Chronic Pain Pt 2 Flashcards
NSAIDs
Analgesic effect: within hours
Trial: full anti-inflammatory effect may require
higher dose for ≥ 7 days
If high GI risk, add gastroprotection
Naproxen → 220-500 mg po BID
● 375 mg po BID (sometimes considered anti-inflammatory)
● 500 mg po BID (anti-inflammatory dose)
Ibuprofen → 400-800 mg po TID
● 600 mg po TID (anti-inflammatory dose)
Diclofenac → SR 75-100 mg po daily
Celecoxib → 100-200 mg po daily-BID
Diclofenac gel → 1.16-2.32% TID-QID
Around the clock w constant levels for at least 7 days
Give it a week trial before stopping
Recommended not to go higheer anymore eg. 150mg/day
Increased risk of AE
Only studied in OTC strengths
No evidence to tell us that more effective using 5-10% strengths
anecdotal
NSAIDs
Evidence
NSAIDs may reduce pain intensity and disability in
patients with chronic low back pain
Recommended to be considered as a first-line
pharmacologic option for chronic low back pain in
most guidelines
Topical may be more well tolerated but oral may be more feasible
Try pulling back from oral NSAID
Acetaminophen
Initiate at 2.6-4 g/d; may allow up to 4 weeks to
assess benefit/tolerability. (Consider limiting to ≤ 3.25 g/d
if using long-term and ≤ 2.6 g/d in EtOH abuse/cirrhosis)
Evidence
Chronic low back pain → does not appear effective
(but may be trialed, as relatively safe compared to alternatives)
Neuropathic pain → generally not recommended
Chronic - limit to 3-3.25g/day is ideal
2-2.6g of EtOh abuse
Relatively safe compared to alternatives
May be part of multimodal analgesia
Opioids
Typically not first-line options for chronic pain
Reserved for when inadequate response to
non-pharmacologic and other preferred options
(and when potential benefit is thought to exceed potential risk)
Dont have dose limits, watchful doses
Not compelling evidence for chronic pain
Risks are well known
Opioid Trial
Screen for risk of abuse
Discuss risks and benefits
Set appropriate goals
● Main goals should be related to function
Start low, go slow; ↑ gradually
(minimum 2 days, but preferred ≥ 2 weeks at a given dose)
Adequate trial duration: 3-6 months
Try to keep it less than 50 morphine equiv dosing
Typically titrate up every couple of weeks
Tramadol
μ opioid receptor agonist
Also inhibitor of serotonin and
norepinephrine reuptake
Several formulations available (short and long acting)
SA: 50-100 mg po q4-6h (Max 400 mg/d)
LA: Initial → 75-100 mg po q24h
May titrate slowly to 200-300 mg
? 300 mg/d = 50 MEDD ? (estimation may be unreliable)
Adequate trial: ~ 4 weeks
Use long acting formulation
A lot of inter-indivudal variabilit
Wait 7-14 days to titrate the dose typically
Tramadol
Adverse Effects
● Similar to other opioid agonists, plus:
● ↑ Seizure risk
● ? ↑ hypoglycemia risk
● Serotonin syndrome
● QTc prolongation
Parent drug gives it serotongeric/seizure risk
Possible increae of hypoglyceia and QTc prolongation
More likely to see at hgiher doses
Buprenorphine
Partial μ receptor agonist
κ receptor antagonist
Patch → Initial: 5 mcg/hr (apply q7days) (opioid naïve)
Usual: 10-20 mcg/hr (q7days)
Buprenorphine/naloxone
➔ Initial: 2 mg/0.5 mg SL tab daily
➔ Titrate slowly to 8-16 mg/2-4 mg SL tab daily
(may require divided BID-QID if for pain)
Gaining favour in area of chronic pain management
Keppa and delta receptor
Partial agonist
Does not have ciling effect when looking at analgesia
When looking at respiratory depression, it does have ceiling
Less europhria and stimulate less cravings that other agents
Pless tolerance development
Pain better if divided BID-QID
Fentanyl (Transdermal)
Not for opioid naïve!
Not for acute pain!
Slow onset, slow offset
Remember: 25 mcg/hr patch = 60-134 MEDD
Patient info:
● Applied to flat, non-hairy area (chest, back, upper arm)
○ if applying to area with hair, clip (don’t shave) the hair
● New patch applied q72h (remove old patch)
● Store out of reach of children and do not apply in front
of them
● Apply at different location with subsequent patch
(preferably other side of body)
● Heat causes it to release faster → don’t use heating pad
on area of body where patch is applied
Cumbersome to use in pt with pain
If pain is well controlled, it can be used for convenience
Some pt may need more breakthrough
Surrounding when they are due for patch change, 2-3 days?
May have more pain that day
Substrate of 3A4
having irritates the area, affects the drug absorption
Or go into a hot tub
Increases risk of OD
Fold tgt when disposing
At least 3 days before putting it back n the site you put it on before
Apply to nn-irrated skin
Cannabinoids
slide 48
Could be an option for some pt
Chronic non neuropathic pain
Monitoring - the 5 A’s
Analgesia - assess pain (e.g., SCHOLAR + NRS)
Activities - functional assessment; coping; physical,
social, psychosocial function
Adverse effects - ask specifically about sedation,
constipation, and cognitive dysfunction
Aberrant drug behaviours
Accurate documentation - including date to review
Aberrant Drug Behaviours
Indicator Example
*Altering route of delivery ● Injecting, biting, or crushing oral formulations
*Accessing from other sources ● Taking from friends/relatives, purchasing from street, double-doctoring
Unsanctioned use ● Multiple unauthorized dose escalations
Drug seeking ● Recurrent prescription loss; stating “nothing else works”
Repeated withdrawal symptoms ● Marked dysphoria, myalgia, GI symptoms, craving
Social features ● Deteriorating or poor social function
Views on the medication ● Acknowledges being addicted; resists tapering/switching
Tools
Pain Assessment and Documentation Tool (PADT)
● Clinician-directed interview
Current Opioid Misuse Measure (COMM)
● Patient self-assessment
Evaluating Therapy
Assess treatment plan periodically
Consider
● Change in underlying pain condition, medical
history, and psychological/social factors
● Level of function
● Progression towards therapeutic goals
● Presence of adverse effects
● Adherence
Clinical Pearls
● Consider choosing a drug that may cover multiple
complaints (e.g., sleep issues, weight gain, etc.)
● Sleep is a frequent concern. If pain is a cause of poor
sleep, consider a longer-acting analgesic to cover the
nighttime period and/or agents that are helpful in
sleep and pain disorders
● “I tried that, it didn’t work” → get full history
○ Adequate trial?
○ Drug used/dosed appropriately?
55 ○ Appropriate goals?
