Principles In Pain Management For Wound Care Patients

A significant number of wound care patients may present to your office with chronic pain present for more than three months. These authors provide a guide to treating patients with mild, moderate and severe pain, and review key principles in prescribing and monitoring opioid use.

The definition of chronic pain is pain that lasts past the time of regular healing or for greater than three months in a given patient.¹ According to the 2012 National Health Interview Study, 11.2 percent of adults in the United States present symptoms indicative of chronic pain.²

Consequently, the rate of opioids prescribed by attending physicians is increasing dramatically with approximately 259 million opioid prescriptions tallied annually, presenting a myriad of serious risks for patients taking these medications.³

Accordingly, we propose a set of guidelines and recommendations for treating patients with chronic pain to ensure that patients get proper treatment and are not subject to undue risk through the unnecessary use of opioids.  

Before prescribing any medication to patients experiencing chronic pain, one must establish a baseline level of pain and function. This commonly occurs using a standardized method such as the PEG scale, commonly known as the “pain scale.”⁴ The three items set forth by the PEG scale include the patient’s Pain intensity during the past week, how pain has interfered with Enjoyment of life during the past week and how pain has interfered with General activity in the past week.

The PEG is a three-item scale that asks each patient to assign his or her pain to a number 0–10 with 0 indicating no pain experienced and 10 indicating the most severe pain experienced. How a patient scores on the PEG scale allows one to classify the pain as mild, moderate or severe.  

How To Define And Treat Mild Pain
Mild chronic pain is pain that falls between 0–3 on the PEG scale and has persisted for at least three months. There are a variety of treatments that one can use in combination to treat mild pain effectively. Treatment of mild chronic pain should not require opioid prescription. Alternately, acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, diclofenac or celecoxib (Celebrex, Pfizer) and others should be sufficient to manage mild pain. Doses for acetaminophen can approach a maximum of 3,600 mg/day.

In addition to oral medications, one can prescribe topical anesthetics, including lidocaine patches (Lidoderm, Endo Pharmaceuticals) and salicylate creams, which the patient can use as needed. Patients presenting with diabetic neuropathy may use gabapentin at a starting dose of 100 mg qhs and folic acid supplementation.

Physical therapy in combination with a transcutaneous electrical nerve stimulation (TENS) unit or other electronic muscle stimulation device can also be useful, and one may implement this for patients on an as needed basis in an effort to provide some pain relief and increase blood flow. One can use a combination of any or all of these therapies, and the physician can easily tailor these therapies on a case-to-case basis depending on the needs and tolerance of the patient.  

When Patients Present With Moderate Pain
Moderate chronic pain is pain that falls between 4–6 on the PEG scale and has persisted for three months or longer. The treatment modalities used to treat mild pain may still be effective at fully or partially alleviating moderate pain as well, but they may not.

Patients presenting with moderate pain may require opioid prescription, including hydrocodone/acetaminophen, oxycodone/acetaminophen or tramadol with or without acetaminophen. Before establishing opioid prescriptions, clinicians should exhaust all other treatment options and thoroughly discuss all risks and benefits with the patient. One should always keep opioids at the minimal effective dose to reduce the risk of dependence and/or overdose.

Pertinent Insights On Effective Treatment Of Severe Pain
Severe chronic pain is pain that falls between 7–10 on the PEG scale and has persisted for three months or longer. Severe pain will be physically debilitating for patients, preventing them from conducting everyday activities and significantly reducing their quality of life.

Severe pain often requires the prescription of opioids, including medications such as extended-release or immediate-release oxycodone (OxyContin, Purdue Pharma). In the event that a patient has adverse reactions or allergies to other viable medication, one may prescribe PO hydromorphone (Dilaudid, Purdue Pharma) or morphine. These are short acting medications but we largely discourage their use unless these agents remain the only options.

Finally, if the patient is hospitalized, one may prescribe IV narcotic medication or patient-controlled anesthesia after consulting with the pain management specialist on call (see the table “A Closer Look At Common Pain Management Options” at right).

Keys To Safe And Effective Opioid Use
Physicians need to be cautious when pursuing a treatment pathway that includes opioids. Opioids are highly addictive and pose a serious health risk to patients.

Opioid abuse and addiction is a serious problem affecting millions worldwide, but especially in the United States, which accounts for an estimated 80 percent of all opioid consumption in the world.⁵ The overwhelming quantity of opioids consumed in the United States has led to a laundry list of public health issues between 1999 and 2014.⁶ These issues include more than 165,000 deaths from opioid overdose and more than 420,000 emergency department visits. There has also been immeasurable harm to patients and their families as a result of opioid use disorder and the physical and psychological damage associated with opioid addiction.

