to Opiates for Pain Management

May 10, 2016

Agenda Presentation

Alternatives to Opiates for Pain Management • Q&A • Upcoming Events

Hosted by New Jersey Hospital Association Soniya Sheth RN, MSN, CPNP

Presenter: Alexis LaPietra, DO

Medical Director ED Pain Management, St. Joseph’s Regional Medical Center,

New Jersey Hospital Association Webinar

lapietra@sjhmc.org

Alexis LaPietra, DO Medical Director ED Pain Management

St. Joseph’s Regional Medical Center New Jersey Hospital Association Webinar

May 10, 2016

The prescription opioid epidemic

Discuss opioid alternatives for acute pain Medications Modalities

Fun stuff too

1.9 million

94%

51

18,893

29,467

Newscientist.com 19Jan2016

0

1

2

3

4

5

6

7

1990 2005 2010 2015

Death Rate Prescription Opioid OD

1990-2015

White Drug OD AA + Hispanic OD 0

1

2

3

4

5

6

7

1983 1986 1989 1990

Death Rate HIV-AIDS

1983-1990

HIV-AIDS

1990 1995 2000 2005 2010 2015

Opioid Rx Habits vs. Rx Opioid OD Deaths

Rx opioid DEATHS Rx Opioids

Vicodin has been the #1 dispensed

prescription for the past 6 years.

168,000 adolescents between 12-17 years old are addicted to prescription opioids

American Society of Addiction Medicine 2016

Europe 11.4%

Canada 0.6%

5% of the world’s population consumes

56% of the worlds opioids

USA 5.1%

Dalal 2013

Addiction

Acute Pain

Feel Better

Opiates Alternatives

……but they are not the solution for all pain

THINK before you prescribe

USE alternatives whenever possible

CARE about the patient

“ALternatives To Opiates” St. Joseph’s Regional Medical Center

Multi-modal non-opiate approach to

analgesia for specific conditions

The goal is to utilize non-opiate approaches as

first line therapy, and educate our patients. Opiates will be second line treatment

Discuss realistic pain management goals without

patients

Discuss addiction potential and side effects with using opiates

Family Medicine

Physical therapy

Pain Management

Eva’s Village Peer Counselors

Straight & Narrow

Prescription Opioid

Overdose Prevention and Naloxone Distribution Program

COX-1, 2, 3 inhibitors

Nitrous Oxide

Inflammatory Cytokine Inhibitors

NMDA Receptor

Antagonists

Sodium Channel Blockers

GABA agonists/modulators

NSAIDs and Tylenol

Nitrous Oxide

Corticosteroids

Ketamine

Lidocaine and

Ropivacaine

Benzodiazepines Neurontin

How can we apply this?

Renal Colic

Lumbar Radiculopathy, acute on chronic

Acute Headache/Migraine

Musculoskeletal Pain

Extremity Fracture/Joint Dislocation

Toradol 30 mg IV 1 L 0.9% NS bolus

Tylenol 1000 mg PO

Cardiac Lidocaine 1.5 mg/kg in 100 mL NS over 10 minutes MAX 200 mg

Intractable oncological pain Improved pain with fewer side effects, compared

to opiates alone Little to no toxicity Improved quality of life

Post-operative pain relief Reduced pain at rest, with movement, and with

cough No statistical difference in adverse events

Ferrini 2004 Vigneault 2011

Immediately reduced

pain lasting up to 24 hours

Less opiates

Decreased LOS

Quicker bowel function return

Less nausea

No difference in rate of death, arrhythmia, toxicity, or other heart disorder

Moderate evidence that intravenous lidocaine has an impact on pain scores compared to placebo Kranke 2015

RCTof 240 patients, ages 18-65 years old with renal

colic

IV Lidocaine 1.5 mg/kg compared to morphine 0.1 mg/kg Pain scores were significantly reduced at 5, 10, 15,

an 30 minutes in IV lidocaine group

Soleimanpour 2012

IV Lidocaine

Perioral numbness 2.5%

Transient dizziness 8.3 %

Dysarthria 1.7%

Without side effect 87.5 %

Morphine

Hypotension 2.5%

Vertigo 1.7%

Nausea/Vomiting 9.1%

Without side effect 86.7 %

Soleimanpour 2012

Toradol 30 mg IV 1 L 0.9% NS bolus

Tylenol 1000 mg PO

Cardiac Lidocaine 1.5 mg/kg in 100 mL NS over 10 minutes MAX 200 mg

Renal Colic

Lumbar Radiculopathy

Acute Headache/Migraine

Musculoskeletal Pain

Extremity Fracture/Joint Dislocation

Tylenol 1000 mg

Ibuprofen 600 mg Toradol 30 mg IV or IM

Flexeril 5 mg or 10 mg Valium 5 mg or 10 mg

Trigger Point Injection

Gabapentin 300 mg or 600 mg

Corticosteroids

Lidoderm patch, MAX 3 patches

Ketamine 0.3 mg/kg IV

infusion over 10 mins Ketamine 0.1 mg/kg

per hour drip Galer 2004

Moore 2014 Balakrishnamoorthy 2015

Renal Colic

Lumbar Radiculopathy, acute on chronic

Acute Headache/Migraine

Musculoskeletal Pain

Extremity Fracture/Joint Dislocation

Opiates are not as effective as compared to standard treatments

Opiates make acute migraine medications less efficacious

(eg: triptans)

Opiate use can promote chronic migraine, migraine relapse, and increase ED visits

Opiate dependent migraine patients have increased

anxiety, disability, and depression

Only role for opiates is for pregnant women when there are contraindications to other medications

