Many patients with non-healing ulcers are already in significant pain prior to surgery. Many of these patients will require escalating doses of pain medications following surgical debridement and grafting. Some will already have developed tolerances to pain medications. So, what do we prescribe to control their pain? More importantly, what can we prescribe and still maintain a level of comfort in writing the prescription?
With these questions in mind, Robert Snyder, DPM, engaged in a Q&A session with Andrew J. Goldberg, MD, the Director of the Northwest Pain Management Center in Margate, Fla.
Q: Do all of these patients require aggressive pain medications?
A: Clearly not. As we know, the majority of patients do well with routine pain medications, like Percocet, Vicodin and Darvocet, that we typically prescribe.
Q: When do we need to explore other options of pain medications?
A: This should be considered when we face certain clinical scenarios. Perhaps the patient is already taking large doses of narcotics (i.e. 10 to 12 Percocet per day) prior to surgery, or maybe the recovery room informs us the patient is in severe pain despite large does of parenteral narcotics (i.e. intramuscular Demerol or morphine), or we find the surgery to be much more extensive then we expected.
Q: Now that we have recognized the difficult patients, which drug do we choose?
A: Before you can choose what post-op pain medication to use in a challenging patient, you need to know where the patient will receive post-op care, whether it’s in an in-patient hospital setting, a skilled nursing facility/in-patient rehabilitation or a home/assisted living facility. The location of the patient’s post-op care will determine what options we have for pain medication.
Q: Many of my patients are already admitted to the hospital, so what would you recommend in this setting?
A: That’s easy. I feel a Patient Controlled Analgesia (PCA) infusor would be the best choice. This technique allows the patient to regulate his or her own use of the narcotic. In addition, this would eliminate nursing response time to administer pain medications. Typically, morphine and Demerol are the agents used. Many wound care surgeons may not know how to order such a device. Well, there is no need to worry. Chances are the work has most likely already been done for you by the anesthesia department.
In most hospitals, prewritten PCA order forms are already in existence and can be found in the recovery room. Simply check off the box of the medication you want to use. The dosages and settings are already written in. The guidelines for monitoring and patient education are also already found on the order forms. My usual algorithm for PCA is the following:
a) My first choice is PCA morphine, demand dose of 1mg, lockout of 6 minutes, 4-hour limit of 24mg, with no basal rate.
b) If the patient is allergic to morphine or cannot tolerate it, my second choice would be PCA Demerol, demand dose of 10mg, lockout of 6 minutes, 4-hour time limit of 240 mg, with no basal rate.
c) If the patient cannot tolerate the Demerol or has a history of seizures, my third choice would be PCA fentanyl, 12.5 microgram demand dose, 6 minute lockout, 4-hour time limit of 240 micrograms, and no basal rate.
Q: Are there any other options for an in-patient?
A: Yes, I find intravenous Toradol quite useful. This central acting nonsteroidal antiinflammatory drug has analgesia properties equivalent to morphine without the worries of respiratory depression. A routine dose would be 30mg IV q 6h, either standing or prn pain. Either way, it should not be used for more than five days.
Keep in mind that you should not prescribe this drug for patients with the following medical problems: renal insufficiency, significant liver dysfunction, coagulopathy or a history of a GI bleed. If you still have difficulty in controlling the pain level despite the above modalities, take advantage of the patient’s in-patient status by calling a pain management consultation through the anesthesiology department.
Q: What about this patient you described who has been transferred to a skilled nursing unit (SNU)? What options do we have?
A: Keep in mind that admission to the SNU is essentially a step below an in-patient status but certainly a step up from home or assisted living facility status. The only limitation one has in prescribing narcotics in the SNU setting is the inability to use intravenous narcotics. This basically eliminates PCA or any IV narcotic push. Options may still include intramuscular routes such as morphine and Demerol. Even Toradol can be used in this setting.
Once the acute phase of the post-op pain is over, it is simple to return to oral pain medications only. Initially, I would recommend Demerol 75mg and Vistaril 25mg IM q 4h prn for severe pain and Percocet 5/325 1-2 PO q 4h prn pain for mild to moderate pain. Once the patient no longer requires intramuscular orders, simply discontinue this route of narcotic administration.
Q: What about those patients in the SNU that require eight to 10 Percocet 7.5/500 per day or Vicodin ES per day? Do you feel comfortable keeping the patient on that kind of a dose?
A: No, I feel this provides increased risk to the patient. Remember, the patient receives substantial amounts of acetaminophen with these dosages. The recommended upper limit of daily acetominophen intake is 4000 mg. Patients receiving more than this dose are predisposed to an increased risk of liver toxicity. In addition, the patient is still most likely developing significant breakthrough pain throughout the day.
My first inclination would be to use a safer short acting narcotic, such as MSIR (morphine sulfate immediate release), which does not contain acetominophen. An MSIR 15mg tablet is basically equivalent to one Percocet tablet. Because MSIR lacks acetominophen, it has no ceiling limit. My typical starting dose would be MSIR 15mg tablets, 1 to 2 PO q4h prn pain.
Q: Are there alternative narcotics available?
A: Absolutely. There are long acting narcotics available that provide a constant plasma level of pain medication. This class of medication avoids the peaks and troughs of the short acting narcotics, thereby giving the patient a more consistent level of pain relief. In today’s clinical practice, you have four long acting narcotic options: MS Contin (long acting morphine), Duragesic Patch (long acting fentanyl), Oxycontin (long acting Percocet) and methadone.
In a patient receiving five to six Percocet per day, I feel very comfortable starting Duragesic Patch 25mcg/hr. At this dose, the patient should have significant relief and no significant side effects. This is even the case for elderly patients as well. In addition, this medication lasts 72 hours. I write my typical prescription as “Duragesic Patch 25mcg/hr, apply one to the skin and change q3 days, #5 (enough for 15 days).”
Q: The majority of my patients go home after wound care surgery. What are my options for those patients with persistent or severe pain?
A: Once again, we are limited by the amount of acetaminophen found in the particular pain medication you prescribe. For example, what do we give the patient who is already taking 8 Percocet per day preoperatively for the pain? They will most likely need more at home. If you have enough time to anticipate this problem, simply refer the patient to a comprehensive pain specialist. Alternative narcotics such as MSIR will be recommended, with appropriate dosing, thus eliminating guesswork.
The pain physician will also recognize other causes (i.e. ischemic changes and ischemic neuropathy) that contribute to the patient’s discomfort. Antiseizure medications (i.e. Neurontin, Gabitril) and antidepressants (i.e. Elavil, Trazadone) are just a few classes of drugs for treating this kind of pain. By treating pain at different sites along the pain pathway, we can reduce the amount of narcotics this patient may need postoperatively.
Dr. Goldberg is board-certified in Pain Management as well as Anesthesiology.
Dr. Snyder (shown at right) is a Diplomate of the American Board of Podiatric Surgery and the American Academy of Wound Management.