A Guide To Pain Management In Wound Care
These panelists discuss identifying the etiology of pain in patients with wounds and share their perspectives on various treatment modalities ranging from nonsteroidal anti-inflammatory drugs (NSAIDs) to the use of regional nerve blocks before surgery.
How do you approach wound care patients when they complain of wound pain?
As Eric Lullove, DPM, explains, sometimes patients with wounds have arterial disease, infection or severe neuropathy. He says their pain is real and physicians need to address that. “Treating them as you would any other patient with pain is always a good place to start,” notes Dr. Lullove.
Kazu Suzuki, DPM, CWS, ascertains the history, pain quality, pain characteristics and whether the patient’s previous pain therapy worked. Dr. Suzuki also measures pain severity with a four-tier system. His pain scale includes 0 (no pain), 1-3 (mild pain), 4-6 (moderate pain) and 7-10 (severe pain). He always strives to keep the pain scale below 3/10, saying it is considered to be an “acceptable level” of pain.
As Dr. Suzuki notes, it is quite common for his patients to complain of pain being more noticeable at night. He says this is because they may overlook minor pain during the day when their minds are occupied with work or are otherwise taking care of other business.
Leon Brill, DPM, CWS, emphasizes identifying the etiology of the pain in a wound care patient. He notes ischemia and infection are the two most important etiologies that one needs to rule out. As he stresses, pain, especially pain with acute onset, may be an ominous sign and one must identify the underlying cause before treating the pain. One should perform vascular and/or imaging studies, according to Dr. Brill.
Which drug do you start with in terms of your pain medication prescribing?
Dr. Suzuki prescribes pain medication based on the analgesic ladder devised by the World Health Organization (www.who.int ). This ladder describes managing cancer pain but he says it translates into any pain management situation.
Step 1 calls for a non-opioid plus an adjuvant such as acetaminophen and NSAIDs. Step 2 entails opioids for mild pain (hydrocodone and oxycodone with acetaminophen). Step 3 is opioids for moderate and severe pain (oxycodone extended-release and a fentanyl patch). Finally, Dr. Suzuki notes that Step 4 involves interventional procedures, such the use of spinal cord stimulators.
In general, Dr. Suzuki prefers acetaminophen (Tylenol, McNeil Consumer Healthcare), noting it is a versatile and safe analgesic as long as patients stay within safe dosing. As he says, the Food and Drug Administration’s new guideline is to limit the daily acetaminophen dose to 3,000 mg per day, which was lowered from the previous guideline of 4,000 mg per day. Dr. Suzuki explains this is because many “combination” drugs, such as hydrocodone/acetaminophen (Vicodin, Abbott Pharmaceuticals), include acetaminophen and cites reports of accidental overdoses of acetaminophen.
For example, he notes that some elderly and frail patients may have pressure ulcers and difficulty communicating. In that case, Dr. Suzuki would prescribe acetaminophen 650 mg four times a day (with three meals and before bedtime) as he believes giving them a baseline analgesia is an important part of palliative and hospice care.
For inpatients at his hospital, Dr. Suzuki always starts with IV hydromorphone (Dilaudid, Purdue Pharma) for moderate and severe pain. He reserves meperidine (Demerol, Sanofi Aventis) for the selected patients who are truly allergic to morphine or hydromorphone. Moreover, Dr. Suzuki always tries to use subcutaneous or intravenous routes to administer parenteral analgesics because intramuscular pain medication has erratic absorption and consequently erratic pain relieving effects.