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What are the two major types of pain?
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What is nociceptive pain?
- normal processing of stimuli that damages normal tissues or has the potential to do so if prolonged
- usually responsive to nonopioids and/or opioids
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What is neuropathic pain?
- abnormal processing of sensory input by the PNS or CNS
- tx usually includes adjuvant analgesics
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What are the two types of nociceptive pain?
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What is somatic pain?
- arises from bone, joint, muscle, skin, or connective tissue
- usually aching or throbbing in quality and is well localized
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What is visceral pain?
- arises from visceral organs, such as the GI tract and pancreas
- may be subdivided:
- tumor involvement causes aching and fairly well-localized pain
- obstruction of hollow viscous causes intermittent cramping and poorly localized pain
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What are the two types of neuropathic pain?
- centrally generated
- peripherally generated
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What is centrally generated pain?
- Deafferentation pain:
- injury to the PNS or CNS
- phantom limb(PNS)
- burning pain below the level of a spinal cord lesion (CNS)
- Sympathetically maintained pain:
- dysregulation of the ANS
- reflex sympathetic dystrophy/causalgia (complex regional pain syndrome I and II)
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What is peripherally generated pain?
- Painful polyneuropathies:
- pain along many peripheral nerves
- diabetic neruopathy
- alcohol-nutritional neuropathy
- Guillain-Barre syndrome
- Painful mononeuropathies:
- a known peripheral nerve injury
- nerve root compression
- nerve entrapment
- trigeminal neuralgia
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What is the definition of pain according to the International Association for the Study of Pain?
an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such
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What are the transmitters of pain?
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What opioid receptors are involved with pain?
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Which opioid receptor is involved in psychotomimesis (onset of psychosis)?
kappa
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What are the advantages to APAP for pain?
- can be used for mild-moderate pain
- no tolerance/dependence
- widely available
- musculoskeletal or visceral pain
- less toxicities than NSAIDs
- inexpensive
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What are the disadvantages to APAP for pain?
- ceiling effect to analgesia
- CI in liver disease
- max dose 4g (caution in combo products)
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What are the advantages to NSAIDs and ASA for pain?
- wide spectrum of activity (acute/chronic)
- mild to moderate pain
- nociceptive > neuropathic
- no tolerance/dependence
- additive analgesia w/opioids
- may allow for lower opioid dose
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What are the disadvantages to NSAIDs and ASA for pain?
- ceiling effect to analgesia
- not sufficient alone for severe pain
- potentially serious SE
- CI in thrombocytopenic pts
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What are the advantages to opioids for pain?
- acute and chronic pain
- nociceptive > neuropathic
- no ceiling effect to analgesia
- multiple routes available (PO preferred)
- use for ATC and PRN dosing
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What are the disadvantages to opioids for pain?
- avoid meperidine, propoxyphene
- avoid agonist-antagonist combinations
- physical dependence
- tolerance
- addiction potential
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What are the advantages to opioid agonist-antagonist derivatives for pain?
- ceiling effect on respiratory depression
- lower abuse potential than morphine
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What are the disadvantages to opioid agonist-antagonist derivatives for pain?
- high rate of psychotomimetic effects
- ceiling effect to analgesia
- w/d effects seen in opioid-dependent pts
- avoid in chronic pain management
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What are the advantages to opioid antagonists for pain?
reverse the effects of agonist and agonist-antagonist opioids
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What are the disadvantages to opioid antagonists for pain?
no analgesic effects
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What are the advantages to central analgesics for pain?
- indicated for moderate to moderately severe pain
- binds to mu receptor and inhibits NE and 5-HT reuptake
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What are the disadvantages to central analgesics for pain?
- enhances the risk of seizures
- SE similar to opioids
- DI (SSRIs, TCAs, others) increase risk of seizures
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What is the metabolite of Fentanyl?
none
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What is the metabolite of meperidine?
nor-meperidine
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What is the metabolite of morphine?
M6G
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What is the metabolite of oxymorphone?
6-OH-oxymorphone
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What is the metabolite of tramadol?
M1
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What is the metabolite of oxycodone?
oxymorphone
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What is the metabolite of propoxyphene?
nor-propoxyphene
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What is the metabolite of hydromorphone?
H3G
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What is the metabolite of codeine?
morphine
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What is the metabolite of methadone?
none
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Which opioids do not have an OH group and are consequently useful for pts with allergic rxns?
- hydrocodone
- hydromorphone
- oxycodone
- buprenorphine
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What is the analgesic onset for fentanyl IV?
1-5 min
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What is the onset for Fentanyl patch?
- 12-16 hrsnot for acute pain
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What is the analgesic DOA for Fentanyl patch?
- 48-72 hrs
- great for chronic pain
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What is the half-life of methadone?
12-190 hrs
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What is the analgesic DOA for methadone?
2-4 hrs
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What is the analgesic DOA for most opioids?
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What type of pain are NSAIDs good for?
- anti-inflammatory pain
- bone pain
- metastatic bone pain
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What type of pain are corticosteroids good for?
- anti-inflammatory pain
- bone pain
- metastatic bone pain
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What typeof pain are TCAs good for?
neuropathic pain - very good for this
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What type of pain are SSRIs and bupropion good for?
- diabetic neuropathy
- central neuropathic pain
- peripheral neuropathic pain
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What type of pain are SNRIs good for?
- polyneuropathies
- fibromyalgia (duloxetine, milnacipran)
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What cautions should you heed with amitriptyline for pain?
- caution in cardiac disease
- not recommended in elderly
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What type of pain is CBZ good for?
- trigeminal neuralgia
- diabetic neuropathy
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What type of pain is lamotrigine good for?
- HIV sensory neuropathy
- diabetic neuropathy
- central poststroke pain
- spinal cord injury
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What type of pain is gabapentin good for?
- postherpetic neuralgia
- diabetic neuropathy
- phantom limb pain
- spinal cord injury
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What type of pain is pregabalin good for?
- diabetic neuropathy
- postherpetic neuropathy
- fibromyalgia
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What type of pain are ketamine and methadone good for?
- cancer related pain
- somatic pain
- neuropathic pain
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What type of pain is lidocaine good for?
- postherpetic neuralgia with allodynia
- apply directly to area of maximum pain - only good for a small area
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What type of pain is tramadol good for?
- postherpetic neuralgia
- diabetic neuropathy
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What are the SE of opioids?
- constipation - stool softener and GI stimulant, fiber, hydration, (tolerance does not develop)
- N,V - may need antiemetic (codeine is worst)
- pruritis - benadryl for a couple of days
- mental confusion/delirium - decrease dose, Fentanyl may be a good choice
- sedation - keep a diary
- respiratory depression - most feared SE, usually very old or young and pulmonary compromised (monitor resp rate, usually see sedation first)
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What are the routes of administration for opioids?
- PO - when the gut works, use it
- IV bolus
- IV infusion
- IV patient-controlled analgesia
- transdermal
- transmucosal (PO) - lollipop, buccal tabs
- SQ
- IM - should not be used
- PR - oxycontin gelcaps
- intranasal - stadol (not for chronic pain)
- nebulised - morphine for dyspnea
- epidural - fentanyl faster, morphine longer
- intrathecal
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What are the ABCs of pain?
- Ask and assess
- Believe the pt
- Choose the intervention
- Deliver the intervention (in a timely fashion)
- Empower the pt and family
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What is the analgesic ladder?
- pain score 1-3:
- mild pain
- give non-opioid +/- adjuvant
- pain score 4-6:
- moderate pain
- give opioid +/- non-opioid +/- adjuvant
- pain score 7-10:
- severe pain
- give opioid +/- non-opioid +/- adjuvant
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How do you calculate oral rescue dosing?
- calculate total opioid mg per 24h period:
- give 10-20% q 1-2h prn (except Fentanyl buccal or lolli - start these at lowest dose)
- if an SR product, increase dose or change to different opioid
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How do you calculate IV rescue dosing?
- calculate total opioid mg/h:
- give 25-50% of hourly dose q 30min prn
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If using methadone for daily dosing, what should be done for rescue dosing?
use a morphine for rescue dosing
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What should be monitored for pain tx?
- pain scale
- respiratory rate
- sedation
- # of rescue doses and total mg/d
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What is used for tx of pain d/t Sickle Cell?
- APAP or NSAIDs
- opioids
- adjuvants
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What is used for tx of pain from osteoarthritis?
APAP (up to 4g/d) - mild pain
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What is used for tx of pain from rheumatoid arthritis?
- APAP - mild pain
- NSAIDs - moderate to severe pain + inflammation
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What is used for pain from fibromyalgia?
- amitriptyline (best)
- cyclobenzaprine (best)
- tramadol (moderate)
- SSRI (moderate) (fluoxetine)
- SNRI (moderate) (venlafaxine)
- duloxetine (moderate)
- pregabalin (moderate)
- NOT NSAIDs or opioids
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What is used for tx of low back pain?
- APAP
- NSAIDs
- skeletal muscle relaxants
- TCAs (chronic tx = >4wks)
- BZDs
- tramadol
- opioids
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What is used for pain from cancer?
- morphine - moderate to severe
- NSAIDs, APAP or slow titration of morphine - mild
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What is the role of the pharmacist in pain management?
- opioid conversions
- recommending adjuvants (commonly forgotten by drs)
- stock sufficiently
- professional development
- compounding
- CE
- pain management teams
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