1. PTP 546 Module 14 & 15 Pharmacology of Pain Management: Acute and Chronic Jayne Hansche Lobert, MS, RN, ACNS-BC, NP 1Lobert

2. Pharmacology of Pain Management Opioid Analgesia Opioid Agonists: Treatment of Severe to Moderate Pain – Ex: Morphine (Astromorph, Duramorph) – Ex: Fentanyl (Sublimaze; Duragesic ) – Ex: Hydromorphone (Dilaudid) – Ex: Methadone (Dolophine) Opioid Agonists: Treatment of Moderate to Mild Pain – Ex: Codeine; Codeine/Tylenol (T#3, T#4) – Ex: Hydrocodone (Hycodan); Hydrocodone/Acetaminophen ( Vicodin) – Ex: Oxycodone (Oxycontin); Oxycodone/Acetaminophen (Percocet) 2Lobert

3. Pharmacology of Pain Management Opioid Analgesia Prototype Opioid Agonist: Morphine Gold-standard: 30mL is used to evaluate all other pain meds. – Action: binds with both mu & kappa receptor sites – Therapeutic Effect: treatment of severe pain provides analgesia and euphoria – Side Effects: sedation, dizziness, hypotension, itching (switch to different), nausea, constipation (if long term, will always decrease GI mobility), respiratory depression (doctors worry, but really need to look out for sedation as always 1 st ), constriction of pupils – Note: multiple routes  multiple half lives to consider; addictive potential  physical & psychological dependence – Note: opioid antagonist is Naloxone (Narcan)=used to STOP, to reverse drug overdose. 3Lobert

4. Pharmacology of Pain Management Opioid Analgesia Treatment Considerations – Route Oral; Transmucosal-Lollipop (used for children-expensive) Intravenous: Patient Controlled Analgesia Pumps, Continuous IV, Bolus IV Epidural: Epidural Pumps- usually at home; Intrathecal (into brian) - Subcutaneous, Transdermal Rectal or suppository – Half Life Impacted by route of administration Impacted by formulation: ex: sustained release – High Alert Medications Controlled substances Require special precautions Addictive potential – Equianalgesia All pain meds judged in relation to morphine Charts are available – Adjunctive Meds and Treatments 4Lobert

5. Pharmacology of Pain Management Prototype Opioid Antagonist: Nalaxone (Narcan) – Action: blocks both mu and kappa receptors – Therapeutic Effect: complete or partial reversal of opioid effects – Side Effects: rapid loss of analgesia  hypertension, hyperventilation, pain – Note: administered when opioid overdose is suspected; IV administration  reversal in minutes 5Lobert

6. Pharmacology of Pain Management Other Pain Management Medications – NSAIDS Inflammation is what causes the pain so NSAID (anti- inflamatory) used to decrease pain. ASA, Motrin, Toradol, etc. – Centrally Acting Drugs Tramadol (Ultram) – Miscellaneous Agents/Classes Acetaminophen (Tylenol) Antidepressants – Elavil Anticonvulsants – Neurotin, Dilantin 6Lobert

7. Pharmacology of Pain Management Other Pain Management Medications NSAID’s – Ex: Acetylsalicylic Acid(Aspirin/ASA) – Ex: Ibuprofen(Motrin) – Ex: Ketorolac (Toradol) – Treatment Issues & Considerations Used for anti-inflamatory effect that will decrease pain. – Side Effects: Gi bleeding, peptic ulcer, dyspepsia, Kidney dysfunction. No Aspirin/Motrin if h(x) of GI bleeds from NSAID’s 7Lobert

8. Pharmacology of Pain Management Other Pain Management Medications – Centrally Acting Drugs: Tramadol (Ultram) Action: weak binding of mu receptors but also relieves pain by inhibition of norepinephrine and serotonin reuptake Therapeutic Effect: treatment of moderate pain, chronic pain. Side Effects: vertigo, dizziness, headache, lethargy, nausea and vomiting 8Lobert

