ancillaryservices therapy. Note that pain may be treated more aggressively and be desired in a hospice situation that is appropriate in a wound clinic.
Pharmacological Options
Most physicians are comfortable with prescribing neuropathic agents, NSAIDS, and acetaminophen. Many also use tramadol, anxiolytics, topical agents, and hydrocodone or codeine. But there is a general reluctance to prescribe other opioids. A commonly repeated phrase is that “stronger” opioids are being considered when the appropriate descriptor is “more potent.” Remember: Morphine and hydrocodone have similar potency. Codeine is ineffective in a substantial group of patients due to its metabolism and is generally not well tolerated. • Acetaminophen: appropriate for mild pain and fever; 24-hour dose limits to 4,000 mg (3,000 mg in the elderly; 2,000 mg with liver disease patients). • NSAIDs: ibuprofen, naproxen; limit use with gastrointestinal and renal effects. • Steroids: multiple side effects; delay wound healing; must be tapered and used sparingly. • Neuropathic pain agents: (antidepressants): duloxetine, amitriptyline; neuroleptics: gabapentin, pregabalin. • Opioids: most commonly hydrocodone, codeine, morphine, hydromorphone, oxycodone, and fentanyl. • Others: tramadol;* muscle relaxants; anxiolytics; topical capsaicin; or lidocaine. *
owers seizure threshold, interacts L with antidepressants, and has a narrow therapeutic window.
Opioids
Opioids are discussed in terms of their relationship to morphine. Morphine IV is equal to one-third of the oral dose. Oral hydromorphone is about five times as potent as oral morphine. A 25 mcg/hr fentanyl patch is about as much as 50 mg of morphine spaced out over 24 hours. Calculating a patient’s morphine equivalent daily dose (MEDD) over 24 hours
allows a prescriber to adjust doses and switch to alternative medications. There are multiple different tables (available on the web and in various publications) to use to help providers calculate equivalent doses. It is important to remember the concept of incomplete cross-tolerance, a physiological response to a medication as a result of tolerance to a pharmacologically similar drug, prior to a medication change. Also remember that neuropathic pain agents may potentiate the effect of opioids, so a lower dose may be necessary. Neuropathic pain: Examples include peripheral neuropathy, phantom limb, shingles, and chronic ulcerations. Many times this pain is chronic and does not resolve completely after tissue damage has resolved.1 Nociceptive pain: AKA “regular” pain. This could be a new wound or ulcer, wound dehiscence, trauma, or other types. As tissue injury heals, the pain resolves.1
Common Opioid Side Effects: “CRAM IT” Constipation Respiratory depression Addiction Miosis Itching Throwing up (nausea/vomiting — this is not an allergy)
Most side effects resolve after seven days. Constipation does not, and must be managed.
Starting A Regimen
There are multiple issues to consider prior to prescribing pain medication. The first (or primary) determination is choosing the medication to be used. Secondary to this decision is determining how to manage the risks involved. Primary questions to consider in selecting a drug include: 1) Where is the pain? This is important: The wound care provider is not responsible for treating chronic back pain for a wound on the foot. 2) What type of
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pain is present? 3) Is it neuropathic or nociceptive? 4) What are the patient’s goals for pain management? Complete pain relief may have more side effects, and many patients will desire pain reduction to tolerable levels rather than have more side effects. 5) Does the patient have any allergies or previous response to medications that should guide the drug selection? 6) Are there comorbidities that would guide the medication choice? With experience, these questions are easily answered and an appropriate medication can be chosen without much delay. Incomplete cross-tolerance: A physiological response to a medication that occurs when patients get used to one type of opioid, but don’t necessarily tolerate the new opioid at the equivalent dose. When switching medications, calculated doses need to be decreased by about 50% initially.
Secondary questions that help assess whether or not the risk of opioids will be well managed include: 1) Is the patient receiving pain medications from any other provider? If yes, consider referring the patient back to the treating physician or call the treating physician to coordinate care. If no, let the patient know that by asking for pain medications he/she must agree not to attempt to get additional pain medications elsewhere. 2) Does the patient or anyone in his/her family/ household have a history of addiction to alcohol, tobacco, pain medications, or illegal drugs? 3) Is there a risk of diversion? 4) Who will protect and administer the medications? Consider making these particulars part of the patient-provider contract to outline expectations and responsibilities. A sample contract by the American Academy of Pain Management is available online (www.naddi. org/aws/NADDI/asset_manager/get_ file/32898/opioidagreements.pdf). Though the FDA hadn’t reached a final decision on hydrocodone combinations as of press time for Today’s Wound Clinic, wound care providers may want to consider ordering prescription pads for Schedule II drugs and attending relatable continuing education in order to be Today’s Wound Clinic® May 2013
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