Gelfand. 2013

Cleveland Clinic Algorithm Prior to algorithm 66% of ED patients received

opiates and 44% went home with a script for them After implementation 19% of ED patients

received opiates and 5% went home with scripts ▪ P<0.005

Abstract presented at American Headache Society 2015

Toradol 30 mg IV

AND

Reglan 10 mg IV AND

Sumatriptan

6mg sc

If >50% relief

Discharge

<50% Relief

Dexamethasone 4-8 mg IV

AND

Magnesium 1 mg IV AND

Valproic Acid 500 mg in 50

mL over 20 minutes

If >50% relief

Abstract presented at American Headache Society 2015

Corticosteroids Handful of studies reveal benefit Risk vs benefit

Valproic Acid Cochrane Review, NNT 3-7 depending on study May be more effective than sumatriptan

Singh 2008 Colman 2008 Linde 2013 Ghaderibarmi 2015

If patient still has intolerable pain, place in observation with neuro consult

NO OPIATES, if possible

They are harmful

Renal Colic

Lumbar Radiculopathy, acute on chronic

Acute Headache/Migraine

Musculoskeletal Pain

Extremity Fracture/Joint Dislocation

Acute neck, upper and lower back pain

Joint and Soft Tissue Pain Rotator Cuff Tendonitis Arthritis of Knee Lateral Epicondylitis Greater Trochanteric Bursitis Biceps tendonitis

Ibuprofen 600 mg Toradol 30 mg IM

Tylenol 1000 mg PO

Flexeril 5-10 mg PO Valium 5-10 mg PO

Lidoderm patch

Trigger Point Injection

Intranasal Ketamine (0.5 mg/kg)

MAX dose: 50 mg Con: 50 mg/mL 1 mL per nare

Ibuprofen 600 mg Toradol 30 mg IM Voltaren gel

Tylenol 1000 mg PO

Lidoderm patch

Intranasal Ketamine

Joint and Soft Tissue

Injection

Renal Colic

Lumbar Radiculopathy, acute on chronic

Acute Headache/Migraine

Musculoskeletal Pain

Extremity Fracture/Joint Dislocation

Ideally in the ED…..

Nitrous Oxide + Intranasal Ketamine Upon arrival Set up for ultrasound guided nerve block

Ultrasound Guided Nerve Block Dislocation- Lidocaine 0.5% Fracture- Ropivacaine 0.5%

Tylenol 1000 mg PO q 4-6 hours

Naprosyn 500 mg PO q 12 hours

Elevation, Immobilization, Rest and Ice

Operative Treatment

American

Holland

Ankle fracture Inpatient Outpatient

98% 82%

64% 6%

p<0.001 p<0.001

Hip fracture Inpatient Outpatient

85% 77%

58% 0%

p<0.001 p<0.001

Lindenhovious 2009

Trigger Point Injection (TPI)

Nitrous Oxide

INDICATIONS

Palpable taunt band or

nodule

Palpation reproduces pain

Chronic painful condition

CONTRAINDICATIONS

Cellulitis over target area

Anticoagulation

Allergy to local

anesthetic

Acute (<24 hours) muscle trauma

Equipment 0.5% marcaine without epinephrine 1-2 mL ▪ +/- steroids

25 gauge needle Alcohol swap Band-aid Consent ▪ Infection, bleeding

Patient may feel “jerk” or “twitch” when needle

contacts the trigger point- that’s good!

Move needle in and out a few millimeters in a clock wise motion to get circumferential coverage

Apply a band-aid

Let patient know they may have some

soreness when local anesthetic wears off

Check out youtube.com for some videos

Tasteless colorless gas administered in combination with oxygen via mask or nasal hood Maximum concentration 70% N2O

Absorbed via pulmonary vasculature and does not combine with hemoglobin or other body tissues

Rapid onset and elimination <60 seconds

Becker 2008

Analgesic and anxiolytic agent Use along with local anesthetic or other pain

medications Only monitoring is pulse oximetry

No NPO requirements, patient can drive after

administration, no IV line needed

Babl 2015

Amazing for pediatrics pain and sedation Venipuncture, laceration repair, imaging, fracture/joint

reduction Mounting evidence in acute pain management in adults

Pre-Hospital pain relief

Active labor pain

Colonoscopy and Bronchoscopy

Herres 2015 Furuya 2009 Atassi 205 Ducasse 2013 Klomp 2012 Aboumarzouk 2011

Laceration repair

Incision & Drainage

Wound Care

Foreign body removal

Central Venous Access

Peripheral venous access

Fecal Disimpaction

Adjunct for Dislocations Splinting

COPD or severe active asthma Vitamin B12 deficiency Otitis Media, Sinusitis Bowel Obstruction Altered level of consciousness Psychiatric disease, EtOH, Head Injury

Complex Advanced Cardiac Disease CHF

1st trimester pregnancy

If your patients are in pain and alternatives to

opiates are not working…. Give them opiates, with caution

Just be aware that for some people opiates may lead to addiction, have a conversation about their use, and revisit it often

Renal Colic IV Lidocaine 1.5 mg/kg

Radiculopathy TPI, Lidoderm, Gabapentin

Headache TPI, Valproic Acid, Haldol, Steroids

Musculo. Pain TPI, joint/soft tissue injection, Lidoderm

Fx/dislocation Nitrous Oxide, IN ketamine, USRA

Questions?

(Please submit all questions into the Q & A box at the bottom of your webinar screen)

I will read each question in the order it is received, if the question is

directed towards a specific presenter please specify

Presenter: Alexis LaPietra, DO

Medical Director ED Pain Management, St. Joseph’s Regional Medical Center, New Jersey Hospital Association Webinar

Please contact Dr. La Pietra with any questions at

lapietra@sjhmc.org

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Mario School of Pharmacy, Rutgers University