Event 2: Acute Pain Treatment

Pain accounts for 70% of Emergency Department visits
Road traffic crashes are responsible for approximately 50 million injuries, per year, worldwide
In 2015, 3,378 Emergency Department visits were from fractures
Pain is one of trauma patients' most prevalent complaints
Trauma pain management recommendations:
- Assess the patient's pain frequently
- Utilize multimodal analgesia therapy

Reference:

Ahmadi A, et al. Pain management in trauma: A review study. J Inj Violence Res. 2016;8(2):89-98; Todd KH. A review of current and emerging approaches to pain management in the emergency department. Pain Ther. 2017; Rui P, et al., National Hospital Ambulatory Medical Care Survey:2015 Emergency Department Summary Tables.

Harold's Rib Fracture and Treatment

Rib fractures:

Most commonly caused by direct impact
Occur in 10% of trauma patients
Include a complication rate of 13%, with half of these including pulmonary complications
Can predict other injuries. Greater than 90% of patients with multiple rib fractures have other injuries
Number of rib fractures correlates with risk of complications and/or mortality

Impact of Rib Fracture Pain:

Rib fractures can cause severe pain
Treatment of the pain is appropriate to improve respiratory function
Rib fractures limit the patient's ability to cough and take deep breaths
- Can result in atelectasis and pneumonia
Respiratory monitoring is required as a standard of care (end tidal CO2 monitoring)

Opioids are recommended with rib fractures like Harold's because reducing pain may prevent the need for intubation and can prevent pneumonia.

Analgesic modalities include:

Epidural analgesia
Intravenous opioids (patient-controlled)
Intercostal blocks (paravertebral or interpleural blocks)

Patients are at risk for multiple thoracic complications including:

Pneumonia
Acute Respiratory distress
Pulmonary effusion
Pulmonary emboli
Aspiration
Atelectasis or lobar collapse

Reference:

Witt CE BE. Comprehensive approach to the management of the patient with multiple rib fractures: A review and introduction of a bundled rib fracture management protocol. 2017; Peek J, et al. Comparison of analgesic interventions for traumatic rib fractures: A systematic review and meta-analysis. Eur J Trauma Emerg Surg. 2018. Harding AD, et al. Treating pain in patients with a history of substance addiction: Case studies and review. J Emerg Nurs. 2014;40(3):260-2; quiz 292.

Harold's Distal Tibia Fracture

There are three types of ankle fractures.

Tibia: shinbone
Fibula: smaller bone of lower leg
Talus: small bone that sits between heel bone and tibia and fibula

Distal Tibia Fracture Treatment

Nonsurgical: Surgery is not required if the broken bone is not out of place.
Surgery: If the fracture is out of place and the ankle is unstable.
Ligament Damage: There may be ligaments damaged. The ligaments of the ankle hold the ankle bones and joint in position. This can lead to chronic ankle problems.
Recovery: It takes at least six weeks for the broken bones to heal and may take longer for the involved ligaments and tendons to heal.
Rehabilitation: Physical therapy and home exercises are important to strengthen the muscles around the ankle.

Reference:

Goost H, et al. Fractures of the ankle joint: Investigation and treatment options. Dtsch Arztebl Int. 2014;111(21):377-388. Shibuya. N; 3. Ankle Fracture. Aofas.org. http://www.aofas.org/footcaremd/conditions/ailments-of-the-ankle/Pages/…. Published 2018. Accessed July 26, 2018.

Harold's Neck Pain

Neck pain resulting from motor vehicle crashes are often classified as whiplash-associated disorders (WAD)
Whiplash-associated disorders are injuries to the neck that occur with sudden acceleration or deceleration of the head and neck relative to other parts of the body
More than 85% of patients experience neck pain after a motor vehicle crash

Pain with neck pain and associated disorders (NAD) and whiplash-associate disorders (WAD) are often experienced as:

Neck pain and upper limb pain
Headaches
Stiffness
Fatigue
Cognitive deficits
Shoulder and back pain
Numbness
Dizziness
Sleeping difficulties

Neck Pain Treatment

Treatment approaches for neck pain and whiplash associated disorder (WAD) consist of a multimodal approach:

Rest
Heat or cold
Over the counter pain medications
Prescription medications
Exercise
Physical therapy
Foam neck collar
Muscle relaxants
Injections

Exercise consists of:

Rotating neck in both directions
Tilting head side to side
Bending neck toward chest
Rolling shoulders

Reference:

Bussieres AE, et al. The treatment of neck pain-associated disorders and whiplash-associated disorders: A clinical practice guideline. J Manipulative Physiol Ther. 2016;39(8):523-564.e27.

