Pharm Exam 2 Pain

• causes unecessary suffering
• stimulates sympathetic respone
• decreases immune function
• weakens already debilitated patients
• increases poor compliance with therapy
• impinges on work, family, leisure
• diminishes hope

• Scales: 0-10
• Simple descriptor (none, mild, moderate, severe)
• Faces
• When? initiation; dose increase;peak of analgesic

a pharmacologic property causing the occurrence of withdrawal symptoms with abrupt discontinuation or administration of an antagonist

the pharmacologic effect in which with repeated administration, increasing doses are necessary to provvide the same effect

psychological dependence, a behavioral syndrome marked by drug craving, compulsie efforts to secure a drug supply, hoarding, and drug-related interference with pyschological, social, or physical function

• Work in periphery
• Affect prostaglandin synthesis

• Work in CNS
• Bind to the mu, kappa, and delta receptors

• analgesic
• antipyretic
• no anti-inflammatory effects
• max dose: 4000 mg/day
• risk of hepatotoxicity with higher doses
• Ofirmev - IV acetominophen
• Antidote: acetylcsteine (Mucomyst, Acetadote)

• COX found in all tissues, encourages synthesis of prostaglandins
• COX 1: present in all tissues, protects gastric mucosa, supports renal function
• COX 2: at site of tissue injury & brain; mediates inflammation, pain, fever response

• Gastric erosion and ulceration (-)
• Bleeding tendencies (-)
• Acute renal failure (-)
• Protection against myocardial infarction (+)

• Suppression of inflammation (+)
• Alleviation of pain (+)
• Reduction of fever (+)

Asprin (acetylsalicyclic acid, ASA)

• analgesic, antipyretic, antiinflammatory
• Initial ang effect: 1 hr
• Max anti-inflammatory effect- in 2 wks
• ADR: GI upset, bleeding
• Toxicity: tinnitus, sweating, dizziness

• Inhibit both COX1 and COX2
• Analgesic, antipyretic, anti-inflammatory
• Initial analgesic effect: 1 hr
• Maximum anti-inflammatory effect: 2 wks

• Vitamin I
• NSAID
• Advil, Nuprin, Motrin,

• Enhance efficacy of other agents
• Add analgesia
• Treat concurrent symptoms

• to treat neuropathic pain: (gabapentin (Neurontin)
• to treat fibromyalgia: pregabalin (Lyrica)
• Others: cyclobenzadrine (Flexaril)

• adjuvant to treat neuropathic pain
• Neurontin

• Adjuvant to treat fibromyalgia
• Lyrica

• Adjuvant
• Flexaril

• Opioid agonist
• Opioid agonist/antagonist
• Opiod antagonist

• Treat moderate to severe pain
• Bind to mu opioid receptors in CNS
• No ceiling effect
• No major organ disfunction
• Generally manageable side effects

• Step 2 opioid
• more emetogenic and constipating

• Step 2 opioid
• Vicodin, Lorcet, Norco
• Stronger than codeine
• available in varying doses, limited by acetaminophen content

• Step 2 opioid
• Percocet, Percodan, Tylox
• also available as a single entity?

• Ultram
• Centrally acting nonopioid analgesic
• Binds to mu opioid receptor
• Inhibits uptake of serotonin and norepi in the CNS
• Indicated for moderate to moderately severe pain
• Equianalgesic to Tylenol with codeine #3

• Ultram
• dose 50-100 mg q 4-6 hr
• Onset 1 hr
• Peak 2-3 hrs
• similar side effects to opioids
• May cause seizures with therap doses

• Step 3 opioid
• MSO4, MS, Roxanol, MS Contin, Oramorph, Kadian, Avinza

• Step 3 opioid
• Duration: 2-3 hours
• PO Doses: 1/4 analgesic effect
• Toxic metabolite: normeperidine (not reversible with Narcan)
• Do not use for more than 48 hrs or at doses >600 mg/24 hr

Look up in book

• Increase dose 25-50% until there is either a 50% reduction in pain rating or the patient reports satisfactory pain relief
• A repeat dose can be give at time of peak if previous dose is ineffective and side effects are minimal.

• ATC does more effective than PRN for pain that is expected to continue
• More effective if given before pain becomes severe
• Provide analgesic to allow for uninterrupted sleep

• Noninvasive is best
• PO is effective if doses are high enough
• IV route is safest and fastest for titration
• IM is painful and unreliable: AVOID
• Transdermal useful for chronic pain

• Nor recommended for 1st line therapy
• Bind to kappa receptors
• Partial agonist
• Partial antagonist (may cause withdrawal in physically dependent patients on opioid agonists
• Greater risk of dysphoric side effects

• Talwin
• Opioid Agonist Antagonist

• Stadol
• Opioid Agonist Antagonist

• Nubain
• Opioid Agonist Antagonist

• Buprenex, Butrans
• Opioid Agonist Antagonist

• Moderate to severe chronic pain
• Transdermal patch lasts up to 7 days
• No alcohol during use

• Treat patient with immediate-release opioids for 48 hrs to learn average daily dose
• Approximately 2/3 of estimated daily dose should be used for sustained-release
• Provide supplemental immediate release opioid for breakthrough pain

• morphine (MS Contin, Oramorph, Avinza, Kadian)
• oxycodone (Oxycontin)
• Hydromorphone (Exalgo)
• fentanyl (Duragesic)
• oxymorphone (Opana ER)
• methadone

• MS Contin & Oramorph (8-12 hrs): Do not crush or chew; swallow hole
• Kadian & Avinza (24 hrs): Caps can be opened and sprinkled on soft, moist food

• Oxycontin (8-12 hrs)
• Do not crush or chew; swallow whole

• Sustained release (Exalgo)
• Once every 24 hrs
• Do not crush or chew; swallow whole

• gradual increase in serum levels
• Steady state achieved in 12-24 hrs
• Duration of action: up to 72 hrs
• Elimination half life: ~17 hrs
• Transdermal application bypasses GI tract

• Opana
• Titrate on short-acting form
• Then convert to long-acting form Q 12 hrs

• Inexpensive
• Accumulates with repeated dosing

• Reaches max intensity within 3 minutes
• Lasts an average of 30 min
• Doses should be equiv to about 10-20% of the 24 hr total dose. Doses may be given every 2 hrs as needed
• Do not use sustained-release meds for breakthrough pain

• Fentora
• For breakthrough pain

• constipation (give stimulant lax: Senokot)
• nausea & vomiting
• sedation
• respiratory depression

• Relistor
• Tx for constipation caused by opioid use
• Acts peripherally as mu-opioid receptor antagonist-blocks opioid effects in GI tract
• Blocks GI tract effects without loss of analgesia
• SQ injection qod

• S=sleeping, easily aroused, Requires no action
• 1=awake and alert. Requires no action
• 2=occasionally drowsy; easy to arouse. Requires no action
• 3=frequently drowsy, arousable, drifts off to sleep during conversation. Decrease opioid dose
• 4=somnolent, minimal or no response to stimuli. Decrease opioid; consider naloxone (Narcan)

• Short-acting opioids, taper doses
• 50% x 2 days
• 25% every 2 days
• Discontinue after 2 days at min dose

• Step 2 opioid
• Vicodin, Norco
• stronger than codeine
• limited by acetominophen content

• suppress pain by blocking impulse conduction along axons
• Block Na channels
• Block all function, both sensory and motor

• Esters: procaine (Novocain)
• Amides: lidocaine (Xylocaine)

• widely used local anesthetic
• used with epinephrine
• control of dysrhythmias

• Marcaine, sensorcaine
• epidural and local

• ester
• used in EENT procedures
• topical only
• do not use with epinephrine
• produces euphoria
• physical dependence
• avoid with cardiac patients

• topical: mixture of locals (lidocaine/prilocaine)
• by injection: infiltration, nerve block, IV regional, epidural, spinal

• Produce unconsciousness, lack of response to all painful stimuli
• Two groups: inhalation, IV

• Stage I: analgesia
• Stage II: delirium
• Stage III: surgical anesthesia
• Stage IV: medullary paralysis

IV Anesthetic

• Seratonin agonist
• Migraine treatment

• Disease-Modifying Antirheumatic Drug (DMARD)
• Treatment of RA

• DMARD
• Tumor necrosis factor blocker

• deposit of uric acid crystals in joint
• increased uric acid production or decreased excretion