This begs the question: Are opioids doing more harm than good? Accordingly, in an attempt to curtail the issues associated with overprescribing opioids, the Centers for Disease Control and Prevention (CDC) has set forth recommendations for managing opioid prescriptions in patients with chronic pain.¹

One of the first recommendations from the CDC is to establish a timeframe to begin or continue to prescribe opioids for chronic pain.¹ One should only consider opioid prescriptions when the perceived benefits for the patient outweigh the risks. If the provider chooses opioids for the patient, he or she should prescribe them concurrently with non-opioid and non-pharmacologic therapies. Before the patient begins opioid treatment, it is imperative that the provider review desired outcomes for pain management and function within reason.

Unlike most non-narcotic pain medications (NSAIDs, acetaminophen, etc.), most opiates do not have a maximum clinically safe dosage. With continued usage, the patient will develop a tolerance and require more and more of the drug in order to achieve the same initial therapeutic effect. This is problematic because at higher dosages, the side effects and complications increase, and patients are at greater risk for addiction or overdose. In order to determine a timeframe for opioid use for a given patient and safely prescribe opioids, physicians should not prescribe more than two weeks’ worth of medication at a time. They also should continuously evaluate patients for therapeutic improvement and signs of addiction or abuse so they can determine the level of benefit or risk associated with treatment. Discontinue opioid prescriptions if no improvement occurs.

The decision to pursue opioids as a treatment should take a number of factors into account focusing on patient safety and risk assessment. One important aspect often overlooked when prescribing opioids is concurrent medication. In 2013, a study found that just under 60 percent of patients taking opioids took them in combination with other prescription drugs, which can lead to death or other harmful outcomes.⁵ Concurrent medications, including benzodiazepines and muscle relaxants, have a similar sedating effect to opioids. When patients take these medications in combination with opioids, the side effects can increase exponentially and drastically increase the risk of death.

Additionally, clinicians should review the patient’s history of controlled substance prescriptions, using their state prescription drug monitoring programs, in order to determine previous abuse, risk for addiction or if the patient already has a recent prescription. Monitor this throughout treatment. Finally, give special consideration to patients with sleep-related breathing disorders, hepatic or renal insufficiency, mental health conditions, prior overdose or substance abuse, those over 65 years old, and pregnant women. These groups of patients are at a higher risk for complications associated with opioid use.

Determining The Correct Opioid And Dosage
Should a physician decide that opioids are the correct choice of treatment, the next step is determining which opioid to use and how to dose it. At the start of opioid therapy, the provider should begin by prescribing a low dose of immediate-release opioids. Do not prescribe extended-release and long-acting opioids right away.

Providers should be wary of patient risks when increasing dosage to greater than 50 morphine milligram equivalents per day and attempt to prevent dosage increases to greater than 90 morphine milligram equivalents per day. When physicians deem it necessary to increase the dosage to greater than 90 morphine milligram equivalents per day, steady justification and adherence to safety parameters are essential. Providers should continuously be evaluating benefits and patient risk one to four weeks after opioid treatments begin, and proceed with these assessments at least every three months thereafter.  

Since opioids expose patients to risks that include misuse, abuse and overdose, all which have a risk of fatality, it is imperative to assess each patient consistently for pain and risk in order to determine the need for and possibly refer the patient for proper intervention.

As for the dosing regimen for opioid medication, we generally recommend that you titrate the dosage every one or two days and titrate by 25 to 50 percent per day. Once the opioid pain medication is no longer needed, we recommend decreasing the dosage gradually to prevent unpleasant withdrawal symptoms.

Final Notes
Unfortunately, there are very few available treatment alternatives to opioids for the treatment of severe chronic pain. Accordingly, opioids will be the correct treatment modality for many patients with more severe chronic pain. A significant portion of the risk associated with opioids is rooted in a lack of patient education as well as a lack of attention on the part of the clinician. Clinicians should ensure close monitoring of patients taking opioids and counsel them properly on the risks and benefits with these medications. Doing so can help optimize results in managing pain in this patient population while lowering the risk to the patient.

Dr. Suzuki is the Medical Director of the Tower Wound Care Centers 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. He can be reached at Kazu.Suzuki@cshs.org.

Mr. Lockhart is affiliated with Tower Wound Care Centers in Los Angeles.

Ms. Birnbaum is affiliated with Tower Wound Care Centers in Los Angeles.

References

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.     Kroenke K, Theobald D, Wu J, et al. Comparative responsiveness of pain measures in cancer patients. J Pain. 2012; 13(8):764–72.
4.     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.
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 https://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 https://wonder.cdc.gov/mcd.html .