Acute Pain

From Clinicaltools.com

Contents 1 Course 9: Acute Pain and Opioids: Patients with Post-Surgical Pain or Unanticipated Pain 1.1 Need 1.2 Goal 1.3 Objectives 1.3.1 Objective A. Use Opioids When Appropriate 1.3.2 Objective B. Use Opioids Appropriately 1.3.3 Objective C. Consult or Refer 1.4 Case Studies/Simulated Patients

Course 9: Acute Pain and Opioids: Patients with Post-Surgical Pain or Unanticipated Pain

Need

Many clinicians do not take the appropriate clinical steps to avoid triggering or contributing to an addiction problem when managing acute pain. Acute pain, for example, from trauma, is one of the most common conditions for which opioids are prescribed in primary care (Fleming et al., 2007; Reid et al, 2002). Physicians studied in a teaching hospital did not use a standard approach to common issues in addiction medicine and pain management (Merrill, et al, 2002).

Goal

The learner will manage the acute pain in primary care, in a way that avoids triggering or contributing to addiction problems.

Objectives

After completing this course, the learner will be able to:

Objective A. Use Opioids When Appropriate

Use opioids for treating acute pain only when appropriate

1. Take a medical history that includes evaluation of substance abuse and risks for substance abuse (as described in detail in core course)
2. Weigh safety vs. pain management when prescribing opioids for acute pain
3. Utilize appropriate non-opioid pharmacotherapy for mild to moderate acute pain
4. Use non-opioid medications on a schedule rather than as needed before trying opioids
5. Use opioids only for moderate to severe acute pain

Objective B. Use Opioids Appropriately

Use opioids appropriately for treating acute pain

1. Identify yellow flags that suggest opioids should be prescribed with caution in a patient with acute pain
2. Use the lowest potency opioid that will be effective
3. Use opioids in combination with other medicines and other treatments (physical, interventions)
4. Use a short trial of opioids and re-evaluate
5. Follow guidelines appropriate for treatment of pain in patients who have untreated addiction, are in treatment for addiction, or are in recovery (see courses on these topics)
6. Develop and use exit strategies

Objective C. Consult or Refer

Refer patients with acute pain who require opioids for specialist care and consult with specialists when appropriate

1. Refer or consult with a pain specialist regarding patients who require opioid therapy who are already on opioids and require further opioid therapy for acute trauma
2. Refer or consult with a pain specialist regarding patients who exhibit "yellow flags" suggesting possible substance abuse or high risk

Case Studies/Simulated Patients

Case 1: Herman Heroin - 44YOWM

• Chief Complaint: Acute pain due to foot fracture.
• Narrative: Herman is open about his long-standing heroin addiction. He broke his foot this weekend and it was treated in an emergency clinic.
• Opioid Issue: Active heroin addiction and acute pain from trauma.
• Relevant Past Medical, Psychosocial, Family History: Although he has been through rehab many times, in recent years he has repeatedly refused addiction treatment.
• Objectives Covered: A, C

Case 2: Anna Ankle - 34YOAF

• Chief Complaint: Pain from acute ankle injury not responding to her medication for chronic pain.
• Narrative: Anna takes about 6 Percocet a day to control chronic back pain from a car accident injury - she gets some of the Percocet from her orthopedist (3 tablets/day) and "dips into" her husband's supply of "pain meds" from prior dental surgeries. Anna fell down the porch steps and fractured her foot and needs something additional for the acute pain.
• Opioid Issue: Acute pain from trauma in a patient already on opioids for chronic pain.
• Relevant Past Medical, Psychosocial, Family History: Anna hurt her back in a car accident 8 months ago. She goes to physical therapy twice a week.
• Objectives Covered: B, C

Case 3: Saul Surgery - 55YOWM

• Chief Complaint: Needs pain management after upcoming surgery.
• Narrative: Saul is a former heroin and methadone addict. He has been clean for 10 years - has not used pills, heroin, or alcohol during this time. He needs pain management for his upcoming hip replacement surgery. The surgeon anticipates that the pain will be severe and recommends opioids for at least the first 5 days following surgery to control the pain.
• Opioid Issue: Formerly addicted to heroin; anticipated severe postoperative pain.
• Relevant Past Medical, Psychosocial, Family History: Saul lives alone but has many good friends also in recovery.
• Objectives Covered: B, C