Pain mgtpdf

Dear Physician:
Physician education/training for a review of pain management is now available. This will
involve:
A. Complete the self-learning module that is attached.
This is approved for 4 CME Category I credit.
Instructions for completion include:
1. Review information in the booklet
2. Complete the written exam.
3. Complete evaluation.
4. Return written exam and evaluation form to Jayne Sheehan.
5. Upon receipt of required paperwork, a certificate of completion will be
sent to P. Eppinger in the Medical Staff office in order to pursue
credentialing of this service on your behalf. A copy will be sent to you
only if requested.
6. J. Sheehan will record the CME credits.
Thank you,
Jayne Sheehan, RN, MSN, CRNP
Director of Professional and Allied Health Education
07/09
rsharesoncmeendmatpainmanagement
Please only print out pages 1-8 for your records and to complete the questions and
evaluation. Please review the Power Points from this document. If you would like a
print out of this Enduring Material, Please contact Lori Graham (x4050) or Jayne
Sheehan (x4052). Thank you!

ENDURING MATERIAL
JAMESON MEMORIAL HOSPITAL
COMPREHENSIVE REVIEW COURSE IN
PAIN MANAGEMENT FOR NON-SPECIALISTS
COURSE DIRECTOR: VEERAIAH C. PERNI, M.D.,
ASSOCIATE CLINICAL PROFESSOR OF ANESTHESIOLOGY, NEOUCOM.
ORIGINAL PROGRAM DATE: MAY 16, 2009
Chronic pain is a complex disease affecting more individuals than diabetes, heart disease, and cancer
combined. There are approximately eighty million sufferers and it is the most common reason to seek
medical help.
Description:
This four hour comprehensive review course on pain management is intended to describe and define the
various types of pain that a primary care physician is confronted with on a regular basis. The course will
offer methods to proper diagnosis and various aspects of pain management. In order to provide better
outcomes with reduced side effects, the standard of care issues, protocols, schedules, and suggestions on
timely transfer of care issues will be reviewed.
Objectives:
After this course, participants should be able to:
1. Describe the pain definition, classification and methods for understanding of proper diagnosis.
2. Describe the various methods of multidisciplinary pain management, including
alternate, non-traditional methods.
3. Demonstrate understanding of the principles of pharmacologic methods for pain
management, including side effects, abuse, governmental regulations, and accountability.
4. Describe the multiple aspects of interventional pain management techniques.
5. Post written test to evaluate the skills on pain management with 85% as a passing score.

Pain Management
To receive CME credits for this test, you must mark your answers,
complete the evaluation/enrollment information, and return them in
the envelope provided to Jayne Sheehan or Lori Graham.
Accreditation Statement
Jameson Health System is accredited by the Pennsylvania Medical
Society to sponsor continuing medical education for physicians.
This CME activity was planned and produced in accordance with
ACCME Essentials and Standards.
Designation Statement
Jameson designates this educational activity for maximum of 4.0
AMA PRA Category 1 credit(s)™. Physicians should only claim credit
commensurate with the extent of their participation in the activity.
Disclosure Statement
All Faculty and CME Committee do not have any real or apparent
conflict(s) of interest or other relationships related to the content of
this presentation.
We encourage participation by all individuals. If you have a disability,
advanced notification of any special needs will help us better serve
you.
Original date: 05/09
Updated:
Expires: 05/2011

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Questions for Pain Symposia
True or False
1. Prescription opiates has overtaken heroin and cocaine as number
one drug of abuse/addiction in the US.
2. The mid-1990s saw a major rise in the number of new non-medical
users of therapeutics (all Classes).
3. The CAGE questionnaire is an instrument in identifying patient
with potential addiction problems.
4. Pseudoaddiction describes the behavior of chronic pain patients
who have inadequate pain treatment.
Multiple Choice
5. Techniques that help suppress head and facial pain include:
a. Trigeminal Nerve block
b. Sphenopalatine block
c. Cervical Nerve root block
d. All of the above
6. Procedures which diagnose or improve sympathetic mediated pain
include:
a. Stellate injection
b. Lumbar sympathetic block
c. Sphenopalatine block
d. Superior Hypogastric plexus and Celiac Plexus block
e. All of the above
7. Which of the following is an example of neuropathic pain?
a. Cancer Pain
b. Postoperative pain
c. Chronic low back pain
d. Post herpetic neuralgia

8. Which of these treatments is approved for migraine
prophylaxis?
a. Aspirin
b. Lamotrigine
c. Fluoxetine
d. Topiramate
9. Which of the following is NOT involved in fibromyalgia?
a. Long standing pain in 11 of 18 standardized areas
b. Central nociception
c. Rash and hair loss
d. Psychological components
10. Which of the following have demonstrated some efficacy
in treating fibromyalgia?
a. Venlafaxine and selective serotonin reuptake inhibitors
b. Tricyclic antidepressants (TCAS), pregabalin, tramadol
c. Opioids
d. Non-steroidal anti-inflammatory drugs (NSAIDS) and
COX-2 specific inhibitors
11.Anticonvulsants have some efficacy in treating neuropathic
pain. Which of the following is approved for treatment of
post herpetic neuralgia?
a. Carbamazepine
b. Gabapentin
c. Lamotrigine
d. Topiramate
12. TCAs are effective for the treatment of low back pain,
neuropathic pain, and migraine. Which of the following
commonly limits their use?
a. Cost
b. Potential for addiction
c. Formulary restrictions
d. Anti-cholinergic side effects

13. Nonselective NSAIDS are not recommended for preemptive
Analgesia because________________________.
a. they are ineffective
b. prolonged clotting times are a concern
c. no intravenous formulations are available
d. postoperative nausea and vomiting are possible
14. Which of the following is highly suggestive of opioid addiction
in patients?
a. “Lost” prescriptions
b. Evidence of deterioration in work or social life
c. Concurrent alcohol or substance abuse
d. All of these

Both pages of the evaluation must be filled out 1
Created 11/09
CME Program Evaluation: Enduring Material (Credits expire May 30, 2011)
Evaluation must be completed and turned in for certificate.
Program Title: Comprehensive Review Course in Pain Management for Non-Specialists
Speaker/Presenter: Drs. Perni, Monroe, Ranieri, and Wrightson
Learning Objectives:
1. Describe the pain definition, classification and methods for understanding of proper diagnosis.
At the conclusion of the presentation, the participant should be able to:
2. Describe the various methods of multidisciplinary pain management, including alternate, non-traditional methods.
3. Demonstrate understanding of the principles of pharmacologic methods for pain management, including side effects, abuse,
governmental regulations, and accountability.
4. Describe the multiple aspects of interventional pain management techniques.
5. Post written test to evaluate the skills on pain management with 85% as a passing score
Please rate the following… Excellent Good Fair Poor
Overall activity…    
Clarity of session content…    
Relevance of content to you…    
Quality of visual aids/handouts…    
Presenter’s overall performance…    
Presenter’s knowledge of subject area…    
Presenter’s presentation skills…    
Presenter’s ability to respond to questions…    
Location of CME activity…    
Statement of changes this program has made on your practice.
Some questions allow for more than one answer.
1. This activity will assist in improvement of:
□ Competence
□ Performance
□ Patient Outcomes
2. I plan to make the following changes in my practice by:
□ Modifying treatment plans.
□ Changing my screening/prevention practice.
□ Incorporating different diagnostic strategies into patient evaluation.
□ Using alternate communication methodologies with patient and families.
□ Other.
□ None. This activity validated current practices.
3. What is your level of commitment to making the changes stated above?
□ Very committed
□ Somewhat committed
□ Not very committed
□ Do not expect to change practice

Both pages of the evaluation must be filled out 2
Created 11/09
4. What are the barriers you face in your current practice setting that may impact patient outcomes?
□ Lack of evidence-based guidelines
□ Lack of applicability of guidelines to current practice or patients
□ Lack of time
□ Organizational or Institutional
□ Insurance or Financial
□ Patient Adherence or Compliance
□ Treatment related to adverse events
□ Other: Explain
5. This activity supported achievement of the learning objectives.
□ Strongly Agree
□ Agree
□ No Opinion
□ Disagree
□ Strongly Disagree
6. The material was organized clearly for learning to occur.
□ Strongly Agree
□ Agree
□ No Opinion
□ Disagree
7. The content learned from this activity will impact my practice.
□ Strongly agree
□ Agree
□ No Opinion
□ Disagree
8. The activity was presented objectively and free of commercial bias.
□ Strongly agree
□ Agree
□ No Opinion
□ Disagree
If you answered Disagree or Strongly Disagree to any of the statements above, please explain your disagreement with
the statement(s) in space below. Any other comments about today’s program can be made here also.
Please print your name Specialty

Pain Management for Non-Specialists
“Introduction to Pain Management”
Presented by:
Veeraiah C. Perni, M.D.
Director of Anesthesiology,
Jameson Memorial Hospital
Associate Professor of Clinical Anesthesiology
Northeastern Ohio Universities
College of Medicine

I, Veeraiah C. Perni do not have any
conflicts of interest in relation to
this presentation.

