Given the numbers of patients seeking relief from chronic wound pain, it is imperative to provide responsible, effective pain management. These authors provide a guide to treating patients with mild, moderate and severe pain, with an eye on the safe prescription of opioids and the potential for medical marijuana.
Chronic pain, defined as pain present for greater than three months, affects approximately 11.2 percent of the adult population in the United States.1,2
One would first establish pain management in wound care by obtaining baseline levels of discomfort and functioning, which commonly occurs using the PEG pain scale, defined by Pain intensity during the past week, pain interfering with Enjoyment of life during past week, and pain interfering with General activity in the past week.3 Patients rate each of the three PEG items on a scale from 0–10. Tallied scores from the PEG scale enable the provider to classify pain as mild, moderate or severe.
Mild chronic pain is defined by a PEG score between 0–3, and one should treat this level of pain using modalities other than opioid prescriptions. Patients can often achieve mild chronic pain management with acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) including ibuprofen, diclofenac (Voltaren, Novartis), naproxen or celecoxib (Celebrex, Pfizer). One can prescribe topical anesthetics with oral medications, including salicylate creams and lidocaine patches (Lidoderm, Endo Pharmaceuticals) and diclofenac patches (Flector patch, Pfizer). Patients with diabetic neuropathy may benefit from folic acid supplementation (Metanx, Alfasigma) and oral medications, such as gabapentin (Neurontin, Pfizer) as well as pregabalin (Lyrica, Pfizer), duloxetine (Cymbalta, Eli Lilly) and amitriptyline (Elavil). Transcutaneous electrical nerve stimulation (TENS) with physical therapy serves as an effective modality for mild pain relief and increased blood flow, prescribed on a case-specific basis at the discretion of the provider.
Moderate chronic pain, corresponding to PEG scores between 4–6, may have initial management with the treatment modalities applied to that of mild pain. Patients presenting with moderate pain, however, may require opioid analgesics. Opioids commonly prescribed for chronic pain in wound care include hydrocodone/acetaminophen, oxycodone/acetaminophen or tramadol with or without acetaminophen. It is important to note, though, that opioid prescriptions in the United States have increased dramatically, amounting to 259 million prescriptions per year.4 Consequently, it is vital that providers make a conscious effort to attempt all other treatment modalities before turning to opioid analgesics to reduce the risk of dependence or overdose.
A PEG score of 7–10, indicating severe chronic pain, is extremely debilitating for affected patients. Opioid analgesics are most commonly prescribed for severe chronic pain, including immediate or extended-release oxycodone (OxyContin, Purdue Pharma), hydromorphone (Dilaudid, Purdue Pharma) or morphine.
A Closer Look At Safeguards To Prescribing Opioid Analgesics Safely
Before prescribing opioids for chronic pain, it is imperative to consider the highly addictive nature of opioids and potential for serious health repercussions to patients. The United States accounts for 80 percent of all opioid consumption in the world and has ultimately contributed to 165,000 opioid overdose fatalities and 420,000 opioid-related visits to the emergency department.5,6
As of Oct. 2, 2018, physicians are mandated to consult the Controlled Substance Utilization Review and Evaluation System (CURES) database prior to prescribing, ordering, administering or furnishing a Schedule II-IV controlled substance.7 After this date, the clinician must consult the CURES database the first time when prescribing a patient a controlled substance (with some exemptions), and at least once every four months if the controlled substance remains a part of the patient’s treatment plan.
To curtail the likelihood of overprescribing opioids, the Centers for Disease Control and Prevention (CDC) has created recommendations for managing patients with chronic pain.1 The CDC guidelines begin with establishing a two-week timeframe for prescribing opioids that starts only when patient benefits outweigh the risks. The two-week timeframe is an attempt to moderate the tolerance patients quickly build to their opioid medications at a given dose. Every two weeks, re-evaluate patients and discontinue prescriptions if no improvement has occurred.
