Exploring a wide range of issues with managing pain in patients with wounds, these panelists share their experience in addressing pain associated with post-op wounds, discuss debridement-related pain and review how the advent of drug monitoring prescription programs has improved appropriate screening of patients.
How do you address debridement-related pain with your patients?
In the outpatient setting, Kazu Suzuki, DPM, and David Swain, DPM, employ topical lidocaine. After the application of lidocaine 2% gel and five to 10 minutes of patient examination, Dr. Suzuki says his patients are usually comfortable with the anesthesia at that point. Dr. Swain uses either lidocaine gel or solution, and finds it effective in most cases.
If initial efforts at topical anesthesia fail, Dr. Suzuki utilizes injectable lidocaine, which he says is easier to inject due to partial numbing in the area from the previous gel application. Dr. Swain uses benzocaine spray if there is a contraindication to lidocaine.
However, if topicals are unsuccessful, Dr. Swain either performs surgical debridement or opts for autolytic or enzymatic debridement.
Christine Miller, DPM, DMM, PhD, FACCWS, takes a patient-centered, multidisciplinary approach. She emphasizes that reviewing current medication lists on each patient visit and having an open dialogue with patients about their pain level are the “driving forces behind debridement-related pain management.”
What forms of pain management and/or pain management protocols do you employ for patients with post-op wounds?
Emphasizing the importance of differentiating between patients who are opioid naïve versus those who have chronic pain, Dr. Miller says a multimodal pain control model is the standard at her institution for patients who are relatively opioid naïve. She explains this model’s algorithm begins with non-opioid analgesics including acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs) or COX-2 inhibitors (coxibs) with local anesthetics. Only after failure of these initial efforts will she consider intermittent opioid analgesics. When it comes to a patient with chronic pain, Dr. Miller consults the patient’s primary care physician (PCP) or a pain management specialist.
Emphasizing a “pain ladder” approach, Dr. Suzuki starts with acetaminophen at maximum dose (one gram every six hours).
“I try to avoid NSAIDs because of the GI bleed complication, which is a major worry in my wound care patients,” relates Dr. Suzuki.
When acetaminophen fails, Dr. Suzuki says tramadol 50 milligrams every six hours in conjunction with acetaminophen can be effective for moderate to severe pain in non-elderly patients. Alternately, he explains that careful usage of Schedule II medications hydrocodone or oxycodone combined with acetaminophen may work well for moderate to severe pain in patients with post-op wounds. Dr. Suzuki maintains it is important to minimize the dosage and duration of these drugs.
Due to the nature of his practice, Dr. Swain says most of his post-op patients are inpatients and prefers to consult with specialists on pain management for these patients.
“With all of the changes over the past 10 years, I rely more on my internal medicine physicians and pain specialists for guidance,” notes Dr. Swain.
In light of the opioid abuse epidemic, what kind of screening do you do for patients with wound pain? Has your screening protocol changed in recent years as a result of increasing opioid abuse?
Each panelist cites state-related legislation and prescription drug monitoring programs (PDMPs) as being effective in reducing questionable drug-seeking behavior. Dr. Swain, who practices in Florida, says physicians are required to screen patients that get pain medications through E-FORCSE (Electronic Florida Online Reporting of Controlled Substance Evaluation Program).
“This has led to a dramatic decrease in pain medication prescriptions,” notes Dr. Swain. “Now that most Floridians have become aware of this screening system, the number of drug-seeking encounters has decreased in my practice.”
Dr. Miller, who also practices in Florida, concurs and adds that the state has enacted in the past year “some of the strictest narcotic prescribing regulations in the country.” Due to these regulations, she points out that prescribing narcotics for pain management primarily falls to the PCP or pain management specialist, and one can only prescribe acute pain medication for a very limited duration (three- or seven-day exemptions).
In order for an acute pain medication prescription to be filled, Dr. Miller says it is mandatory for the prescribing physician to access a prescription drug monitoring program and link an appropriate diagnosis with the prescription as “an acute pain exemption.”
For her patients who are in a pain management program, Dr. Miller candidly tells them that her wound care clinic will not prescribe narcotics. If the patient obtains an outside opioid prescription, then he or she is in violation of that contract and risks dismissal from the pain management program.
Citing the Conrolled substance Utilization Review and Evaluation System (CURES) registry for pain medications, Dr. Suzuki says it is “fairly easy” to identify pain medication seeking patients as clinicians get notified from pharmacies or insurance companies when one patient tries to obtain pain medications from multiple docs or pharmacies. He notes that programs like this provide “the most accurate and reliable methods” to detect patients with opioid abuse issues as even the most astute clinician cannot accurately quantify pain due to its subjective nature.
How do you handle pain management in elderly patients with wounds given potential polypharmacy issues?
Due to the use of prescription drug monitoring programs such as the aforementioned E-FORCSE, Dr. Miller says there has been improvement in identifying potential polypharmacy issues.
Dr. Swain advocates for open conversations with the patient and his or her family.
“We go over options and make the best choice for that patient’s particular situation,” he says, “Sometimes these options include palliative care and hospice.”
Dr. Swain then helps set up the appropriate referrals as needed.
Dr. Suzuki addresses pain management in the elderly through multiple methods, including dose adjustment, adjunctive pain medications such as gabapentin or pregabalin (Lyrica, Pfizer), topical pain patches, and TENS units. He also notes that many of his patients have praised cannabidiol (CBD) oil.
“Many of my patients have pre-medicated with it, whether they have ingested it or applied it topically, and they tell me (CBD oil) has been a ‘life saver’ in controlling their pain and restoring good sleep habits,” notes Dr. Suzuki.
In California, where Dr. Suzuki practices, he notes CBD oil use is legal but acknowledges that CBD oil may not be legal in other states.
Dr. Miller is the Co-Director of Wound Care and Limb Salvage at the University of Florida College of Medicine. She is a Fellow of the American College of Clinical Wound Specialists.
Dr. Swain is a board-certified wound specialist physician (CWSP) of the American Board of Wound Management, and a Diplomate of the American Board of Podiatric Medicine. He is the Medical Director of the St. Vincent’s Wound Care and Hyperbaric Center at St. Vincent’s Southside Hospital in Jacksonville, Fla., and is in private practice in Jacksonville, Fla.
Dr. Suzuki is the Medical Director of the Suzuki Wound Care Clinic in Beverly Hills, CA. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles CA. He can be reached at Kazu.Suzuki@cshs.org.
1. Suzuki K, Birnbaum Z. Pain management and wound care patients: Key principles. Podiatry Today. 2018;31(12):36-41.