Planning is a fundamental part of our culture, from identifying pre-schools for our infants (often at the time of birth!) to preparing kids for high school and college years before admission. We plan for emergencies as discussed in the blog, “Must Have Unexpected Plan” and provide instructions for when we pass away, shared in the blog “Your Living Trust…details you need to know”. New Year goals help us to plan to live better lives as explained in “Target Change”. Yet, there are some areas that we don’t plan, and maybe it’s because we are not aware that we can. One area that often goes unplanned…pain management in unexpected emergency situations. The inspiration to write this blog comes from a recent experience with a family member requiring surgery to repair a fall fracture. The focus was on, “fix it” and a discussion about pain management following surgery was not. This blog will share the importance of having pain management discussions now, for you and those family members you advocate, so you might have a voice in choosing pain meds and being aware of potential side effects. Before an emergency event takes place know all pain management options. Controlling pain should be individualized to the patient’s age, sensitivity levels, health status and other drugs currently taking. Doctors work best when we give them needed information to effectively treat the patient, be it family members or ourselves. Making pharmaceutical decisions based on another person’s success can be dangerous to your loved ones, and to you.
“It is much more important to know what sort of patient has a disease than what sort of disease a patient has? William Osler
Plan Ahead – Physician Discussion
Falls and emergency medical situations happen suddenly, without warning. Here are some questions you can discuss with your physician. Often pain management conversations take place prior to a planned surgery and therefore, I feel, it might also be a good idea to have such discussions ahead of an unexpected emergency.
Questions To Review With Your Physician
Contact your/loved one’s family practice doctor to discuss pain management options in the event there could be a future situation/need.
- What pain medications are typically administered following emergency need and/or surgery? Dose?
- Length of expected duration on such pain meds?
- Can my family member(s)/I request a very minimum dose first and increase only as needed?
- What are all the side effects known for this/these drugs?
- Can this drug(s) be stopped immediately or is there a tapering off process?
- After no longer taking the drug(s), how long do these drug(s) remain in the body? And, what types of withdrawal symptoms, if any, can be expected?
- What signs might I expect that would indicate a family member or myself could be having a serious reaction and therefore the need to stop the administered pain medication?
- Whom would I immediately notify about this reaction in order to cease taking the pain medication? Would this medication then have to be removed from my pharmaceutical/drug listing? Who would have that authority?
- I do not want any form of Opioids. Other options in place of Opioids?
- Can age and overall health contribute to the effects of drugs? What long term effects could these drugs have on young children following my child’s surgery? Or the elderly who are frail? Other options with less risks?
The goal from this discussion is to have a written statement sharing your pain management preferences that could be placed alongside a HealthCare Directive, for easy access in the event of an emergency. This might also be something you give to your family practice doctor to add to medical records.
Pain Management Drugs
Before you are administered pain medication, you should be asked about your level of pain. Years ago I remember patients, when asked this question, were given a pain chart. Recently, I haven’t seen this chart and in fact, it took me a while to find one online. The chart illustrated below is found in the article, ZERO PAIN, for your reference.