9. Pharmacology of Pain Management Other Pain Management Medication – Ex: Acetaminophen (Tylenol) Action: inhibits synthesis of prostaglandins which mediate pain and fever Therapeutic Effect: analgesia; antipyresis Note: No anti-inflammatory properties Side Effects: liver failure; hepatoxicity with excessive intake Note: Adult daily max= 3- 4 grams/day; note OTC and prescribed combination meds with acetaminophen; dose reduction with alcoholism 9Lobert

10. Pharmacology of Pain Management Other Pain Management Medications – Ex: Anticonvulsants Gabapentin (Neurotin) Topiramate (Topamax) – SE: fatigue, drowiness – Ex: Antidepressants Amitriptyline Hydrochloride (Elavil) Treatment Issues and Considerations? Side Effects? 10Lobert

11. Pharmacology of Pain Management Opioids: Treatment Issues – Physical & Psychological Dependence Incidence: more over-dose on opioids then heroine and cocaine. Treatment – Pharmacological: suppression withdrawal symptoms associated with detoxification – Withdrawal Sx: restlessness, anxiety, insomnia, chilled, tremors, and a high death rate if untreated. » Methadone: liquid » Buprenorphine hydrochloride (Bupernex): sublingual Maintains drug: lower analgesic potential » Suboxone: naloxone & buprenorphine (newest) Non-Pharmacological: individual and group therapy, use (methadone) to decrease dependence. 11Lobert

12. Pharmacology of Pain Management Patient Controlled Analgesia (PCA) – Self administration of opioids (typically IV) in small frequent doses using a special pain pump – Clinical Use: post operative acute pain and chronic pain management – Advantages: Immediate administration of medications Equal or superior analgesia Less opioids used therefore less side effect potential 12Lobert

13. Pharmacology of Pain Management PC A Dosing Strategies – Loading Dose One time initial dose-wake up call in the morning – Basal Dose/Background Dose Hourly continuous dose: 7am to 7pm – Demand Dose Patient administered dose – Lockout Intervals Allowed frequency of demand dose; ex: every 10 minutes, always have another HCW validate. – One Hour and Four Hour Max Limit Equals basal dose and max demand dose – Total demand dose attempted versus Total demand dose successfully delivered 13Lobert

14. Pharmacology of Pain Management Administration Routes for PCA – Intravenous Short term: peripheral IV access Long term: long term venous access – Epidural Short term: external catheter placed in subarachnoid space Long term: tunneled subarachnoid catheter is connected to an internal access port or drug reservoir – Transdermal Long term: external patch with button – Regional: typically local anesthesia similar to one time blocks Short term: catheter placed in joint or wound near peripheral nerves Advantages/Complications: local effect, less side effects? 14Lobert

15. Pharmacology of Pain Management Medications used for PCA – Opioid Morphine Hydromorphone (Dilaudid) Meperidine (Demerol)-rarely used. – Side Effects: sedation, hypotension, itching, nausea, vomiting, respiratory depression – NonOpioid Bupivacaine (Marcaine)-Epidural sometime bad SE. Ropivacaine (Naropin) – Side Effects: sedation, hypotension, itching, nausea, vomiting, respiratory depression, numbness, tingling, motor impairments, urinary retention 15Lobert

16. Pain Management Principles – Always ask about the presence of pain – Perform a comprehensive pain assessment – Avoid IM injections – Treat persistent pain with scheduled meds – Use shorting acting strong opiates to treat moderate to server pain Morphine, hydromorphone, oxycodone – Use long acting strong opiates once pain is controlled and can detect the cycle, so not always “chasing” the pain. Ms contin, fentanyl patch, oxycontin – Mange opioid SE aggressively. Ex: constipation will negatively effect adherence. Lobert16

17. Pain Management Acute Pain: – Pharmacological: Opioids Non-opioids (NASIDS- gi bleeding and Tylenol=liver damage) Antidrepssents, anticonvulsants, local anesthetics. Lobert17

18. Pain Management Chronic Pain: > then 3 months – Chronic Pain: rate pain lower, as they learn to tolerate the pain. How is it affecting your life? – Pharmacological Opioids Non-Opioids: NSAIDS and Tylenol Adjuvants: anti-depressents, anticonvulsants, local anesthetics. Other: PT, heat, cold, E-stem, message, acupuncture, distraction, imagery, support, other CAM, ablative technique, botulism toxin, epidural steroids. Lobert18