, according to an expert who outlined his strategies at the American Academy of Dermatology Virtual Meeting Experience.
Dr. Robert Micheletti
The exceptions relate primarily to patients with issues complicating pain control, such as those with psychosocial problems exacerbating the pain response, drug-seeking behavior, or both, according to Robert G. Micheletti, MD, chief of hospital dermatology, University of Pennsylvania, Philadelphia.
To stay out of trouble, Dr. Micheletti advocated a systematic approach to the control of pain that includes documentation, clear expectations, and a sparing use of opioids only at the lowest acceptable dose for periods measured in days.
Using a case of pyoderma gangrenosum to make several points, he recognized that some patients do have a level of pain that warrants a short course of opioids, but this is not his first step. Rather, the initial focus, after administering standard therapies for this disease, is wound care, which often attenuates symptoms. He adds non-pharmacologic treatments, such as ice, heat, and rest when appropriate. The initial pharmacologic approach is alternating doses of an NSAID and acetaminophen.
“If necessary, a short course of opioids is reasonable for patients with acute pain,” he acknowledged. But he wants to avoid providing more opioids than needed to address the initial period of acute pain. In the case of pyoderma gangrenosum, he suggested a typical prescription might be 12 pills of 5 mg oxycodone taken every six hours. A followup appointment within a week provides the opportunity to reassess.
“Set clear expectations,” Dr. Micheletti said. This includes explaining that the goal is manageable pain, not complete pain relief, which is often unobtainable. For painful conditions such as pyoderma gangrenosum, hidradenitis suppurativa, or vasculitis, a short course will generally be sufficient to get past the most significant discomfort.
There are several reasons that Dr. Micheletti encourages dermatologists to take responsibility for pain related to skin diseases. One is the potential for inefficiencies and delays common to referrals, but another is the value of the dermatologist’s expertise in judging pain as a symptom of the disorder. With effective treatment, pain should self-resolve.
“If the patient is not getting better medically, then change therapies,” Dr. Micheletti said. When referred to a non-dermatologist, the pain expert might not recognize what persistent pain is revealing about the underlying condition.
Repeatedly, Dr. Micheletti made the point that dermatologists should manage pain related to skin disorders because of their ability to assess complaints in the context of the disease.
“We are the experts. We should understand when what we are seeing should or should not be painful,” he said. He added that dermatologists are also in the best position to judge “when analgesia is no longer needed.”
With this same logic, dermatologists are in a good position to distinguish nociceptive from neuropathic pain. Some conditions are likely to have both, and this should influence choice of pain relief. Citing a patient with calciphylaxis as an example, Dr. Micheletti suggested that drugs with efficacy against neuropathic pain, such as gabapentin, should be one of the options to consider before moving to opioids. In those with sufficient pain to warrant an opioid, however, Dr. Micheletti would consider tramadol, which acts on both types of pain.
Treating pain is not always straightforward, Dr. Micheletti acknowledged. For example, depression and mood disorders are known to exacerbate pain and are reasonable targets of pain control. The stress related to disruptive psychosocial problems can be another factor in risk of pain.
“Be prepared to acknowledge and address these types of issues,” Dr. Micheletti said. Although these are the types of patients some dermatologists might prefer to refer to a pain specialist, he said that the contribution of factors outside of skin disease should not be allowed to obscure a dermatologic source of pain.
“Just because a patient has psychosocial issues does not mean that there is no pain,” he said.
A systematic approach to the assessment and treatment of pain will help sort out these issues, but Dr. Micheletti also said, “Know your comfort zone.” When patients require opioids, there are several appropriate steps important or mandatory to provide adequate protection for the patient and the physician. In addition to documentation, it is reasonable to verify that the patient is not obtaining opioids from other prescribers, a step that is mandatory in some states.
When opioids are needed, Dr. Micheletti suggested a standard approach that includes short courses without refills. He recommended avoiding long-acting opioids and drugs not commonly used by non-pain specialists, such as codeine, hydrocodone, or fentanyl.
“This is not a prescribe and walk away situation,” he said.
Dr. Adam Friedman
Although the same general approach is employed by Adam Friedman, MD, professor and chair of dermatology, George Washington University, Washington, he is a little less reluctant to refer patients to pain specialists.
“For complex situations, you need complex solutions. In the case of significant pain and even itch, I will collaborate with the GW Pain Center,” he said. For severe pain, the solutions might include nerve blocks or even intravenous ketamine for in-patients.
He also made the point that dermatologists, even if they are uncomfortable prescribing opioids, “should be equipped to use relevant medications such as topical anesthetics, gabapentinoids, and SSRIs” to control pain related to skin conditions.
Dr. Micheletti reports no relevant conflicts of interest. Dr. Friedman has consulting relationships with several pharmaceutical companies, including Amgen, GlaxoSmithKline, and Valeant.