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.
The answer for Dr. Lullove depends on the patient’s experience with pain relief. Sometimes, he says it is necessary to ascertain blood levels of narcotic-type medications before initiating therapy to determine dosing. Dr. Lullove also notes that some wound care patients may have kidney dysfunction, which can alter the amount needed to dispense. Either way, Dr. Lullove says assessing a starting point must be patient-dependent. He uses the American Academy of Pain Management guidelines for acute and chronic pain management.
After identifying the etiology of pain, Dr. Brill initiates treatment. He will generally start patients with painful neuropathy on gabapentin (Neurontin, Pfizer) and titrate the dosing as needed. In patients with ischemic pain, Dr. Brill uses hydrocodone combinations or tramadol (Ultram, Janssen Pharmaceuticals). He says local treatment with lidocaine patches frequently helps. In patients with wounds and inflammatory disease, his first line of treatment is an NSAID.
“Needless to say, treating the underlying cause is most important,” says Dr. Brill.
Do you use NSAIDs? Do you have a favorite kind of NSAID?
When patients have wounds with inflammatory disease as a cause of their wound-related pain, Dr. Brill uses naproxen (Naprosyn, Roche) or meloxicam (Mobic, Boehringer-Ingelheim). To those drugs, he will add an H2 receptor antagonist such as ranitidine (Zantac, Boehringer-Ingelheim).
Dr. Suzuki often prescribes celecoxib (Celebrex, Pfizer), noting it has a long half-life and one can prescribe it for acute pain at 200 mg bid or for osteoarthritis or less acute pain with 200 mg qd dosing. He likes other NSAIDs with a longer duration, such as naproxen sodium (250 to 500 mg PO q12h) and diclofenac sodium (50 mg PO bid-tid), which one can use in combination with the other drugs. Dr. Suzuki notes this combination may work synergistically.
Although NSAIDs have their place, Dr. Lullove says most geriatric patients have kidney and/or cardiac issues that may prevent the use of NSAIDs in the therapy of wounds for pain relief. He emphasizes the need to take a thorough medical and medication history to manage geriatric patients. For younger patients, NSAIDs can play a vital role but Dr. Lullove advises always balancing bleeding risk with wound management.
“I should mention that, with any other pain medications including NSAIDs, most of our patients have their own ‘favorite’ pain medications,” says Dr. Suzuki. “Asking them ‘what worked the best for you’ may help you in guiding your prescription since there are an overwhelming choice of medications and combinations for pain management.”
Do you utilize regional blocks prior to lower extremity surgery?
All three panelists use regional blocks. Dr. Suzuki has been requesting regional blocks to be administered by specifically trained anesthesiologists prior to most of his lower extremity surgeries. Since the post-op pain is most intense in the first 24 to 48 hours, he believes regional blocks are quite useful in controlling post-op pain and minimizing the use of heavy-duty opioids, which often cause constipation.
Dr. Lullove has found regional blocks to be very effective in lower extremity surgery, especially when the patient has serious comorbidities that can threaten the normal use of inhaled anesthesia or general anesthetic use. Regional blocks are great for the management of post-procedure pain and patients seem to tolerate them when applied, according to Dr. Lullove. He says one should keep in mind that regional anesthesia has inherent risks such as swelling, infection at the injection site, systemic toxicity (rare) and cardiac and/or pulmonary problems (rare).
On the other hand, Dr. Suzuki has not had a great experience with a portable pain pump that infuses lidocaine and other anesthetics to the operative site. He says such pain pumps may not be suitable for foot and ankle surgery, which occurs within smaller tissue compartments than other orthopedic surgeries.
Dr. Brill practices at the Limb Salvage Center at the BrillStone Building and is President of the BrillStone Corporation in Dallas. He is a Fellow of the American College of Foot and Ankle Surgeons, and is also a consultant in wound care and reconstructive foot and ankle surgery at the Wound Care Clinic at Presbyterian Hospital in Dallas.
Dr. Lullove is in private practice in Boca Raton and Delray Beach, Fla. He is a Staff Physician at West Boca Medical Center in Boca Raton. Dr. Lullove is a Fellow of the American College of Certified Wound Specialists.
Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo.
For further reading, see “Key Insights On Using Medications In Wound Care” in the May 2010 issue of Podiatry Today.