Download - Analgesics
Analgesics
Opioids (Narcotics)
Non-Opioids(NSAIDS)
Management of Gout
ABC’s of Pain Treatment
Non-Drug Pain Management Techniques
DistractionIce/Heat
TV/ read/visiting
RelaxationBreathing, yoga
Tapes, music
Massage
Biofeedback
Acupuncture
ImageryPleasant mental picture
Pain NeuroTransmitters Pain Relief Meds
Substance P
Glutamate
GABA
Norepinephrine
Serotonin
Histamine
NSAIDS
Antidepressants
Anti seizure meds
Muscle relaxants
Local salves- capsaicin
Narcotics
Opioids (God Morpheus of Dreams)
Narcotics (Narcosis—stupor)
Produce analgesia by binding to opiate receptors in the CNS, brain and spinal cord involved with the transmission of pain impulses.
Endogenous opioids are present at brain sites
Released during stress, pain & anticipation of pain
Clinical Indications
Analgesia
Acute Pulmonary Edema
Cough
Diarrhea
Anesthesia
OpioidsNarcotics
MOAReceptors
Tolerance
Dependence
Selected AgentsMorphine, Fentanyl,
Codeine, Propoxyphene
Oxycodone
Organ Effects
CNSAnalgesia
Euphoria
Sedation
Respiratory depression
Cough
Miosis
Truncal rigidity
Nausea & vomiting
PeripheralCardiovascular
Genito-urinary
Bilary
Gastrointestinal tract
Uterus
Other
Common Opioid Side Effects
Constipation
Mental clouding, fatigue
Nausea, vomiting
Itch
Euphoria, Dysphoria
Sweating
Urinary retention
Toxicity Opioid Antagonists
Tolerance
DependencePhysical
Psychological
Overdose
Drug Interactions
Contraindications
AgentsNaloxone
Naltrexone
MOA
Indications
Abstinence Syndrome
Gooseflesh, rhinorrhea, chills
Analgesic Ladder
Mild to moderate painNSAID (ASA)Adjuvant analgesic (APAP, antihist)
No adequate reliefNon-narcotic analgesic (NSAID)Weak opioid (Codeine, propoxyphene)
Strong opioid (Fentanyl or Morphine) with adjuvant analgesic
Opioid Drug Interactions
Other CNS depressants respiratory depression
Etoh liver, respiration
MOA inhibitors induce excitability, hypotension or HTN (reduce opioid dose by ¼ and use as test dose)
Oxycontin Abuse
FormulationsIR or SA
When tablets are crushed, snorted or extracted & injected.
Effective, less toxic, well-tolerated medication.
Backlash ‘war on drugs’ challenges legitimate users
Non-Opioid AgentsNon-Steroidal Anti-Inflammatory Drugs (NSAIDS)
Aspirin (prototype)Indications
Anti-inflammatoryAnalgesicAnti-pyreticAnti-platelet
ToxicityRF, RespirFailure
Selected AgentsDiclofenac,EtodolacIbuprofen,KetorolacNaproxen
COX-2 InhibitorsCelecoxibMobic
MOAToxicity
NSAIDS Drug Interactions
Anticoagulants increase bled risk
Diuretics decrease diuretic effect
Herbals (feverfew, garlic, ginger, ginkgo) GI distress & anti-platelet effects
Methotrexate result in MTX toxicity, adjust dose per serum levels & patient’s renal function
DMARDs- Disease Modifying Anti-Rheumatic Drugs
Azathioprine
Cyclophosphamide
Hydroxychloroquine
Leflunomide (Arava)
Methotrexate
Penicillamine
Gold salts
Biological –DMARDs (TNF)
Etanercept (Enbrel)
Infliximab (Remicade)
Anakinra (Kineret)
Corticosteroids
Inhibit inflammationCause leukocytes to be sluggish
Complications with long term useRebound deteriorationImportance of TaperSample Agents
Prednisone, prednisolone, dexamethasone
Glucocorticoids Adverse Effects
CVNa retention
GIPUD
MetabolicRedistribution of fat, hyperglycemia
Immuneinfections
DematologicImpair wound healing
MusculoskeletalOsteoporosis
Bone fractures
NeuropsychiatricPsychosis/mood
OpthalmicCataracts/glaucoma
What is Gout?
What Causes Gout?
Higher than normal levels of Uric Acid can be part of inheritance
Obesity
High alcohol intake
High food intake containing purines
Some drugs that treat BP
Long standing kidney disease
Treatment of Gout
Avoid red meat
Avoid organ foods (Offal) liver, kidneys, tripe, sweetbreads, tongue
Avoid shellfish, scallops, peas, lentils, beans
Reduce weight & alcohol use
Review medications
Drug Management of Gout
ColchicineAcute attackReduces leukocytes
& uric acid production
NSAIDSUriosurics
Probenecid
AllopurinolPreventative
Summary Slide
ABC’s of Pain Treatment
Non-Drug Pain Management Techniques
Opioid Narcotics
Common Opioid Side Effects
Opioid Drug Interactions
Drug Management of Gout
Case Study Pain Management
OP is a 33-year-old male with degenerative disc disease who is on chronic pain management. He was previously employed as a front-end mechanic. In September he tripped while carrying a tire, fell down a concrete stairway and twisted his back. He developed left leg pain two days later. The patient has not worked since and has been on disability.
Prior treatments with traction, heat, cortisone injections and NSAIDS were of minimal assistance. A myelogram revealed a herniated disc at L5S1.
Currently he is maintained on Hydrocodone/APAP 5/5008-10 per day. This medication “ just takes the edge off his pain”
and causes him diaphoresis and constipation.
FH: mother arthritis cigarettes 1 ½ PPD x15yr Father deceased ETOH- 3 beer/day more on weekend
MEDS: Vicodin 5mg 8-10 per day DSS 100 mg bid Valium 5 mg tid prn spasms
Points to Ponder
Discuss options for pain management.
Describe an analgesic ladder.
Why is “maintenance” Vicodin a potential problem.
List some patient education issues you may try to address.