The CDC further emphasizes conducting a thorough review of patients’ clinical history of controlled substance prescriptions using the Controlled Substance Utilization Review and Evaluation System.7 All providers with Drug Enforcement Administration (DEA) certificates are required to register for CURES, and to review patients’ most recent CURES data no more than 24 hours or one business day prior to his or her visit.7
After prescribing opioid analgesics, the provider must check the CURES website at least once every four months after the date of the continued first dose.8 Alerts are built into the CURES database, which notifies providers if they are prescribing opioid therapies at inappropriate thresholds. Those thresholds include: patients having six or more prescribers in the past six months, concurrent prescription of opioids and benzodiazepines, opioids prescribed for 90 consecutive days or more, more than 90 mg of morphine equivalents prescribed per day, or more than 40 mg of morphine equivalents of methadone per day.8 These alerts are implemented for the purpose of protecting patients from potentially fatal medication interactions, and developing rapidly increasing tolerance and dependence.
If, after patient assessment and medical history review, one determines the patient requires an opioid prescription for pain, implement START principles to follow safe parameters for opioid use:
• Supplement with immediate release analgesic. Underestimate the patient’s opioid use for 24-hour periods and provide rescue medications for breakthrough pain, including immediate release opioids or non-opioids.
• Titrate doses every one to two days, as it takes 24 hours for plasma concentrations to reach equilibrium.
• Adjust the dose by 25 to 50 percent. A 25 to 50 percent increase in the daily dose is permitted contingent upon patients’ needs and stability.
• Reassess patients’ analgesia and tolerance throughout treatment, while monitoring addiction development, misuse and abuse. Do not increase opioid dose when patients experience worsening pain without first identifying the source of pain.
• Tailor doses per reassessment and in turn, titrate up or down. Decrease the prescribed dose in the presence of adverse events. If patients’ pain is improved, begin to decrease the dosage gradually to prevent withdrawal.
Insights On The Potential Of Medical Marijuana As An Adjunctive Pain Medication
As of Jan. 1, 2018, the state of California is allowing the recreational as well as medical use of marijuana. About the half the states allow medical marijuana, and it is quite conceivable that we will see the nationwide adoption of its medical use in our lifetime, to follow the example set by Canada, Australia and many Western European countries. As a matter of fact, in our wound care center, we see more and more patients “self-prescribe” medical edible marijuana to control their wound pain, in addition to, or in place of traditional pain medication regimen.
The active chemical components of cannabis are divided in two: tetrahydrocannabinol (THC), which is responsible for the euphoria effect that marijuana is notorious for; and cannabidiol (CBD), the “therapeutic” counterpart that has the purported benefits of anti-inflammatory, anti-oxidant, anti-anxiety and anti-epileptic properties without THC’s psychoactive effect. Anecdotally, patients may use a CBD supplement either topically as an anti-inflammatory (for example, for an arthritic or otherwise painful joints) or take it orally (edible products or oil tincture) as an anti-anxiety and a pain reliever as an adjunctive to prescribed pain medication.
To prescribe CBD supplements for your patients, you may write a paper prescription for “Rx: CBD oil, Dx: Foot pain” and refer your patient to a local dispensary, or you may purchase CBD products over the internet directly from the manufacturers. Three examples of reputable CBD manufacturers are 2Rise Naturals, Charlotte’s Web, and Lord Jones. As quality-controlled CBD oils should contain only a trace amount of THC, they are not psychoactive and they are considered legal in all 50 states. The analogy here is that a poppy seed bagel may contain a trace amount of codeine, but it is not prohibited under the law.
As for the CBD dosage, the common recommendation is to start low, as low as 10 mg per day orally before bedtime for seven days, then increase gradually based on the clinical response, for a maximum daily dose of 200 mg. We should note that, as with any other pain medication, we saw a variable response to CBD supplementation in our patients, meaning some patients had a good clinical response while the others did not find it helpful.
How The Authors Manage Chronic Wound Pain In Clinical Practice
When patients with chronic wound pain present to our practice, first of all, we try to ascertain the history, pain quality, pain characteristics and whether the patient’s previous wound pain therapy worked. We measure pain severity with a four-tier system; pain scale includes 0 (no pain), 1–3 (mild pain), 4–6 (moderate pain) and 7–10 (severe pain) on the PEG scale. We always strive to keep the pain level below 3/10, which is considered to be an “acceptable level” of pain.
We should note it is quite common for patients to complain of pain being more noticeable at night; this is because they may overlook minor pain during the day when their minds are occupied.
In our clinic, we prefer acetaminophen (Tylenol, McNeil Consumer Healthcare) as the baseline pain medication, noting it is a versatile and safe analgesic as long as patients stay within safe dosing, keeping the daily acetaminophen dose to a maximum 3,000 mg per day, or 1,000 mg TID with meals.
For elderly and frail patients who may have pressure ulcers and difficulty communicating, we would prescribe acetaminophen 650 mg four times a day (with three meals and before bedtime). Giving patients a baseline analgesia is an important part of palliative and hospice care.
For inpatient use, we often start with intravenous opioid medication for moderate and severe pain, while reserving meperidine (Demerol, Sanofi Aventis) for the selected patients who are truly allergic to morphine or hydromorphone. Moreover, we use subcutaneous or IV routes to administer parenteral analgesics because intramuscular pain medication has erratic absorption and consequently has erratic pain-relieving effects.
We may prescribe celecoxib, 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. We also use other NSAIDs with a longer duration, such as naproxen sodium (250 to 500 mg PO q12h) and diclofenac sodium (50 mg PO bid-tid).
Neuropathic pain may result from pre-diabetes, diabetes or chemotherapy, or it may have no clear-cut cause. Interviewing patients is the fastest and easiest way to diagnose neuropathy, as most patients are acutely aware of their “numb feet” problems or “tingling” sensations, or otherwise painful foot conditions of varying degrees. We also use a new neuropathy measuring device called the Dynamic Neuroscreening Device (DND, Prosenex), which measures large fiber neuropathy (using the vibratory test) and small fiber neuropathy (using the two-point temperature discrimination test). The device replaces tuning forks and monofilaments, allowing one to measure and track the improvement or progression in patients’ nerve conductivity in the lower extremities.
Gabapentin is a commonly prescribed prescription medication for neuropathic pain. Even though its original indication was for seizures and post-herpetic neuralgia, physicians learned over the years that gabapentin is quite effective in controlling diabetic neuropathy, fibromyalgia pain, arthritic pain, and even for alcohol dependence. For pain management use, we recommend starting low, then increasing the dosage weekly, based on the clinical response. As the most common side effect is “somnolence,” we found it is quite useful for wound patients with pain and with sleeping issues. Prescribe gabapentin at a starting dose of 100 mg QHS, then titrate up in divided doses for TID with meals and QHS, as high as 3,600 mg daily in divided doses. Pregabalin, duloxetine and amitriptyline are other choices for diabetic neuropathic pain if a patient fails gabapentin.
As noted above, we may recommend an edible cannabidiol supplement as an alternative or adjunctive to gabapentin, as CBD is believed to be anti-inflammatory and anti-anxiety. We should note that a CBD supplement does not cause respiratory depression as opioids do, and we are not aware of any documented case of fatality due to CBD overdose.
As for the diet intervention, we have witnessed an improvement in diabetic neuropathic pain after patients overhauled their diet and eliminated simple carbohydrates. We know scientifically that plant-based diets can prevent and treat type 2 diabetes, although in reality it’s not easy to convince patients to eat healthier. We do recommend and prescribe the Prolon five-day diet program (L-Nutra), which developed at the University of Southern California and is clinically proven to cause weight loss and increase health, in an effort to steer our patients toward healthier eating habits.9
Duloxetine (Cymbalta, Eli Lilly) is a newer medication that is indicated for diabetic neuropathic pain as well as chronic musculoskeletal pain. Patients cannot use duloxetine if they have renal impairment (creatine clearance < 30), which may be the case for some patients with diabetes.
Opioid medications, such as hydrocodone or oxycodone, may have a role as rescue medications, but as a last resort for the treatment of neuropathic pain as neuropathy is often a lifetime condition and to prevent opioid dependency. As with treating any other specialized medical condition, we believe it’s a good idea to get a neurologist and pain management specialist involved early if you find you are not managing the pain adequately on your own for your patients. By the same token, given that anxiety and depression have a strong connection to physical pain, it is perfectly reasonable to consider referring patients with pain issues to a psychotherapist or psychiatrist.
As a physical therapy modality, we often recommend transcutaneous electrical nerve stimulation (TENS), which patients can purchase from Amazon for $30 to $40. The TENS units are perfectly safe alternatives to oral medications or adjunctive treatments as long as patients do not have a pacemaker or other implantable cardiac device.
Oral supplements of folic acid and alpha lipoic acid provide “meaningful” pain relief in diabetic neuropathy. However, these supplements would be the second line of treatment after gabapentin since it reportedly takes a few weeks of supplement use before patients can feel any pain-relieving effect.
Dr. Suzuki is the Medical Director of the ICM Medical Group Wound Care Center at www.suzukiwoundcare.com. He is also a medical staff of the Cedars-Sinai Medical Center in Los Angeles. He can be reached at Kazu.Suzuki@cshs.org.
Ms. Birnbaum is a second year student at the Western University of Health Sciences, College of Medicine of the Pacific, in Pomona, CA.
1. Dowell D, Haegerich T, Chou R. CDC guideline for prescribing opioids for chronic pain. J Am Med Assoc. 2016; 315(15):1624–45.
2. Hakakian C, Suzuki K. What you should know about emerging wound care dressings. Podiatry Today. 2014; 27(8):52–58.
3. Krebs EE, Lorenz KA, Bair MJ. Development and initial validation of PEG: a three item scale assessing pain intensity and interference. J Gen Intern Med. 2009; 24(6):733–8.
4. Kroenke K, Theobald D, Wu J, et al. Comparative responsiveness of pain measures in cancer patients. J Pain. 2012; 13(8):764–72.
5. Nowak L, Nader JA, Stettin G. A nation in pain: Focusing on U.S. opioid trends for treatment of short-term and long-term pain. Available at http://lab.express-scripts.com/lab/publications/a-nation-in-pain . Published Dec. 9, 2014.
6. Centers for Disease Control and Prevention. Multiple cause of death data. Available at http://wonder.cdc.gov/mcd.html . Published Dec. 20, 2017.
7. Department of Consumer Affairs, State of California. CURES 2.0. Board of Accountancy. Available at www.dca.ca.gov/licensees/cures_update.shtml.
8. CURES 2.0 User Guide. Department of Justice. Available at www.oag.ca.gov/sites/all/files/agweb/pdfs/pdmp/cures-2.0-user-guide.pdf .
9. Wei M, Brandhorst S, Shelehchi M, et al. Fasting-mimicking diet and markers/risk factors for aging, diabetes, cancer, and cardiovascular disease. Sci Transl Med. 2017;9(377). pii: eaai8700.
10. Neighmond P. Words matter when talking about pain with your doctor. NPR. Available at www.npr.org/sections/health-shots/2018/07/23/626202281/words-matter-when-talking-about-pain-with-your-doctor?utm_source=npr_newsletter. Published July 23, 2018.
11 How much CBD should I take? Beginners guide. YouTube. Available at https://www.youtube.com/watch?v=gkkpqnDOn2c&feature=youtu.be . Published Nov. 28, 2017.
12. Armstrong DG, Meyr AJ. Basic principles of wound care management. UpToDate, www.uptodate.com/contents/basic-principles-of-wound-management . Published Aug. 20, 2018.