Evolution of Pain Medicine
Pre- 20th Century
20th Century Pain Management
Revolution in Pain Management
Recent Development

Recent Developments in Pain Management
Local anesthetic supplements
Novel applications of opiates
Non-opioid pharmacologic agents
On-demand, patient-controlled
analgesia
Multi-model analgesia
Regional analgesia techniques
Pain as a “fifth vital sign”
Future of Pain Medicine

Introduction to
Pain Management Cont’d
Epidemiology of Chronic pain
● Chronic Pain- a public health problem
● 30% of US population has chronic pain
● Prevalence of chronic pain increases
with age
● Estimated economic cost for chronic
pain at $100 billion per year

● Pain not taken seriously by the
physician
● Doctor’s lack of knowledge of chronic
pain
● Inadequate Pain management
Inadequacies in the treatment of pain

● Inadequate medical education
● Healthcare system not recognizing
pain relief as a quality of life priority
● Therapy related side effects
● Compliance and regulatory issues
● Increased life expectancy leads to
increase in painful chronic medical
condition
Barriers to appropriate Pain Management

● 50% of elderly living at home and 80% at long
term care facilities have persistent pain
● Physical and psychological toll leading to
depression
● Non-adherence to analgesics exacerbates pain
● Shift the goal of pain treatment to functional
improvement from decreased suffering
● Patients on combination treatments fare best
Barriers to appropriate Pain Management
Cont’d

● Musculoskeletal -
● Neuropathic -
● Visceral pain -
● Metabolic -
● Other -
arthritic fractures
Diabetic, post herpetic
neuralgia
Constipation, urinary
Retention, CAD
Vitamin D deficiency,
osteoporosis, Paget’s
Disease
Fibromyalgia, cancer, PVD,
dental
Common sources of pain in the elderly

Rickie K. Monroe,M.D.
Staff Anesthesiologist

I, Rickie K. Monroe, do not have any
conflicts of interest in relation to
this presentation.

Goal is painless or nearly painless surgery
Anesthesiologist are committed to explore
mechanisms for acute postoperative pain

Quantifying clinical postoperative pain
Visual analogue scale(VAS) or verbal score
Recovery room nurses and floor nurses use
this score to quantify acute pain
Most adult patients can report a verbal pain
score using the range “0” for no pain “10” as
the worse pain imaginable.

After nearly all surgeries, pain with activities
is much greater than at rest!
Pain with activities persist much longer after
most surgery than pain at rest.

Parenteral opiods have limited effects on pain
after surgery only decreasing the baseline
pain at rest
In general, the only group of drugs that
consistently reduces pain responses is local
anesthesics

Epidural analgesia decreases pain with
activities
Continuous regional analgesic techniques like
femoral nerve blocks and brchial plexus block
decrease activity pain!

International Association for the Study of Pain
defines pain as: “unpleasant sensory and
emotional experience associated with actual
or potential tissue damage or described in
terms of such damage”
Pain is subjective and emotional experience

Pain implies perception of a number of
biochemical and physiologic processes
We treat pains of different types because they
vary remarkable in response and effective
drugs depending on the type of pain being
treated.

Peripheral noxious stimulus stimulates
specialized receptors on small myelinated
and unmyelinated fibers (A gamma , C fibers)
Excitatory molecules are released in spinal
cord dorsal horn
Excited neuron sends signals supraspinally
where sensory information is integrated and
perceived as pain

Various reflexes are also excited including
activation of sympathetic nervous system
Regulation takes place by descending
excitatory and inhibitory pathways

Signifies the presence of a noxious stimulus
that produces actual tissue damage
Implies a properly working nervous system
Associated with autonomic hyperactivity, i.e.
hypertension, tachycardia, sweating
Short-lived

Pain from : 1. Recent Surgery
2. Recent Injury
3. Medical Illness
Can be managed immediately
Usually gets better in short time

VISERAL COMPONENT –internal organs heart
,liver intestine
SOMATIC COMPONENT-involving skeletal
muscle

METHOD OF TREATMENT
NSAID’S
Opioids
Side effects:
Intense sedation
Respiratory Depression
Urinary retention
Inhabition of bowel function

Regional Anesthesia
1. Continuous epidural infusion of local anesthetic
2. Spinal administration of morphine(Duramorph)
or Fentanyl(Sublimaze)
3. Peripheral nerve block with local anesthesic
(Marcaine, Naropin)
4. NSAIDS act to inhibit inflammatory-related pain

“ Do not mix pain prescription drugs with
over-the –counter pain relievers without
consulting your doctor”

Non-aspirin Pain Relievers
Acetaminophen (Tylenol)
Dosing (325 -1000 mg po Q4-6hr)
Can relieve headaches and minor pain

Nonsteroidal Anti-inflammatory drugs
Inhibit the synthesis of prostaglandins
Prostaglandins mediate components of the
inflammatory response including fever, pain
and vasodilatation.

NSAID’S
Aspirin (Anacin, Bayer) 325-650 mg po Q 4 prn
Coated or Buffered Aspirin (Ascripton , Bufferin)
Aspirin with Acetaminophen (Excedrin)
Diclofenac (Voltaren)- CV risk, 50 mg po BID-
TID

NSAID’s
Ketoprofen (Orudis) 75 mg po TID
May increase risk of serious and potentially fatal
cardiovascular thrombotic event,MI, and stroke
Used to reduce swelling and irritation as well as
pain
Limit no more than 10 days without talking to
doctor

Naproxen (Aleve)
Over the counter, 250-500mg po q 12 hr
Used to relieve pain, inflammation and fever
Finding which drugs work is a trial & error
process
There is no “magic bullet”
We try different drugs or combinations until we
arrive at what is optimal
Individual treatment

NSAID’s
Side Effects
1. Induced asthma
2. Renal impairment
3. Reduced platelet aggregation with bleeding
risks
4. Risks of peptic ulcer disease
5. Edema
6. Hypertension

Cylo-oxygenase (COX) inhibitors
Are effective analgesics in both inflammatory
and surgical conditions
Decrease opiod reqirements by 30%-50%
There is a central site of action
Increased risk for cardiovascular events such
as MI and stroke : (Vioxx) rofecoxib , (Bextra)
valdecoxib

Pain is severe
Work on nerve cell’s pain receptors
Controversial for chronic pain
There is risk of addiction, the risk is
decreased if used appropriately
Combining medications lets physicians
reduce the amount of narcotics

Commonly administered to treat surgical pain
Should be administered for treatment of
moderate to severe postoperative pain
Opioids in the setting of chronic pain
management have guidelines in all 50 states

Dispensing physicians should become familiar
with the guidelines and maintain appropriate
documentation of compliance
Treatment agreement between the physician and
patient are vital!!!
An understanding of tolerance(increasing amount
of drug needed to produce the same effect) ,or
physical dependence(abrupt cessation of drug
will lead to a withdrawl syndrome) as opposed to
addiction(where drug is used for reasons other
than pain relief)

Respiratory
depression
CNS depression
Hypotension
Syncope
Shock
Seizures
Paralytic ileus
Dependence, abuse
Respiratory arrest
Bradycardia
Muscle rigidity
Cardiac arrest

Codeine
Fentanyl
Morphine
Oxycodone

Morphine (MS
Contin)(15-30 mg po
q8-12hrs)
Avinza – once daily
dosing(30,45,60,75,90
,120 ER)
Methadone -
inexpensive mu
agonist
Duration 6-8 hours
2-4 times more potent
than morphine
Oxycontin(oxycodone)
-2 times more potent
than morphine
Dosage
(10,15,20,30,40,60,80
ER)
No active metabolites
Used in opioid tolerant
patients

Morphine-like
drugs prescribe d
to treat acute pain
or cancer pain
Hydrocodone with
acetaminophen
(Vicodan, Lortab,
Norco)
Acetaminophen
with codeine
(Tylenol#3,etc.)

Duragesic transdermal skin patch- narcotic
treatment for moderate to severe chronic pain
Fentanyl delivery for 72 hours
25 mcg/hr patch ~60 mg per day morphine
Actiq (Transmucosal 200 mcg times 1 Q 30
minute intervals)
Fentora (buccal 100 mcg times 1 Q 30 minute
intervals)
Fast acting medications containing fentanyl
Used for cancer patients who have breakthrough
pain

Respiratory
depression
Respiratory arrest
Bradycardia,severe
Dependence,abuse
Cardiac arrest
Circulatory
collapse
Paralytic ileus

Allows patient to self administer an analgesic
agent
Incremental dose, lockout interval, maximum
dose mg/hr and optional basal rate
Preferred to use incremental dose of opioid
with short lockout interval to allow frequent
dosing ie, morphine 1.5 mg Q 8 min ; 12
mg/hr max.
Basal rate usually used only following
extensive and extremely painful surgery

Has been demonstrated to result in improved
patient satisfaction due to decreased delay in
treatment

Ultram(Tramadol)
Non-narcotic drug that works on opiate
receptors
Indicated for moderate to severe chronic pain
Less risk of addiction
Dosing (50-100mg po q 4-6 hr prn)

Characteristics Drug
Relieve certain pain
Available only by
prescription
Used to help sleep better
Adjust levels of brain
chemicals( Serotonin,
Norepinephine)
Lower doses than that to
treat depression
Amitriptyline
Elavil
Pamelor
Norpramin
Cancer pain, nerve
pain from diabetic
neuropathy, post-
herpetic neuralgia

Cymbalta
Dosing 60 mg po qd
Serotonin and norepinephrine reuptake
inhibitor
FDA approved for treatment of Diabetic
Neuropathy and Fibromyalgia

Help some patients described as having “
shooting “ pain by decreasing abnormal
painful sensations
Still unclear as to how they control pain
Post- herpetic neuralgia from shingles
Tegretol (200-400 mg po bid)
Gabapentin (Neurontin) (300-600 mg po tid)
Pregabalin (Lyrica) (100-300 mg po bid-tid)

Neuaxial delivery of drugs will result in lower
doses of medications need than systemic
delivery
Should result in less opiod related side effects