Opioids – Oxycodone (eg, OxyContin®, Percocet®), Hydrocodone (eg, Vicodin®, Lortab®), Hydromorphone (eg, Dilaudid®), Merperidine (Demerol®), Morphine (similar to heroin) Codeine, Fentanyl, Methadone – These are narcotics, which block pain signals from reaching the brain and can affect the whole body (systemic). According to “Technology Versus Pain: Targeted Drug Delivery And Electrical Stimulation – An Alternative to Systemic Opioids” Dr. Lawrence Poree, MD, MPH, PhD, Department of Anesthesia, UCSF, shares that only 1/100th to 1/300th of the amount of oral pain medication actually gets to the place we need it. The remainder of the drug goes elsewhere throughout the body causing problems such as sedation, confusion, constipation, nausea, vomiting, etc. For this reason, higher doses could be needed to manage pain. And, often times combination drug pain therapy is necessary, as well. Opioids are highly addictive and recent news has been reporting an OPIOID epidemic in our country. Dr. Poree notes that in 2011 prescription drug overdose killed more people than auto accidents. “…each day 44 people die from opioid overdoses and 80 percent of those deaths are unintentional.” The following article is another great resource about Opioids…
Five Tips for Pain Management with Opioids: What You Need to Know About Common Prescription Medications by American Society of Anesthesiologists, 3.14.16
Non-Opioids – Aspirin, Ibuprofen (eg, Advil®, Motrin®), Naproxen (eg, Aleve®, Naprosyn®) Acetaminophen (eg, Tylenol®, Q-Pap®) Anti-inflammatory drugs (NSAIDs), Advil® and Aleve® that are anti-inflammatory and acetaminophen to manage mild to moderate pain. These pain management options can also affect the whole body (systemic) since they do not target/isolate the area of pain. They are not addictive. Internal bleeding/ulcers are a concern when elderly take these medications over a prolonged period of time.
Future of Pain Management
Pain management could be at the precipice of significant change. The video presentation Technology Versus Pain: Targeted Drug Delivery And Electrical Stimulation – An Alternative to Systemic Opioids, referenced earlier, was presented February 2016, by Dr. Lawrence Poree, MD, MPH, PhD, UCSF. Very interesting and informative about the history of and problems we face today with pain management along with technological advances regarding Neuromodulation, current alternative to and future advances in pain management, especially chronic pain.
Zero Pain, June 7, 2017, Mission Magazine, Univeristy of Texas Health Science Center at San Antonio
“All we have now are centrally acting opioid painkillers—fentanyl, hydrocodone and others—which has led to an epidemic of abuse and overdoses,” Dr. Shapiro said. “These medications don’t stop the pain signal but instead cover up the sensation in the brain, which frequently leads to devastating addiction. We want to treat pain at the source, at the sensory neuron, so that the pain signal never gets started in the first place, or if it does get started, doesn’t lead to this vicious cycle of pain and addiction.”
Pain Management and the Elderly
As we grow older we at greater risk to sensitivity and side effects of pain medications as well as to anxiety reducing drugs such as atypical antipsychotics – Risperdal, Seroquel, Geodon, Zyprexa as well as Atavin, Ambilify, etc. These anti-depressant drugs can be administered when hospital and skilled nursing facility patients show signs of frustration and depression, often a result of pain and rehab stress. What works OK for some may have serious adverse side effects on others, whether in different age groups, health status, or the interaction with drugs currently prescribed. Why? Because, how we metabolize drugs determine their effectiveness or … toxicity. Why are elderly (especially if inactive) as well as those with multiple health issues at higher risks of narcotic drug side effects?
According to NCBI Resources Opiates and elderly: Use and side effects, June 2008
“The increasing use of opiates for pain management by healthcare practitioners requires that those prescribing opioids be aware of the special considerations for treating the elderly.”
“With aging, there are changes in body composition: increase in adipose tissue, decrease in lean body mass and decrease in total body water. These changes can affect drug distribution. Therefore, lipophilic drugs tend to have greater volume of distribution, and it can take more time to be eliminated from the body (Linnebur et al 2005). Aging can also bring reduction in hepatic blood flow and volume which can decrease metabolism of drugs.” (Tegeder et al 1999; AGS 2006).
“Some patients metabolize a drug so rapidly that therapeutically effective blood and tissue concentrations are not reached; in others, metabolism may be so slow that usual doses have toxic effects. Individual drug metabolism rates are influenced by genetic factors, coexisting disorders (particularly chronic liver disorders and advanced heart failure), and drug interactions (especially those involving induction or inhibition of metabolism).”