Opioids Can be an Effective Treatment Option

Patients with substance abuse are commonly undertreated for their pain
Addiction is a serious public health concern, but so is the under treatment of pain
Evidence shows that stress from poorly treated pain may trigger relapse or intensify an existing addiction
Chronic opioid therapy can be effective for carefully selected and monitored patients with chronic noncancer pain (CNCP)
Prescribers can structure opioid therapy to accommodate identified risk based on patient evaluation
Recommendations for safe and effective opioid use include:
1. Balancing benefits and risks of chronic opioid therapy for CNCP
2. Appropriate initiation and titration of chronic opioid therapy
3. Regular and comprehensive monitoring while on chronic opioid therapy
4. Anticipation and management of opioid-related adverse effects

Harold's Risk Factors for Opioid Use and Misuse

The following describe risk factors for opioid use and misuse. Harold's risk factors are noted next to each relevant notation.

Demographic factors (e.g., younger age, male sex): May be due to differences in awareness of risks and willingness to engage in risk-taking behavior.

Because Harold is male, he's more at risk for opioid use disorder.

Self-reported cravings: Indicates desire to use the drug and leads to continued opioid use.

Harold has self-reported cravings and desire to use opioids to continue the "good feeling."

Family history of substance use disorders: Genetic factors can influence addiction.

Harold reports his mother has a history of substance use disorder.

History of substance or tobacco use: Shown to be strongly predictive.

Harold reports he smoke 2 packs of cigarettes a day for 20 years (40 packs years).

History of preadolescent sexual abuse: Leads to post-traumatic stress disorder, which is associated with substance use.

Harold did not report a history of preadolescent sexual or post-traumatic stress-disorder (PTSD).

Psychiatric history (e.g., depression): Opioids may be misused for their mood-altering properties.

Harold's health history displays a previous diagnosis of depression.

Reference:

Adapted from "Rational Urine Drug Monitoring in Patients Receving Opioids for Chronic Pain: Consensus Recommendations," by Charles E. Argoff, MD et al., 2018, American Academy of Pain Medicine, 19, p. 102. Adapted with permission.

Harold's Assessment:

Name: Harold Miller
Address 123 Maple St
Birth Date: 01/05/1979
Occupation: Freight worker

Notes on Harold

Transferred to general care one day post trauma
Pain well controlled
Stable dose of Buprenorphine/naloxone (Suboxone^®)
Tapered off opioids

Harold's Pain Management in General Care Unit

Pharmacotherapy

The following discusses appropriate pharmacotherapy for Harold's emergency pain management:

Buprenorphine

Harold should receive buprenorphine/suboxone (Suboxone^®). With Harold's history of opioid use disorder (OUD), buprenorphine/naloxone, would be most appropriate because it is used for opioid detoxification or maintenance treatment of OUD, and can be used to treat pain.

Acetaminophen

Harold should receive acetaminophen. Acetaminophen is a nonopioid analgesic that can be used as part of multimodal analgesia, and is not known to cause physical dependence.

Regional anesthesia

Harold could receive an ankle block to allow for early mobilization with assisted devices to prevent further injury. A block using bupivacaine could last approximately 18 hours. See below for more.

Codeine

Codeine is not the best choice for acute pain. It has variable metabolism, which creates unpredictable efficacy and is a weak synthetic opioid with little to no benefit to patients like Harold. Learn more about codeine.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Harold should receive NSAIDs. Because of his history with OUD, NSAIDs can be used as part of multimodal analgesia to reduce requirements for opioids.

Adjuvant drugs

Harold should receive adjuvant analgesics such as anti-convulsant medications as part of multimodal analgesia or antidepressants. Gabapentin is a commonly used anti-convulsant medicaton to treat pain. Alternatives include pregabalin, duloxetine, tricyclic anti-depressants (e.g., amitriptyline).

Tramadol

Harold should not receive tramadol. It is a weak mu opioid agonist for management of mild to moderate acute and chronic pain and should be avoided because of variable metabolism. It also has other serotonergic pathways. Because tramadol can lead to dependence, it should be avoided in patients with a history of substance use disorder.

Reference:

Dever C. Treating acute pain in the opiate-dependent patient. J Trauma Nurs. 2017;24(5):292-299. CDC Guideline for Prescribing Opioids for Chronic Pain | Drug Overdose | CDC Injury Center. cdc.gov. https://www.cdc.gov/drugoverdose/prescribing/guideline.html. Published 2018. Accessed July 26, 2018. Sporer KA. Buprenorphine: A primer for emergency physicians. Ann Emerg Med. 2004;43(5):580-584. Ahmadi A, et al. Pain management in trauma: A review study. J Inj Violence Res. 2016;8(2)89-98. Chou R, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2)113-130.

Harold's Plan

Harold is due to go home with the following:

Naproxen: 440 mg every 12 hours
Acetaminophen: 650 mg every 4 to 6 hours as needed
Buprenorphine/Naloxone (Suboxone^®): 8 mg/2mg twice daily
Physical Therapy (PT)

Reference: Jamison RN, Edwards RR. Risk Factor Assessment for Problematic Use of Opioid for Chronic Pain. Clin Neuropsychol. 2012 Aug 30 https://www.ncbi.nlm.nih.gov/pubmed?term=22935011.