I. Pruritis
II. Urinary retention
III. Hypotension
I. Sensory or motor
block sensation
II. Respiratory
depression

1) Superficial infection
2) Epidural abscess
3) Epidural hematoma

Group of nerves or single nerve causing pain
Typically using local anesthetic

Interventional Pain Medicine:
Blocks and Procedures
Thomas A Ranieri MD, FIPP

Disclosures
I, Thomas Ranieri, do not have any
conflicts of interest in relation to this
presentation

Pain Physicians
Fellowship Training in Interventional
Techniques
Certifications:
“Special Qualifications” ABA
Diplomat American Board of Pain Medicine
Fellow of Interventional Pain Practice
Diplomat of American Board of
Interventional Pain Medicine

Purpose of Injection/infusion
Therapy
Diagnostic
Therapeutic
Prognostic
Preemptive

Timeline
1. History and Physical
2. Data acquisition and review
3. Diagnostic testing
4. Physical and Behavioral Medicine Evaluation
(Addictionology?)
5. Pharmacologic Intervention
6. Diagnostic/Prognostic/Therapeutic injections
(Precision Localization)
7. Neuroablative Techniques
8. Neuroaugmentive Techniques (SCS,PNS,DAS)
9. Functional Restoration
10. Gainful Employment

Trigeminal Ganglion
Block/Neurolysis
Indications
Trigeminal Neuralgia
Cluster Headaches
Ocular Pain
Cancer Pain
Surgical Anesthesia
Contraindications
Local Infection
Sepsis
Coagulopathy

Cervical Nerve Root
Indications
A-A & A-O joint pain
Occipital Headaches
C/S radiculalgia
Upper Cervical Pain
Contraindications
Local Infections
Coagulopathies
Vertical Metastasis
Suboccipital
craniotomy

Sphenopalatine Ganglion Block
Indications
SPG Neuralgia
Trigeminal Neuralgia
Headaches
Atypical Facial Pain
Herpes Zoster
Ophthalmicus
Cancer
Contraindications
Infection
Coagulopathy
Relative
Altered anatomy ie
surgery, infection or
genetic variations

Stellate Ganglion Block
Indications
Raynaud’s Disease
Arterial Embolism
Meniere`s disease
Herpes Zoster
Post-traumatic
syndrome (CRPS I &
II, Sudeck’s Disease)
Pulmonary Embolism
Contraindications
Anticoagulant
Pneumothorax &
Pneumonectomy on
the contralateral side
Recent Cardiac
Infarction
Glaucoma
Bradycardia

Atlanto-Occipital Block
Occipital Headaches
Pain on rotation when performed
protraction or retraction
Contraindications:
Local Infection
Coagulopathy
C/S instability

Atlanto-Axial Block
Indications:
Occipital Headaches – sub-occipital region
C1-C2 Hypomobility
Contraindications:
Infections
Surgical Fusion
Cervical Surgery
Relative:
Arnold Chiari
Mets to the Cervical Corpus
Dens Fracture
Bleeding disorder

Cervical Facets
Indications:
Whiplash Injuries
Mechanical Neck Pain
Cervical Sprain/Strain
Cervicogenic Cephalgia
Contraindications:
Infections
Coagulopathy

Cervical Discogram
Indications:
Persistent neck and arm pain
Equivocal Findings on MRI
Prior to Cervical Fusion
S/P Fusion to ID transitional levels
Cannot distinguish between scar and recurrent disk
Contraindications:
Infection
Bleeding
Immunocompromised

T2 and T3 Sympathetic Blocks
Indications include upper extremity SMP
and Vascular disease
Contraindications:
Absolute: Infection, bleeding & sepsis
Relative: Thoracic aneurysm and
Respiratory Insufficiency

Other Blocks and Procedures
Intercostals – Injections/Cryo/RFL
Thoracic – facets, disco, epidurals, SNRB –
blocks/RFL/Discectomy
Suprascapular – blocks and RFL
Lumbar – Epidurals, SNRB, Disco,
Facets/RFL/Annuloplasty/Perc-D
Endoscopic Discectomy
Percutaneous Facet Fusion
Celiac and Splanchnic N Blocks/lysis/RFL

Disk Procedures
Symptomatic Disk Disruption
IDET
Biaculoplasty, Disk-it, Stereotactic Disk
Lesioning
Intervertebral Disk Displacement
Nucleoplasty - C/S, T/S, L/S
DeKompressor – C/S, T/S, L/S
SED – C/S, L/S, T12-L1 disk

Stereotactic Radiofrequency Disk
Lesioning

Endoscopic Discectomy
Patient – Monitored Anesthesia Care
Patient has failed all conservative
measures
Patient prefers not to undergo open
discectomy
Does not burn any bridges

Transforaminal Lumbar
Discectomy (SED)

TruFuse
Facet Mediated Pain
Failed all conservative measures
including RFL
Burns NO bridges
Patients receive general anesthesia
Addresses underlying problem

Indications
Isolated Facet based back pain
Minor instability
Adjunct to motion limiting devices
Augment posterior stabilization
Contraindications
Trauma, High Grade instability, Spondylolysis
and Grade 2 or higher Spondylolisthesis

Vertebral Augmentation
Indications – VCFx due to osteoporosis,
Tumor, angiomas
Contraindications – infection, coagulopathy,
vertebra Plana, Retropulsion, non-
visualization
Kyphoplasty – Balloon Tamp cavity creation,
endplate elevator and PMMA delivery
Vertebroplasty – PMMA delivery

Epiduroscopy
Epidural steroid injections in patients
with previous surgery
Lysis of perineural adhesions
Puncture and aspiration of synovial
cysts and CSF inclusion cysts
Irrigation of spinal canal after and
extruded or sequestered disk fragment

Spinal Cord Stimulation
Indications:
Failed Back
Peripheral Vascular Disease and ischemic pain
CRPS
Post-Herpetic Neuralgia
Visceral Pain – Angina, thoracic or AAA
Deafferentiation
Torticollis, MS and Cerebral Palsy
Peripheral Nerve Stimulation

SCS
Demonstrated relief with the temporary
electrode ( 50% or greater)
Cleared by Behavioral Medicine
Failed all Measures including surgical
Not addicted or in litigation

Drug Administration System
• Indications:
– Pain type and generator appropriate
– Demonstrated opioid responsiveness
– No untreated psychopathology
– Demonstrated relief with trial catheter

DAS
• Exclusion Criteria:
– Aplastic Anemia and systemic infection
– Known allergies to the materials in the implant
– Known allergies to the medicines considered
– Active intravenous drug use
– Psychosis or dementia

Intrathecal Drug Administration

Summary
• Interventions are performed to identify,
treat and ablate pain generators
• In depth knowledge of fluoroscopic
anatomy is necessary
• Each individual case presents its own
problems relative patients own intentions
i.e. secondary gain, depression,factitious
• Each case must pass the “Yo Mama” test

Proper Opiate Prescribing
Guidelines
John D. Wrightson, M.D. FAAPMR
Board Certified in Physical Medicine,
Rehabilitation & Pain Management

I, John D. Wrightson, do not have any
presentation.

Guidelines
When is prescribing appropriate?
What information is necessary before prescribing?
What are the laws regarding prescription narcotic
use?
• For Physicians?
• For Patients?

Guidelines
What are the differences between dependence, tolerance,
addiction and pseudo-addiction?
How should the patient taking long-term opiate medication for
chronic non-malignant pain be managed?
• Treatment options?
What are the requirements necessary to either discontinue
prescription narcotic use or discharge a patient for either abuse
or diversion?

Guidelines
When is prescribing appropriate?
Acute pain : Pain that comes on quickly, can be severe,
but lasts a relatively short time. As opposed to chronic
pain.
Chronic pain: Pain (an unpleasant sense of discomfort)
that persists or progresses over a long period of time. In
contrast to acute pain that arises suddenly in response to
a specific injury and is usually treatable, chronic pain
persists over time and is often resistant to medical
treatments.
Pitfall: How can physicians be certain that a patient’s
pain is legitimate and that the painful condition warrants
the use of narcotics?

Guidelines
What information is necessary before prescribing?
More important for patient’s requiring chronic
opiate management.
What does the patient’s history & physical
examination show?
What is documented in diagnostic testing records?
What documentation is appropriate? (Above, plus
pharmacy records, urine drug screen)

Guidelines
What are the laws regarding prescription narcotic
use?
• For Physicians?
• For Patients?

Guidelines
The Tenets of Lawful Prescribing
A lawful prescription for a controlled substance
must be:
Issued for a legitimate medical purpose
By an individual practitioner acting in the usual
course of his or her professional practice.
Physician-patient relationship exists.
Documented in the medical records.

Guidelines
Summary of Federal Law
Federal law does not preclude the use of opioid’s as analgesics for
legitimate medical purposes, including treating chronic pain and
treating pain in addicts.
Federal law does prohibit the use of opioids to maintain an
addicted state without special registration as an NTP

Guidelines
Patient responsibilities:
Take medication as prescribed
Do not share medication
Do not accept medications from other people, physicians
Essentially, adhere to pain management agreement

Guidelines
What are the differences between dependence,
tolerance, addiction and pseudo-addiction?
Dependence
Tolerance
Addiction
Pseudoaddiction

Guidelines
Dependence: refers to a state
resulting from chronic use of a drug
that has produced tolerance and
where negative physical symptoms
of withdrawal result from abrupt
discontinuation or dosage reduction.

Guidelines
Tolerance: decrease in
susceptibility to the effects
of a drug due to its continued
administration.