Too often I have heard the terms delirium and sundowners applied to elderly who are experiencing confusion. I can’t help but wonder if it’s the drugs administered when hospitalized that are actually the root cause, or at the least, considerably contributing to “confusion” and not simply a default reaction to feeling disorientated in an unfamiliar place such as a hospital or skilled nursing facility? In my own experience I witnessed an an individual on anxiety medication and OxyCODONE suffering confusion and hallucinations, which was diagnosed as Delirium. Yet, once taken off these meds, Delirium vanished and the patient resumed her standard of mental clarity after a few days, still at the same healthcare facility. Questions…
- Since elderly and inactive patients metabolize drugs at a much slower rate, could there be an accumulation effect leading to toxicity of anti-depressant drugs and narcotic pain medications?
- Could possible toxic levels be responsible for triggering Delirium and therefore, not simply the result of feeling disorientated in unfamiliar surroundings?
- If (1) and (2) above could be true, what are other options for safely managing elderly anxiety, depression and pain? Suffering hallucinations is a horrific experience. The memory of those hallucinations linger after the episodes are over!
- Is it possible to have a trained geriatric specialist (PA, NP, or Nurse) at physician family practice offices, considering our growing baby boomer generation is quickly populating this age group, to guide all elderly patients in best care and pharmaceutical options?
What happened to Geriatric Care? The quotes above by NCBI Resources and MSD make it quite clear; drugs are processed slower/differently because of the physiology of elderly patients. Perhaps a form of Geriatric Care should return to Healthcare, providing specific professional guidance and insight to aging patients and their families.
What I Discovered
- If there is a reaction from pain medication, request it be removed. It’s important to minimize withdrawal side effects. Check if gradual removal is needed or if the medication can be stopped immediately. Only a doctor can remove a medication on a medical record.
- Anti-depression drugs such as Ativan or Ambilify can be used to treat anxiety in emergency care and post-surgery recovery. Know drug side effects and red flags to notify healthcare workers. Short term, these drugs can be effective and beneficial. Long term (more than 2 weeks) can present serious side effects best known in advance. Every patient is different and may experience different reactions. I know someone who is so sensitive to medication she experienced the most uncommon side effects, immediately with Ativan. Benefit vs risks should always be considered…with a physician.
- Important next step…Medications triggering side effects that are taken off a medical care chart must also be added to the “allergic” list or DO NOT ADMINISTER list. Do not assume this is automatically done. Only a doctor has this authority and best you request. If this step is not carried out and the drug remains on the patient pharmaceutical list, it can be prescribed again. Follow through with your doctor as well as visiting your online medical portal pharmaceutical listing, if you have one.
- All drugs have some form of side affects. It is important to review benefits vs risks… with your physician, to guide decisions. Internet search should only be used as a guide for questions you can prepare in advance to discuss with your doctor.
This blog post is about questions rather than providing answers. Perhaps you feel as I do…the importance of being informed about pain management options to best plan future healthcare. If we are not in a position to make these decisions, than someone else will. Would you prefer having control over what goes into your body and being fully aware of the potential side effects? Hopefully this post will encourage you to meet with your family practice doctor (or PA, NP, attending nurse) to initiate a conversation about pain management… a good introduction to being actively involved in your healthcare and those you advocate. As the saying goes, every journey begins with a single step. When are you planning to take yours?
- Technology Versus Pain: Targeted Drug Delivery And Electrical Stimulation – An Alternative to Systemic Opioids, February 2016, by Dr. Lawrence Poree, MD, MPH, PhD, UCSF
- Zero Pain, June 7, 2017, Mission Magazine, Univeristy of Texas Health Science Center at San Antonio,
- Five Tips for Pain Management with Opioids: What You Need to Know About Common Prescription Medications by American Society of Anesthesiologists, 3.14.16
- Medication Dictionary WHO Ladder
- NCBI Resources Opiates and elderly: Use and side effects, June 2008
- Drug Metabolism, By Jennifer Le, PharmD, MAS, BCPS-ID, FIDSA, FCCP, FCSHP, Professor of Clinical Pharmacy and Director of Experiential Education in Los Angeles, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego