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Pain Relief Stepladder
Mild, Moderate, Severe
- 1. Mild
- Aspirin
- Acetaminophen
- NSAIDs
- +/- adjuvants
- 2. Moderate
- APAP/Codeine
- APAP/Hydrocodone
- APAP/Oxycodone
- APAP/Dihydrocodeine
- Tramadol
- +/- Adjuvants
- 3. Severe
- Morphine
- Hydromorphone
- Methadone
- Levorphanol
- Fentanyl
- Oxycodone
- +/- Adjuvants
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Non-Opioid Analgesice
- Differ from opioids:
- Ceiling effect applies
- No tolerance or physical dependence
- Not associated with abuse/addiction
- Antipyretic
- Most=Anti-inflammatory
APS recommends consideration for all analgesic regimens unless high risk or ineffective.
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Acetaminophen
(N-Acetyl-Para-Amino-Phenol or APAP)
MOA: ?, central
- Use:
- · Analgesic and anti-pyretic
- · No anti-inflammatory effect
- · No anti-platelet activity
- · No GI damage
- Useful for mild-moderate pain
- · Use alone or in combination
- · Dose limit = 4000 mg/day, divided doses (ALF rec.3000 mg)
- Safety
- · Use with caution in pts with liver dz or alcoholism
- · FDA – hot topic - associated with liver damage, often combined with other meds and pt is unaware
- Drug interactions
- · MinimalWarfarin
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NSAIDs
Salicylates
- Aspirin (Bayer, Ecotrin, Norwich)
- Choline magnesium trisalicylate (Trilisate)
- Diflunisal (Dolobid)
- Magnesium salicylate (Doan’s)
- Salsalate (Disalcid)
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NSAIDs
Aspirin
Acetylsalicylic acid or ASA
MOA: inhibits Cox-1/Cox-2
- Use
- Mild to moderate pain
- Antipyretic, anti-inflammatory
- Low-dose: cardioprotection (only irrev. inhibition of platelet aggregation)
- Safety
- Upper GI disturbance and bleeding
- Increased bleeding time
- Hypersensitivity/bronchospasm in asthma pts (nasal polyps)
- Tinnitus with high doses
- Blood pressure (BP) increases
- Avoid in children <12 with viral illness (Reyes syndrome)
- Risk of hypersensitivity reaction (and cross-sensitivity with NSAIDs)
- Many drug interactions
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NSAIDs
Non-salicylates
- MOA:
- inhibit Cox-1/Cox-2
- Ex: ibuprofen (Motrin, Advil, Caldolor), naproxen (Naprosyn), diclofenac (Voltaren, Flector patch, Pennsaid), indomethacin (Indocin)
- Use
- Mild to moderate pain
- Antipyretic, anti-inflammatory
- Safety
- GI erosion / risk of bleeding (less than aspirin)
- Decreased renal perfusion
- Rashes, hypersensitivity/bronchospasm in asthma pts
- Blood dyscrasias, liver effects, CNS effects, BP
- Drug interactions
- Bind to plasma proteins – many drug interactions
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NSAIDs
COX-2 Inhibitors
Celecoxib (Celebrex)
- Use
- Mild to moderate pain for patients at risk for GI ulcers
- Safety
- Increased risk of cardiovascular toxicity (Black Box)
- Lower GI toxicity than NSAIDs
- Relative risk 2.6 vs. 3.7
- Use of ASA with Cox-2 eliminates advantage
- Sulfonamide allergy
- Renal
- Drug interactions
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Opioids
Full agonist (most common)
- Antagonist (stop effects of opioids)
- Naloxone, Naltrexone
- Mixed Agonist/Antagonist
- Buprenorphine, Butorphanol, Nalbuphine, Pentazocine, Bupenorphine/Naloxone (Suboxone)
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Opioid Classes
- Morphine-like
- Morphine (MS Contin, Kadian, avinza)
- Hydromorphone (Dilaudid)
- Codeine (prodrug for morphine)
- Hydrocodone
- Oxycodone (Oxycontin)
- Meperidine-like
- Meperidine (Demerol)
- Toxic metabolites with repeated dosing
- Esp. renal failure, elderly
- Not recommended for chronic pain
- Fentanyl (Duragesic)
- Methadone-like
- Methadone (Dolophine)
- Propoxyphene (Darvon)
- High adverse reaction profile
- Not recommended for elderly or for chronic pain
- Little evidence that it is any more effective for mild to moderate pain than less toxic non-opioid drugs
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Opioids
Short vs Long Acting
- Short:
- Codeine
- Hydrocodone
- Hydromorphone
- Morphine
- Oxycodone
- Tapentadol
- Fentanyl (ultra-short)
- Long:
- Methadone
- Buprenorphine
- Sustained relase products of short acting
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Opiates Adverse Reactions
Constipation: It is inevitable! Prevent it and treat it. Stool softeners, fluid, fiber, exercise
Nausea/vomiting: Common early in therapy, ↓ with time, Codeine
Sedation/cognitive impairment: Transitory (at initiation and dose escalation), Decrease dose?, trial of psychostimulant, rule out other causes if persistent.
- Potential serious adverse reactions:
- Respiratory depression
- Apnea
- Respiratory arrest
- Circulatory depression
- Hypotension
- Shock
- ►►naloxone (Narcan) = antagonist◄◄
- Other common reactions:
- Pruritus
- Dizziness
- Headache
- Dry mouth
- Urinary retention
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Adjuvants
- Antidepressants
- MOA: block reuptake of norepinephrine (NE) & serotonin, NMDA-receptor antagonism, sodium-channel blockade
- Tricyclic antidepressants (TCAs)
- Analgesia independent of antidepressant effect
- Ex: amitriptyline (Elavil) – more adverse reactions, nortriptyline (Pamelor), desipramine (Norpramin)
- Anticholinergic adverse reactions prominent: dry mouth, urinary retention, constipation, sedation, and orthostatic hypotension, cardiac arrhythmias
- Other Antidepressants:
- Selective Serotonin Reuptake Inhibitors (SSRIs): Fewer adverse reactions but not as effective as TCAs
- Serotonin-NE Reuptake Inhibitors: duloxetine (Cymbalta), venlafaxine (Effexor), milnacipran (Savella)
- Antiepileptic drugs (AEDs)
- Another first line drug class for neuropathic pain
- Especially lancinating
- First generation: carbamazepine (Tegretol), phenytoin (Dilantin)
- Second generation: gabapentin (Neurontin), pregabalin (Lyrica)
Local anesthetics
- Topical agents
- lidocaine 5% patch (LidoDerm), Excellent choice for localized pain, 12 hours on – 12 hours off, Few adverse reactions; don’t use with class I antiarrhythmics
- capsaicin (Zostrix, Qutenza), Chile pepper derivative, Causes burning and stinging sensation, Wash hands after applying
- Miscellaneous
- - First-Line Medications
- - gabapentin (Neurontin)
- - 5% Lidocaine patch (LidoDerm)
- - Opioid analgesics
- - tramadol (Ultram)
- - Tricyclic antidepressants (TCAs)
- - Non-Pharmacologic Techniques
- - Supplement to pharmacological measures
- o Increased pain relief
- - Other advantages
- o Improve mood
- o Reduce anxiety
- o Increase a patient’s sense of control
- § Strengthen coping abilities
- o Assist with sleep
- o Relax muscles
- - Improve quality of life
- - Psychosocial
- o Patient education and preparation
- o Psychological and behavioral techniques
- - Other physical modalities
- o Physical rehabilitation
- o Electrical stimulation
- o Acupuncture
- o Heat and cold
- o Splinting, assistive devices, etc.
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Medication Schedules
- CI
- High potential for abuse; no accepted therapeutic use
- Heroin, LSD
- CII
- High potential for abuse; accepted therapeutic use
- Oxycodone, morphine, cocaine
- No refills
- Can only write for a 30 day supply
- CIII
- Potential for abuse less than CII
- Ketamine, anabolic steroids
- 5 refills
- Prescription expires in 6 months
- Can only write for a 30 day supply
- CIV
- Potential for abuse less than CIII
- Benzodiazepines, phenobarbital, most sleep meds
- 5 refills
- Prescription expires in 6 months
- CV
- Potential for abuse less than CIV
- OTC codeine products, cough medicines
- 5 refills
- Prescription expires in 6 months
- Unscheduled
- No potential for abuse
- Anything else: HTN meds, antibiotics, etc
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