Guidelines
ADDICTION: drug addiction, a condition
characterized by an overwhelming desire to continue
taking a drug to which one has become habituated
through repeated consumption because it produces a
particular effect, usually an alteration of mental
status. Addiction is usually accompanied by a
compulsion to obtain the drug, a tendency to increase
the dose, a psychologic or physical dependence, and
detrimental consequences for the individual and
society.
Mosby's Medical Dictionary, 8th edition. © 2009,
Elsevier.

Guidelines
Pseudoaddiction: Pattern of drug seeking behavior
of pain patients receiving inadequate pain
management that can be mistaken for addiction
Cravings and aberrant behavior
Concerns about availability
“Clock-watching”
Unsanctioned dose escalation
**Can be distinguished from true addiction in that
the behaviors resolve when pain is effectively
treated.

Guidelines
How should the patient taking long-term opiate
medication for chronic non-malignant pain be
managed?
Monthly evaluations
Random urine drug screens & pill counts
Pain Management Agreement
Opiate Informed consent

Guidelines
How should the patient taking long-term opiate
medication for chronic non-malignant pain be
managed?
• Treatment options?
Poly-pharmacy, inclusive of NSAIDS, muscle relaxants,
anti-convulsants, anti-depressants (TCA’s, SSRI’s,
SNRI’s), opiates, etc…
Physical therapy
Occupational therapy
Psychiatric therapy
Cognitive-behavioral therapy
Surgical intervention

Guidelines
What are the requirements necessary to either
discontinue prescription narcotic use or discharge a
patient for either abuse or diversion?
Repeated phone calls to the office requesting early
narcotic refills.
Unusual excuses to explain loss, theft or damage to
narcotic medication.
Tainted urine drug screens.

Guidelines
Continued discharge criteria:
Incorrect pill count
Evidence of Doctor Shopping

Guidelines
Physician obligation to patient:
If discontinuing opiates only:
letter outlining to the patient of such necessity
Offer patient the opportunity to attend rehab
If discharging a patient:
Letter of discharge if patient being released from
practice
Offer patient opportunity to attend rehab
One month supply of discharge or withdrawal medication

Guidelines
Conclusion:
It is often appropriate and necessary to prescribe
narcotic based medications. As long as these
guidelines are adhered to, physicians may
prescribe them without fear of disciplinary action
or prosecution.

Chronic Intractable Pain andChronic Intractable Pain and
Opioids:Opioids:
Relieve sufferingRelieve suffering
Avoid addictionAvoid addiction
Limit liabilityLimit liability
Thomas A Ranieri MD, FIPP, DABIPPThomas A Ranieri MD, FIPP, DABIPP
Allied Pain Treatment CentersAllied Pain Treatment Centers

DisclosuresDisclosures
I, Thomas Ranieri, have no conflict of interest inI, Thomas Ranieri, have no conflict of interest in
relation to this presentation.relation to this presentation.

Prescribing Controlled DrugsPrescribing Controlled Drugs
A Question of BalanceA Question of Balance
““The underThe under--prescribing of controlled drugsprescribing of controlled drugs
for acute, chronic and malignant pain, andfor acute, chronic and malignant pain, and
(perhaps) anxiety is extremely widespread(perhaps) anxiety is extremely widespread
and contributes to significant patientand contributes to significant patient
morbidity.morbidity.””
1988 AMA/White House Symposium1988 AMA/White House Symposium

Prescribing Controlled Drugs:Prescribing Controlled Drugs:
A Question of BalanceA Question of Balance
““The overThe over--prescribing of controlledprescribing of controlled
drugs contributes to societal substancedrugs contributes to societal substance
abuse, iatrogenic dependence, increasedabuse, iatrogenic dependence, increased
morbidity, and a risk managementmorbidity, and a risk management
nightmare.nightmare.””
1988 AMA/White House Symposium1988 AMA/White House Symposium

Number of U.S. TreatmentNumber of U.S. Treatment
Admissions and EmergencyAdmissions and Emergency
Department Mentions forDepartment Mentions for
Narcotic Painkillers, 1995Narcotic Painkillers, 1995--20022002
1995 1996 1997 1998 1999 2000 2001 2002
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
110,000
Treatment
Admissions
Emergency
Department
Mentions

Unintentional Drug PoisoningUnintentional Drug Poisoning
Paulozzi et al.Paulozzi et al. –– Pharmacoepidemiol Drug Saf. 2006 15(9):618Pharmacoepidemiol Drug Saf. 2006 15(9):618--627627
Average Mortality IncreasedAverage Mortality Increased
5%/year from 19795%/year from 1979--19901990
18%/year from 199018%/year from 1990--20022002
Opioid poisoning vs. Cocaine, Heroin from 1999Opioid poisoning vs. Cocaine, Heroin from 1999--20022002
91% inc. with Opioids91% inc. with Opioids
33% inc. with Cocaine33% inc. with Cocaine
12% inc. Heroin12% inc. Heroin
2002 Statistics2002 Statistics
32% Methadone32% Methadone
54% other opioids54% other opioids
13% synthetic Opioids13% synthetic Opioids

Number of new nonNumber of new non--medicalmedical
users of therapeuticsusers of therapeutics
(NSDUH,
2002)

Drug Abuse: An EpidemicDrug Abuse: An Epidemic
Current illicit drug use in 2006(1 mo. Prior to survey) NSDUH SuCurrent illicit drug use in 2006(1 mo. Prior to survey) NSDUH Surveyrvey
Among Populations aged 12 or olderAmong Populations aged 12 or older
20.4 million Americans or 8.3% of population20.4 million Americans or 8.3% of population
Nearly 8,000 initiates per dayNearly 8,000 initiates per day
Among population aged 12 o 17Among population aged 12 o 17
9.8% of population9.8% of population
Among population aged 18 or olderAmong population aged 18 or older
18.5 million current users18.5 million current users
13.4 million (74.9%) employed part or full time13.4 million (74.9%) employed part or full time
Lifetime useLifetime use –– 111.8 million111.8 million
Past yearPast year –– 35.8 million35.8 million
Illicit drug use other than marijuanaIllicit drug use other than marijuana
Life time 72.9 millionLife time 72.9 million
Past year 21.3 millionPast year 21.3 million
Current 9.6 millionCurrent 9.6 million

Chronic intractable pain: theChronic intractable pain: the
clinical challengeclinical challenge
Be aware of theBe aware of the ““Heart SinkHeart Sink”” patient.patient.
Remain within your area of expertise.Remain within your area of expertise.
Utilize Interventional Pain Medicine to validateUtilize Interventional Pain Medicine to validate
complaint (Injection and/or Differential infusions)complaint (Injection and/or Differential infusions)
Stay grounded in you role:Stay grounded in you role:
COMFORT ALWAYSCOMFORT ALWAYS
THENTHEN……....
CURE SOMETIMESCURE SOMETIMES

Prescribing Controlled DrugsPrescribing Controlled Drugs
The DoctorsThe Doctors
PitfallsPitfalls
““I just donI just don’’t prescribe any controlled drugs in myt prescribe any controlled drugs in my
practicepractice””
““If patients abuse their medications, that is theirIf patients abuse their medications, that is their
problem not mineproblem not mine””
““I only prescribe controlled drugs in extremeI only prescribe controlled drugs in extreme
situations, and only if pushedsituations, and only if pushed””

Chronic Pain Management:Chronic Pain Management:
decisions regarding chronic opioiddecisions regarding chronic opioid
therapytherapy
What are the indication for considering chronicWhat are the indication for considering chronic
opioids in chronic pain syndromes?opioids in chronic pain syndromes?
IndicationIndication –– patient specific and disease specificpatient specific and disease specific
ContraindicationsContraindications

Indications forIndications for possiblepossible chronicchronic
opioidsopioids
THE FIVE QUESTIONSTHE FIVE QUESTIONS
Is there a clear diagnosis?Is there a clear diagnosis?
Is there documentation of an adequate workIs there documentation of an adequate work--up?up?
Is there impairment of function?Is there impairment of function?
HasHas nonnon--opioid multi modal therapyopioid multi modal therapy failed?failed?
Are contraindications to opioid therapy ruled out?Are contraindications to opioid therapy ruled out?
Begin opioid therapyBegin opioid therapy……Document! Monitor!Document! Monitor!
Avoid polyAvoid poly--pharmacypharmacy

Contraindications to chronicContraindications to chronic
opioid prescribingopioid prescribing
Allergy to opioid medications ~ relativeAllergy to opioid medications ~ relative
Current addiction to opioids ~ ?Current addiction to opioids ~ ?absoluteabsolute
Past addiction to opioids ~ ?Past addiction to opioids ~ ?absoluteabsolute
Current /past addiction, opioids never involvedCurrent /past addiction, opioids never involved
~~ relative, ??absolute if cocainerelative, ??absolute if cocaine
Severe COPD ~ relativeSevere COPD ~ relative

Prescription Drug AbusePrescription Drug Abuse
The DrugsThe Drugs
All euphoria producing drugs (EPDAll euphoria producing drugs (EPD’’s) haves) have
abuse and dependence producing potentialabuse and dependence producing potential
SedativeSedative--hypnotics / Stimulants / Opioidshypnotics / Stimulants / Opioids
Totally DIFFERENT classesTotally DIFFERENT classes
What do they have in common?What do they have in common?
Acute release of DOPAMINE from the VTM toAcute release of DOPAMINE from the VTM to
the frontal cortexthe frontal cortex

Chronic pain management:Chronic pain management:
ruling out addictionruling out addiction
Perform an AUDIT and CAGE.Perform an AUDIT and CAGE.
Ask family or sig. other the fAsk family or sig. other the f--CAGE.CAGE.
Perform one or more toxicology tests.Perform one or more toxicology tests.
Inquire of prior physicians re: use of controlledInquire of prior physicians re: use of controlled
prescriptions (fprescriptions (f--CAGE).CAGE).
If history of current or prior addiction, everIf history of current or prior addiction, ever
abused opioids?abused opioids?

Screening for Addiction: theScreening for Addiction: the
CAGE and fCAGE and f--CAGECAGE
CAGE =CAGE = CCut down on use? Comments byut down on use? Comments by
friends and family about use that havefriends and family about use that have aannoyednnoyed
you? Embarrassed bashful oryou? Embarrassed bashful or gguilty re: behaviorsuilty re: behaviors
when using?when using? EEyeye--openers to get started in theopeners to get started in the
mornings?mornings?
FF--CAGE = Ask the patientCAGE = Ask the patient’’s significant others significant other
the CAGE about the patientthe CAGE about the patient’’s use of alcohol,s use of alcohol,
drugs or controlled prescriptions.drugs or controlled prescriptions.

Assessment of AddictionAssessment of Addiction
Differentiate between misuse, abuse andDifferentiate between misuse, abuse and
addiction behaviorsaddiction behaviors
Distinguish between primary addictive diseaseDistinguish between primary addictive disease
and pain underand pain under--treatmenttreatment
Refer when neededRefer when needed-- Addictionology, PsychiatryAddictionology, Psychiatry
and Interventional Pain (validation)and Interventional Pain (validation)

TERMSTERMS
ToleranceTolerance: The development of a need to take increasing: The development of a need to take increasing
doses of a medication to obtain the same effect;doses of a medication to obtain the same effect;
tachyphylaxis is the term used when this processtachyphylaxis is the term used when this process
happens quickly.happens quickly.
DependenceDependence: The development of substance specific: The development of substance specific
symptoms of withdrawal after the abrupt stopping of asymptoms of withdrawal after the abrupt stopping of a
medication; these symptoms can be physiological onlymedication; these symptoms can be physiological only
(i.e., absence of psychological or behavioral maladaptive(i.e., absence of psychological or behavioral maladaptive
patterns).patterns).

TERMSTERMS
AddictionAddiction: The development of a maladaptive pattern of: The development of a maladaptive pattern of
medication use that leads to clinically significantmedication use that leads to clinically significant
impairment or distress in personal or occupationalimpairment or distress in personal or occupational
roles. This syndrome also includesroles. This syndrome also includes a great deal of timea great deal of time
used to obtain the medication, use the medication, orused to obtain the medication, use the medication, or
recover from its effects; loss of control over medicationrecover from its effects; loss of control over medication
use; continuation of medication use after medical oruse; continuation of medication use after medical or
psychological adverse effects have occurredpsychological adverse effects have occurred..

TermsTerms
““PseudoPseudo--addictionaddiction””
Definition: Patients with severe unrelieved painDefinition: Patients with severe unrelieved pain
become intensely focused on obtaining relief, and canbecome intensely focused on obtaining relief, and can
mimic aspects of drug seeking (aberrant) behavior.mimic aspects of drug seeking (aberrant) behavior.
(Haddox, 1990)(Haddox, 1990)
This behavior should resolve when adequate pain relief isThis behavior should resolve when adequate pain relief is
provided, without evidence of loss of control, escalation,provided, without evidence of loss of control, escalation,
binging, etc.binging, etc.
Pseudoaddiction is a pseudoPseudoaddiction is a pseudo--diagnosis (ASIPPdiagnosis (ASIPP --2008)2008)

Tips for prescribing of chronicTips for prescribing of chronic
opioidsopioids
Factor in tolerance (already on opioids).Factor in tolerance (already on opioids).
Start low/go slow (not already on opioids).Start low/go slow (not already on opioids).
Slow release, long acting preparations.Slow release, long acting preparations.
Fixed dosing, avoid prnFixed dosing, avoid prn’’s.s.
Avoid opioids forAvoid opioids for ““breakthroughbreakthrough”” pain.pain.
Avoid polyAvoid poly--pharmacy involvingpharmacy involving controlledcontrolled
drugsdrugs!!!!!!

Drugs to Avoid & AlternativesDrugs to Avoid & Alternatives
Controlled drugs to avoid prescribingControlled drugs to avoid prescribing
Side effectSide effect
meperidine, propoxyphene, butalbitalmeperidine, propoxyphene, butalbital
Narrow toxic/therapeuticNarrow toxic/therapeutic
secobarbital, pentobarbital, meprobamate,secobarbital, pentobarbital, meprobamate,
ethchlorvynolethchlorvynol
Lack of efficacyLack of efficacy
carisoprodol (Soma), propoxyphenecarisoprodol (Soma), propoxyphene

Drugs to Avoid & AlternativesDrugs to Avoid & Alternatives
ALTERNATIVES:ALTERNATIVES:
Meperidine =Meperidine = anyany other CII medication!other CII medication!
Butalbital = DHE / compazine / tramadol / etcButalbital = DHE / compazine / tramadol / etc
Sedative Hypnotics =Sedative Hypnotics = anyany benzodiazepinebenzodiazepine
Soma = baclofen / skelaxin / flexeril / etcSoma = baclofen / skelaxin / flexeril / etc
Propoxyphene = other opioids / NSAIDS (cox I orPropoxyphene = other opioids / NSAIDS (cox I or
II) / acetaminophen / tramadolII) / acetaminophen / tramadol

Documentation when initiating aDocumentation when initiating a
chronic opioid treatment planchronic opioid treatment plan
Identify a clear diagnosisIdentify a clear diagnosis
Document an adequate workDocument an adequate work--up.up.
Ensure that nonEnsure that non--opioid therapy failed or is notopioid therapy failed or is not
appropriate (appropriate (treatment rationaletreatment rationale).).
Identify anticipated outcome (treatmentIdentify anticipated outcome (treatment goalgoal).).
Strongly consider anStrongly consider an opioid agreementopioid agreement..
Consult a physician with expertise in the organ systemConsult a physician with expertise in the organ system
involved.involved.

Rules Governing Prescription ofRules Governing Prescription of
OpiatesOpiates
State of Ohio Medical and Pharmacy BoardsState of Ohio Medical and Pharmacy Boards
Cannot prescribe opiates to an addict with Chronic pain unless tCannot prescribe opiates to an addict with Chronic pain unless thehe
patient is under the care of an addictionologistpatient is under the care of an addictionologist
Patients being prescribed opiates for a documented Chronic painPatients being prescribed opiates for a documented Chronic pain
diagnosis must also be evaluated and treated by Psychiatry and/odiagnosis must also be evaluated and treated by Psychiatry and/orr
Clinical PsychologistClinical Psychologist
Must adhere to the state medical rules governing controlled subsMust adhere to the state medical rules governing controlled substancetance
prescriptionprescription

RulesRules
These rules do not apply when prescribingThese rules do not apply when prescribing
nonnon--narcotic medication for chronic painnarcotic medication for chronic pain

RulesRules
Documentation of improvement of function ADLs,Documentation of improvement of function ADLs,
employment, volunteering exerciseemployment, volunteering exercise
Documentation of patient compliance and nonDocumentation of patient compliance and non--
diversiondiversion
Documentation the patient is not an addictDocumentation the patient is not an addict
Specialist can assume the care but is usually aSpecialist can assume the care but is usually a
consultantconsultant
Evaluate progress toward treatment objectivesEvaluate progress toward treatment objectives

What are the Rules?What are the Rules?
Documentation of PathologyDocumentation of Pathology
Validation of complaint by more than one source i.e.Validation of complaint by more than one source i.e.
consultantsconsultants
Identify and document pain mechanismIdentify and document pain mechanism
Prescribe amounts within the PDRPrescribe amounts within the PDR’’s Recommendations Recommendation
Documentation of continued needDocumentation of continued need
Use mostly long acting medications unlessUse mostly long acting medications unless
contraindicatedcontraindicated

DiagnosticsDiagnostics
LaboratoryLaboratory
Imaging and Nuclear StudiesImaging and Nuclear Studies
NeurophysiologicNeurophysiologic
Neural Scan, EMG/NCV, AutonomicNeural Scan, EMG/NCV, Autonomic
Vascular StudiesVascular Studies
Diagnostic InjectionsDiagnostic Injections
ValidationValidation
IdentificationIdentification
SuppressionSuppression
PrognosticPrognostic
Reduction of InflammationReduction of Inflammation

Purpose of Injection TherapyPurpose of Injection Therapy
Augment healingAugment healing –– steroids/ PFP is comingsteroids/ PFP is coming
Promote normal physiologyPromote normal physiology –– Synvisc/PFPSynvisc/PFP
Enhance central modulationEnhance central modulation –– 10%NACL/Phenol10%NACL/Phenol
Validation of Pain complaintValidation of Pain complaint
Identify Pain mechanism and pathwayIdentify Pain mechanism and pathway
Limit consumption of psychoactive substanceLimit consumption of psychoactive substance
Augment and enhance rehabilitationAugment and enhance rehabilitation

Monitoring strategy whenMonitoring strategy when
prescribing chronic opioidsprescribing chronic opioids
Document functional improvement.Document functional improvement.
Titrate opioids to improved function.Titrate opioids to improved function.
Monitor medications (pill counts).Monitor medications (pill counts).
Avoid nonAvoid non--planned escalation.planned escalation.
Monitor for scams (controlled drug consent)Monitor for scams (controlled drug consent)
Perform occasional toxicology tests.Perform occasional toxicology tests.
Document, document, document!Document, document, document!

Scams #1Scams #1
Spilled the bottleSpilled the bottle
The dog ate itThe dog ate it
Lost the prescriptionLost the prescription
Washed in laundryWashed in laundry
Medications stolenMedications stolen
Left somewhereLeft somewhere
The PharmacistThe Pharmacist ““shortedshorted”” meme

Scams #2Scams #2
Physician heal thyselfPhysician heal thyself
Oh, by the wayOh, by the way
You are the only one who understands...You are the only one who understands...
Rx lifting/alteringRx lifting/altering
Late calls/cross coverageLate calls/cross coverage
John Hancock/John Hancock/““Dear DoctorDear Doctor””

Dealing with ScamsDealing with Scams
PrinciplesPrinciples
Cops vs Docs attitudesCops vs Docs attitudes
No offense but...No offense but...
Learn to recognize common scamsLearn to recognize common scams –– USE AUSE A
CONTROLLED DRUG CONSENT!CONTROLLED DRUG CONSENT!
Just say no (and mean it)Just say no (and mean it)
Turn the tablesTurn the tables

Emergency contraindications toEmergency contraindications to
continued controlled drug prescribingcontinued controlled drug prescribing
(above all, first do no harm)(above all, first do no harm)
Altering a prescription = FELONYAltering a prescription = FELONY
Selling Rx. drugs = DRUG DEALINGSelling Rx. drugs = DRUG DEALING
Accidental/intentional overdose = DEATHAccidental/intentional overdose = DEATH
Threatening staff = EXTORTIONThreatening staff = EXTORTION
Too many scams = OUT OF CONTROLToo many scams = OUT OF CONTROL

Emergency contraindications to continuedEmergency contraindications to continued
controlled drug prescribingcontrolled drug prescribing
(above all, first do no harm)(above all, first do no harm)
What is a physician to do?What is a physician to do?
1) Identify the contraindicated behavior.1) Identify the contraindicated behavior.
2) Show where agreement was broken.2) Show where agreement was broken.
3) State that prescribing is inappropriate.3) State that prescribing is inappropriate.
4) Educate about withdrawal symptoms.4) Educate about withdrawal symptoms.
5) Instruct to go to the E.R. if withdrawal.5) Instruct to go to the E.R. if withdrawal.
6) Offer care with out Rx, and/or referral6) Offer care with out Rx, and/or referral..

Signs and symptoms of opioidSigns and symptoms of opioid
withdrawalwithdrawal
HEENT, CV, GI, MS, Neuro/Psych.HEENT, CV, GI, MS, Neuro/Psych.
HEENTHEENT-- dilated pupils, lacrimation, rhinorrhea,dilated pupils, lacrimation, rhinorrhea,
yawningyawning
CVCV-- tachycardia, hypertensiontachycardia, hypertension
GIGI-- nausea, vomiting, diarrhea, abd. crampsnausea, vomiting, diarrhea, abd. cramps
MSMS-- piloerection, diaphoresis, myalgias,piloerection, diaphoresis, myalgias,
arthralgias, bone painsarthralgias, bone pains
N/PN/P--insomnia, anxiety, headache, dysphoriainsomnia, anxiety, headache, dysphoria

Are chronic opioids appropriate?Are chronic opioids appropriate?
ReRe--documentdocument::
DiagnosisDiagnosis
WorkWork--upup
Treatment goalTreatment goal
Functional statusFunctional status
Monitor ProgressMonitor Progress::
Pill countsPill counts
FunctionFunction
Refill flow chartRefill flow chart
Occasional urineOccasional urine
toxicologytoxicology
Adjust medicationsAdjust medications
Watch for scamsWatch for scams
Physical Dependence vs AddictionPhysical Dependence vs Addiction::
Chemical dependenceChemical dependence
screeningscreening
Toxicology testsToxicology tests
Pill countsPill counts
Monitor for scamsMonitor for scams
Reassess forReassess for
appropriatenessappropriateness
Educate patientEducate patient
on need toon need to
discontinue opioidsdiscontinue opioids
EmergencyEmergency??
ie: overdosesie: overdoses
selling medsselling meds
altering Rxaltering Rx
NO!NO!
33--month self tapermonth self taper
(document in chart)(document in chart)
OKOK
1010--week structured taperweek structured taper
OKOK
Discontinue opioids atDiscontinue opioids at
end of structured taperend of structured taper
Pain Patient onPain Patient on
Chronic OpioidsChronic Opioids ++ New PhysicianNew Physician
YES!YES! UNSUREUNSURE NONO
YES!YES!
Discontinue opioidsDiscontinue opioids
Instruct patient onInstruct patient on
withdrawal symptomswithdrawal symptoms
Tell to “go to ER”Tell to “go to ER”
if withdrawal symptomsif withdrawal symptoms

Opioid w/d treatment optionsOpioid w/d treatment options
Gradual self taper over three months**Gradual self taper over three months**
10 week structured taper**10 week structured taper**
Abrupt discontinuation and detoxificationAbrupt discontinuation and detoxification
MethadoneMethadone
ClonidineClonidine
BuprenorphineBuprenorphine
TramadolTramadol
UltraUltra--Rapid Opiate DetoxificationRapid Opiate Detoxification –– Consent &Consent &
ComplianceCompliance
** =** = nonnon--emergency patientemergency patient with a legitimate pain diagnosis.with a legitimate pain diagnosis.

Chronic intractable pain: theChronic intractable pain: the
clinical challengeclinical challenge
Be aware of theBe aware of the ““Heart SinkHeart Sink”” patient.patient.
Remain within your area of expertise.Remain within your area of expertise.
Stay grounded in you roleStay grounded in you role
Utilize Interventional Pain Physician forUtilize Interventional Pain Physician for
Diagnostic/DifferentialDiagnostic/Differential -- Injections/InfusionsInjections/Infusions
FIRSTFIRST…….DO NO HARM.DO NO HARM
THENTHEN……....
CURE SOMETIMESCURE SOMETIMES
COMFORT ALWAYSCOMFORT ALWAYS

Pain Management forPain Management for
the Nonthe Non--SpecialistSpecialist
Presented by:
Veeraiah C. Perni, M.D.
Director of Anesthesiology

I, Veeraiah C. Perni do not have any
presentation.

Practical Pain Management forPractical Pain Management for
NonNon--SpecialistsSpecialists
Target clinical specialty
Guideline objectives
Assessment /Evaluation
Management/Rehabilitation/Treatment
Chronic low back pain: ACP/APS
recommendations
Special focus on Cancer pain and palliative
medicine
Tips on referrals to pain specialist
How to get paid for Pain Management

Target Clinical SpecialtyTarget Clinical Specialty
Family Practice
Internal Medicine
Pediatrics
Physical Medicine and Rehabilitation
Psychology
Surgery
Hospitals/Allied Health Personnel

Guideline ObjectivesGuideline Objectives
Chronic Pain; scope/definition
To improve by bio-psychosocial
assessment
The target is management not elimination
Multidisciplinary team approach; the
primary care physician as team leader
The goal of treatment is to improve
function through fitness and healthy
lifestyle
To improve the effective use of
medications and interventional techniques

Key Points in the History of theKey Points in the History of the
Chronic Pain PatientChronic Pain Patient
Pain location, intensity, quality, onset,
duration, effects of pain, and pain relief
A general history and physical exam are
essential
A history of depression or other
psychopathology
Past or current physical, sexual, or
emotional abuse
A history of chemical dependency
Patient self report is remarkable

Other Methods of AssessmentOther Methods of Assessment
Diagnostic Testing
- There is no diagnostic test for chronic pain
- Plain radiography – musculoskeletal pain
- CT/MRI for spine pathology
- CT Myelography for pts. considered for surgery
- Electromyography / nerve conduction studies for
LMN dysfunction, nerve or nerve root pathology
or myopathy
Functional Assessment
Pain Assessment Tools

Determination of BiologicalDetermination of Biological
Mechanism of PainMechanism of Pain
Pain classification and types of pain
- Neuropathic Pain
- Muscle Pain
- Inflammatory Pain
- Mechanical/compression pain
Decades ago, all chronic pain was treated
similarly
Mechanism – specific treatment
Pain usually has more than one mechanism

Neuropathic PainNeuropathic Pain
Cause – damage or dysfunction of the
nervous system
- sciatica from nerve root compression
- diabetic peripheral neuropathy
- trigeminal / Post herpetic neuralgia
Clinical Features
- the setting; the first clue
- the distribution; follows the nerve distribution
- the character; burning, shooting, stabbing
- findings of physical examination: numbness,
coolness, and allodynia

Muscle PainMuscle Pain
Causes
- muscle pain of chronic pain
- fibromyalgia syndrome and,
- myofascial pain syndrome
Common Clinical Features
- sore, stiff, aching, painful muscles
- fatigue, poor sleep, depression, headache,
and irritable bowel syndrome
- acute muscle pain occasionally
- pain related disability is a challenge to the
health care system

Fibromyalgia Syndrome
- Widespread musculoskeletal disease
Myofascial Pain Syndrome
- regional muscle and soft tissue pain
- trigger points refer pain
- Widespread musculoskeletal disease

Causes
- Tissue Injury, postoperative, osteo-arthritic
pain, infection
- same as nociceptive pain
- inflammatory chemicals stimulate primary
sensory nerves and carry information to the
spinal cord
Clinical Features
- heat, redness, and swelling
Inflammatory PainInflammatory Pain

Mechanical / Compression PainMechanical / Compression Pain
Causes : muscle / ligament strain,
degeneration of discs, facets or
osteoporosis with compression fractures,
fractures, dislocation, obstruction, and
compression by bony tumors
Same as nociceptive pain
Aggravated by activity and usually
relieved rest
Radiology very helpful

Pain ManagementPain Management --AlgorithmAlgorithm
Develop a written plan of care and set
goals using the bio-psychosocial model
All patients with chronic pain must
participate in an exercise fitness program
Set personal goals/restructuring life
Improve sleep, manage stress
Decrease pain
Patients want quick fix, not temporary
relief

Treatment Plan for Chronic PainTreatment Plan for Chronic Pain
Rehabilitation/functional management
Psychosocial management
- Depression
- Cognitive – Behavior therapy
Pharmacologic management
Interventional management
Non-pharmacologic management
Complementary medicine
Referral to multi-disciplinary pain mgmt.
Surgery for placement of a stimulator or
pump

Management of Neuropathic PainManagement of Neuropathic Pain
Eliminate the underlying causes of pain
Local or regional therapies
- Topical Capsaicin, 3 to 4 times daily
- Lidocain cream or patch
- Transcutaneous electrical nerve stimulator
Pharmacologic management
- Gabapentin: 300mgs TID (100% Renal)
- Pregabalin: 50-100 mgs TID
- Other Anticonvulsants:
* Carbamazepine
* Oxcarbazepine 150-300 mgs BID
* Topiramate, Lamotrigine, Tiagabine
* Benzodiazepine, Clonazepam

Pharmacologic ManagementPharmacologic Management
(cont)(cont)-- Neuropathic PainNeuropathic Pain
Tricyclic antidepressants
- Amitriptyline, Notriptyline, Desipramine,
Imipramine, and others
- Potentiate descending inhibitory pathways
- Pain reduction is independent of effect
on depression
- A screening EKG is required in elderly

Corticosteroids
- Pain relief through membrane stabilization
and anti-inflammatory effects
- Short term control of neuropathic radicular
pain caused by edema, tumor invading
bone and acute or sub-acute disc herniation
Opioids
- not known for neuropathic pain but as potent
analgesics
- Methadone and Tramadol are more effective

Management of Muscle PainManagement of Muscle Pain
Physical rehabilitation
Behavioral management
Drug therapy
- Pain and sleep
* Tricyclic antidepressants
Nortriptyline low dose
* Cyclobenzaprine
- Depression and Pain
* Duloxetine
- Opioids rarely needed

Inflammatory Pain ManagementInflammatory Pain Management
Drug therapy
- Pain and sleep
* Tricyclic antidepressants
Nortriptyline low dose
* Carbobenzaprine (short term)
- Depression and pain
* Duloxetine
- NSAIDS, immunologic drugs, other
depressants

Mechanical / CompressiveMechanical / Compressive
Pain ManagementPain Management
Screen for serious medical pathology and
refer to appropriate specialist
Drug therapy
- Tricyclic antidepressants
- NSAIDS
- Other antidepressants

Pharmacologic Management of PainPharmacologic Management of Pain
Key PointsKey Points
A thorough medication history is critical
Base the choice of medications on type and
severity
Medications are not the primary focus in managing
pain
Titrate doses for an optimal balance between
analgesic benefit, side effects, and functional
improvement

For Opioid therapy:
- use a written Opioid agreement for long-
term therapy
- see the Federation of State Medical
Boards at:
http://www.fsmb.org for complete
information

NonNon--Opioid AnalgesicsOpioid Analgesics
AcetaminophenAcetaminophen
To treat mild chronic pain or to supplement
Lack anti-inflammatory effects
Do not damage gastric mucosa
May have chronic renal and hepatic side
effects
Dose; max 4gms./24 hrs.
Caution: Patients with liver impairment

NonNon--Opioid Analgesics,Opioid Analgesics,
NonNon--Steroidal AntiSteroidal Anti--Inflammatory DrugsInflammatory Drugs

To treat mild to moderate inflammatory or
non-neuropathic pain
NSAIDS inhibit prostaglandin synthesis by
blocking the enzyme Cyclooxygenase (COX)
COX-2 agents have fewer GI symptoms but
higher cardiovascular effects. Use along
with gastroprotective agent; Proton pump
inhibitor (Misoprostol)
Use caution in patients with risk of bleeding
Ketorolac not for chronic pain
NSAIDS have significant opioid sparing
properties and reduce opioid-related side
effects

Use of Opioids in Chronic PainUse of Opioids in Chronic Pain
First get familiar with Federation of State
Medical Board documents
For neuropathic pain, not responding to first line
therapies
Opioids are rarely beneficial for inflammatory,
mechanical / compressive pain
Not indicated for chronic headache mgmt.
Have better therapeutic index and low medical
risks
Close monitoring is essential and non-compliant
pts. must be referred to pain or addiction
specialist

Tricyclic AntiTricyclic Anti--DepressantsDepressants
(TCAS)(TCAS)
First line for neuropathic pain with insomnia,
anxiety and depression
Avoid tertiary amines (Amitriptyline,
Imipramine)
TCAS analgesic effects are with lower doses
Maximum analgesic effect may take several
weeks to be seen
Baseline EKG is indicated for pts. at higher
cardiac risk
Common side effects: sedation, dry mouth,
constipation, and urinary retention

Other AntiOther Anti--DepressantsDepressants
Selective Serotonin re uptake inhibitors
Less side effects compared to TCAS, but
less efficient for neuropathic pain relief
Bupropion, Venlafaxine, and Duloxetine
are all efficient against neuropathic pain
Duloxetine in doses of 60 mgs. BID is
beneficial for fibromyalgia

Anticonvulsant or AntiepilepticAnticonvulsant or Antiepileptic
DrugsDrugs
Carbamazepine and Phenytoin:
- effective for neuropathic pain
- Carbamazepine well established for
trigeminal neuralgia
- unwanted CNS side effects
Pregablin:
- Diabetic neuropathy
- Post herpetic neuralgia

Oxcarbazepine; good for neuropathic pain
Gabapentin; excellent for all types of
neuropathic pains. Titrate up gradually
Lamotrigine; Trigeminal neuralgia, post-
stroke pain and neuropathies of HIV
infection

Topical AgentsTopical Agents
5% Topical Lidocaine patches; 12hrs on and 12hrs off
- Excellent safety profile
- Post herpetic neuralgia and other
neuropathic pain syndromes
Capsaicin:
- Depletes the pain mediator substance-P
from afferent nociceptive neurons
- Good for arthritic pain and other neuropathic pain
- Use at least for 6 wks. for benefits
- Side effect – burning; becomes tolerant after a few
weeks

Diagnosis and TreatmentDiagnosis and Treatment
of Low Back Painof Low Back Pain
Joint Practice Guidelines fromJoint Practice Guidelines from
ACP and APSACP and APS
RecommendationsRecommendations

Focused history and physical examination
1. Nonspecific low back pain
2. Back Pain with radiculopathy or spinal
stenosis
3. Low back pain with other spinal cause
Imaging not required for nonspecific LBP
Imaging advised for neurological deficits
or other underlying conditions
Imaging before steroid injections or
surgery

Advise patients to be active and self-care
options
First line drugs: Acetaminophen, NSAIDS
Muscle relaxants for temporary relief of
acute low back pain
Tricyclic antidepressants for chronic LBP
Use of opioids in selected patients
Spinal manipulation for acute LBP, intense
rehabilitation, acupuncture, yoga,
cognitive behavioral therapy for sub-acute
and chronic pain

JAMESON MEMORIAL HOSPITAL
NEW CASTLE, PA 16105
IV PCA - PAIN CONTROL ORDERS
(For Jameson Hospital Medical Staff Only)
Medication □Morphine 1 mg/ml in 0.9% NSS
□HYDROmorphone (Dilaudid) 0.2 mg/ml in 0.9% NSS
□Morphine 5mg/ml (HIGH POTENCY)
□HYDROmorphone (Dilaudid) 0.5mg/ml (HIGH POTENCY)
Initiate the following pain control orders:
SELECT ONE: □ PCA Mode
□ Continuous Mode
□ PCA & Continuous
Typical Ranges
* Consider patient age, renal status, comorbidities and history of
opioid use.
Morphine• IV fluids @ ml/hr HYDROmorphone
• Continuous rate (Delivery): mg/hr
Continuous 1-3 mg/hr 0.2 - 0.5 mg/hr• Loading dose: mg
Loading 1-4 mg 0.3 - 0.5 mg• PCA dose: mg
PCA dose 0.5- 2 mg 0.2 - 1 mg• Lock out time: minutes. (Typical lock out range
10-20 minutes)
• One hour dose limit: mg
• Decreased respiratory rate of less than 8 per min. and/or patient unarousable, administer Narcan 0.04 mg q 1 minute
IV STAT, according to protocol. Then call ordering physician.
• Bolus PRN dose:
• RN may administer a bolus PRN dose of mg once per hour, if needed, until pain relief is achieved.
• Monitor sedation, pain level & vital signs q ½ h for 2 hours, q 1 hr for 2 hours, then q 4 h.
• Continuous Pulse Oximetry - chart q h. If unable to maintain sat above 94%, apply Nasal O2 at 3 liters and
notify physician.
• Notify PCP or ordering physician of inadequate pain relief or persistent nausea.
• Verify all other narcotic medication/sedative orders with physician initiating PCA orders.
• RN must clarify if conflicting orders are present.
• Additional PRN medications:
Physician Date/Time
*Patients in terminal state may be exempt from these monitoring/intervention orders. Physician can cross out
unapplicable orders and initial to eliminate this monitoring.
9/05; Revised 4/09
PHO-1019

JAMESON HEALTH SYSTEM
CONTINUOUS EPIDURAL INFUSION
(Anesthesia Assoc., P.C. Orders ONLY)
Epidural Infusion Only:
• Final concentration: Fentanyl 2 mcg/ml Bupivacaine (0.125%) in 250 ml 0.9% NSS
• Infusion to run @ ml/hr.
• Use yellow striped tubing specifically for Epidural infusion.
• Ambu and Oxygen immediately available.
• Continuous Pulse Oximetry - chart q 1 hrs. Apply nasal O2 at 2 LPM while catheter in place. Call Anesthesia if unable
to maintain sat above 90% and notify PCP or Surgeon.
• Notify anesthesia immediately if patient complains of progressive heaviness in legs or inability to move legs.
• For decreased respiratory rate of less than 8 per minute and/or patient unarousable, administer Narcan 0.04 mg q 1 minute
IV STAT according to protocol, then call Anesthesia and notify PCP or Surgeon.
• Monitor/record respirations q ½ hr x 2 then q 1 hr x 24 hrs. then q 4 hrs.
• Monitor sedation, pain level, and vital signs q ½ hour for 2 hrs and q 1 hr for 2 hrs then q 4 hrs.
• Whenever Epidural dosage increased, reinstate initial monitoring protocol.
• Notify Anesthesia of inadequate pain relief, persistent nausea, sedation level 3 or greater, or respirations less than 8.
Exception: For pts on ventilator - contact physician/service managing ventilator care.
• Hold all other Narcotic medications/sedatives unless ordered by Anesthesia.
• If intubated, Diprivan drip titrated to sedation level of 3 or greater.
• If patient has no IV order from surgeon or primary physician, patient is to have Lactated Ringers at 40 ml/hr.
• Do not begin Lovenox, Coumadin, IV/SQ Heparin until at least 2 hrs. after epidural catheter has been removed
due to risk of epidural hematoma/bleeding.
• If IV/SQ Heparin, Lovenox, or Coumadin ordered, discontinue Epidural catheter and hold dose for 2 hrs following
removal of catheter.
• If air in volumetric infusion set, may disconnect from Epidural catheter, purge air and reconnect to catheter.
• Patient may have:
□ Morphine Sulfate 2 mg IV q 30 min PRN for breakthrough pain for pain level greater than 5 x 2 doses only.
If pain level greater than 5 after 2 doses, notify Anesthesia
OR
□ Dilaudid 0.5 mg IV q 30 min prn up to 4 doses per 4 hr. period
Call Anesthesia if pain level greater than 5 after 4 doses of Dilaudid
• Epidural Bolus prn per Anesthesia.
• □ For nausea, give Zofran 4 mg IV, wait 15 minutes. If nausea/vomiting continues, give Zofran 4 mg IV then
continue Zofran 4 mg IV q 4 hrs prn for nausea/vomiting. Call Anesthesia for persistent nausea/vomiting.
• □ If itching, administer Nubain 5 mg IV. May repeat Nubain 5 mg IV in 15 minutes, once. If itching persists,
notify Anesthesia for further orders.
Physician Date/Time
Revised 7/05; 8/06; 2/07; 4/09
PHO-1005

CONTINUOUS PERIPHERAL NERVE/
FEMORAL NERVE/LUMBAR PLEXUS/
SCIATIC NERVE CATHETER ORDERS
Medication: □ Bupivacaine 0.05% (final concentration) in 250 ml NSS
□ Bupivacaine 0.125% (final concentration) in 250 ml NSS
• Infusion to run at ml/hour on CADD Solis Pain Management Pump.
• Place peripheral nerve catheter infusion pump at the foot of the bed when used in conjunction with
another pain delivery system.
• Use yellow-striped tubing with tag indicating “Bupivacaine Infusion Only”.
• If air in infusion set, may disconnect from the peripheral nerve catheter, purge air and reconnect to
catheter.
• IV Peripheral PCA for 24 hours (see physician Peripheral PCA Order Sheet).
Start: Date Time
Discontinue: Date Time
• Call Anesthesia if patient is experiencing progressive motor block in extremity
• Post-op care: Check site for dislodgement and hematoma, check extremity for circulation, motion and
sensation, and check vital signs: q ½ hour for 2 hours, then q 1 hour for 2 hours, then q 4 hours until
catheter removed.
• Call Anesthesia if catheter dislodges.
Physician Date/Time
Revised 2/07; 4/14/09
PHO-1007

IV PCA INFUSION PUMP ORDERS
PCA ORDERS SHOULD BE ADJUSTED BY ANESTHESIA ONLY
Medication □Morphine 1 mg/ml in 0.9% NSS
□HYDROmorphone (Dilaudid) 0.2 mg/ml in 0.9% NSS
□Fentanyl 10 mcg/ml - * in 0.9% NSS
• CONTINUOUS Rate (Delivery):
• BOLUS (Loading Dose): *Omit Bolus if narcotic given within last hour.
• PCA Dose:
• (Lockout): min
• ONE HOUR LIMIT:
• If pain is not adequately controlled: (pain scale 4 or greater)
PCA dose may be increased to and the 1 hr limit increased to (one time
only)
• If pain level greater than 5 after PCA dose increased one time (pain reassessment), call Anesthesia.
• Monitor sedation, pain level, and vital signs q ½ hour for 2 hrs then q 1 hr for 2 hrs then q 4 hrs.
• Notify Anesthesia if sedation level 3 or greater.
• For decreased respiratory rate of less than 8 per min. and/or patient unarousable, administer Narcan 0.04 mg
IV STAT q 1 minute according to protocol, then call Anesthesia and notify PCP or Surgeon.
• □ For nausea, give Zofran 4 mg IV, wait 15 minutes. If nausea/vomiting continues, give Zofran 4 mg IV
then continue Zofran 4 mg IV q 4 hrs prn for nausea/vomiting. Call Anesthesia for persistent
nausea/vomiting.
• □ If itching, administer Nubain 5 mg IV. May repeat Nubain 5 mg IV in 15 minutes, once.
If itching persists, notify Anesthesia for further orders.
• Continuous Pulse Oximetry - chart q 1 hr. Apply nasal O2 at 2 LPM while PCA in place. Call Anesthesia
if unable to maintain sat above 90% and notify PCP or Surgeon.
• Whenever PCA dosage increased, reinstate initial monitoring protocol.
• If patient has no IV order from surgeon or primary physician, patient is to have Lactated Ringers at 40
ml/hr.
• Place PCA infusion pump at the head of the bed when used in conjunction with another pain delivery
system.
Physician Date/Time
Revised 7/05; 8/06; 2/07; 4/09
PHO-1045

JAMESON HOSPITAL
POST-OP PAIN MANAGEMENT
ORDERS AFTER
INTRAOPERATIVE DURAMORPH
• Patient received mg of intrathecal/epidural Duramorph at (time) intraoperatively.
• Epidural discontinued at: Date Time
• Patient may have:
( ) Morphine Sulfate 1 mg IV q 15 min prn for breakthrough pain up to 5 doses (pain level greater than 5)
*If pain scale still greater than 5 despite prn Morphine, increase Morphine Sulfate to 4 mg IV x 1
dose
*If no relief, notify Anesthesia
( ) a. Until date @ 7:00 a.m.
OR
( ) b. During 18 hours post Duramorph injection. End of 18 hour time frame:
Date Time
OR
( ) Dilaudid 0.5 mg IV q 15 minutes prn up to 4 doses per 4 hour period
*Call Anesthesia if pain level greater than 5 after 4 doses of Dilaudid
( ) a. Until date @ 7:00 a.m.
OR
( ) b. During 18 hours post Duramorph injection. End of 18 hour time frame:
Date Time
• No other IV/IM/PO narcotic for 18 hrs post Duramorph injection unless ordered by Anesthesia.
• Notify Anesthesiologist for additional pain orders while Duramorph protocol in effect.
• Monitor/record Respirations q ½ hr x 2, q 1 hr x 24 hrs then q 4 hrs.
• Notify Anesthesia if sedation level 3 or greater.
• Monitor sedation, pain level, and vital signs q ½ hour for 2 hrs then q 1 hr x 2 hrs then q 4 hours.
• For decreased respiratory rate of less than 8 per minute and/or sedation level 3 or greater, administer Narcan 0.04
mg IV STAT q 1 minute according to guidelines, then call Anesthesia and notify PCP or Surgeon.
• Continuous Pulse Oximetry - chart q 1 hr. until the Duramorph protocol completed.
• Apply nasal O2 at 2 LPM for 18 hours following Duramorph injection until Duramorph protocol is completed. Call
Anesthesia if unable to maintain sat above 90% and notify PCP or Surgeon.
• If patient has no IV order from surgeon or primary physician, patient is to have Lactated Ringers at 40 ml/hr.
• May anticoagulate 2 hrs following epidural discontinuation.
• □ For nausea, give Zofran 4 mg IV, wait 15 minutes. If nausea/vomiting continues, give Zofran 4 mg IV then
continue Zofran 4 mg IV q 4 hrs prn for nausea/vomiting. Call Anesthesia for persistent nausea/vomiting.
• □ For itching, administer Nubain 5 mg IV. May repeat Nubain 5 mg IV in 15 minutes, once. If itching persists,
notify Anesthesia for further orders.
• □ Toradol 30 mg IV q 8 hrs x 3 doses if not contraindicated.
Physician Date/Time
Rev. 7/05; 8/06; 2/07; 5/09

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