Non- Opioid Analgesic Flashcards
Non-pharmacologic therapy for pain
Exercise
Physical therapy
Weight loss
Transcutaneous electrical nerve stimulation (TENS)
Acupuncture
Spinal cord stimulation
Cognitive behavioral therapy, mindfulness,
stress reduction
Non-opioid Pharmacologic Therapy for Pain
Non-steroidal anti-inflammatory drugs (Cox Inhibitors)
-Present in most tissues
-Contribute to platelet aggregation
-Initiate Parturition
-Stimulate production of prostaglandins
-Protect the gastric mucosa
-Regulate Renal blood flow
Cox 1
Not normally present in tissues (except kidneys)
Induced by inflammatory cytokines: IL-1 and TNF-alpha
Inflamed tissue: upregulation of Cox-2 production of prostaglandins ->inflammation
Cox 2
Common Cox Inhibitors
Non-steroidal anti-inflammatory
drugs (NSAIDS):
ASA – inhibits of Cox 1 and Cox2 –
however Cox 1 > Cox2
Celecoxib (Celebrex) – selective COX-2 inhibitor.
Has similar efficacies to that of the non-selective inhibitors, but the GI side effects are decreased by ~50%.
But, no cardioprotection and there is actually increased risk of MI.
First generation Cox-2 selective inhibitor
Withdrawn from the market 2004 2nd to cardiac risks
Cardiac risk was covered up by Merck
2011: Merck pled guilty and settled with US govt for illegal marketing and
deception of the
govt. re: safety
Rofecoxib(Vioxx) (withdrawn)
Warning that NSAIDS can cause heart attack and stroke
Labels revised
NSAIDs can increase the risk of MI,CVA in patients with or without risk for heart disease
Estimates of how much the risk is increased depends on the study
Patients that were treated with NSAIDS after a first MI were more likely to die after the first year after the MI
Increase risk of hrt. Failure with NSAID use (increase edema and fluid retention)
FDA: Drug Safety Communication 7-9-2015
NSAIDS indications and uses
MILD TO MODERATE PAIN
Osteoarthritis (first line tx)
Rheumatoid Arthritis
Tendonitis
Synovitis
Primary dysmenorrhea
Contraindicated
Hypersensitivity (cross-reactivity)
Bleeding disorders (Aspirin, anticoagulants)
Precautions
Renal dysfunction or risk !
Hypertension (or conditions aggravated by fluid retention)
Hepatic dysfunction
Late pregnancy(premature
closure of DA, oligohydramnios)
NSAIDS CONTRAINDICATIONS, WARNINGS AND PRECAUTIONS
Oral anticoagulants
Digoxin
Lithium
Methotrexate
Diuretics
Beta-blockers
Probenecid
NSAID Interactions
Ketorolac (Toradol)
NSAID
Indication: acute pain (post-op)
Parenteral
Oral (10mg tabs)
Nasal spray
IV/IM must be rxd before PO
No longer than 5 days
Frequently confused with tramadol (Ultram) – synthetic opioid analgesic
Topical NSAIDS
MOA:
Inhibit COX2 enzyme, decreasing prostaglandins, desensitizing peripheral nociceptors
50% placebo effect reported
As effective for OA as oral preparations
Low systemic absorption
Daily application may provide effective concentrations in muscle
Absorbed into synovial fluid of synovial joint
Topical diclofenac (Voltaren)
- OTC - rubbing or local heat may increase absorption - BID dosing to affected area - FDA Box Warning for GI and CV effects
Acetaminophen
Weak inhibitor of prostaglandins and similar to selective to Cox-2 inhibitors
Sometimes categorized as an NSAID
Sparse evidence for chronic pain, but does provide analgesia for some patients
Not useful for osteoarthritis
Max dose: 4000 mg/day (FDA), 2000 gm/day for older adults, liver disease
Adjuvant Medications
Antidepressants
Anticonvulsants
Spasmolytics
Corticosteroids
Topical anesthetics
Cannabinoids
Common Adjuvants
Antidepressants: affect the perception of pain and increases well being
Tricyclics - Amitriptyline
Block re-uptake of noradrenaline and serotonin
Neuropathic pain**
SNRIs – inhibit reuptake of norepinephrine and serotonin
duloxetine(Cymbalta)(LBP, Osteoarthritis, fibromyaligia, diabetic neuropathy)
venlafaxine (Effexor XR) (off label)
Anticonvulsants
Gabapentin:
Inhibits GABA inhibition, binds to Na+,Ca+ channels in nerve cell
Chronic pain, fibromyalgia, post-herpetic neuralgia and neuropathic pain
** FDA approval
Pregablin (Lyrica)
Inhibits GABA inhibition, binds to Na+,Ca+ channels in nerve cell
reduction in neuropathic pain and improvement with associated problems such as sleep and anxiety (fibromyalgia, diabetic neuropathy, post herpetic neuralgia**)
Methocarbamol (Robaxin): centrally acting skeletal muscle relaxant
MOA: not fully understood but derivative of guaifenesin
Use: adjunct to rest, PT for MS pain, spasm
SE: sedation, bradycardia
- Cyclobenzaprine (Flexaril): centrally acting muscle relaxant
MOA: not fully understood, similar to tricyclic AD
Use: adjunct to rest, PT for MS pain and spasm
Spasmolytics (muscle relaxants)
Topical Agents (Capsaicin)
Dates to 4000 BC
Columbus brought it back to Europe in the 1400s for medicinal and culinary properties
Desensitizationof nociceptors (sensory receptors for painful stimuli)
OTC – low dose: 0.1% - low efficacy
RX: Single application – (Qutenza) -high dose: 8% - effective for post-herpetic neuralgia, other neuropathies
Applied 30 min by health care professional
Topical Lidocaine
Blocks nerve conduction at site of application
Second-line therapy for some neuropathic pain: post-herpetic neuralgia, diabetic neuropathy
Use for 12 hour period only
FDA Approves NOVEL NSAID
Suzetrigine (Journavx):
MOA: inhibits Na+ ions from entering pain signaling pathway in the perhiphery
Indication: moderate to severe pain (post-op)
Avoid use eGFR < 15
BID PO dosing
SE: N/V
Cannabinoids
Cannabinoids reduced chronic pain and improved quality of sleep
Effect sizes are of questionable importance
No effects on acute pain or cancer pain
Increased the risks of non-serious adverse events (dizziness, fatigue, vertigo, nerv. Sys. Disorder, GI disorder)
Active license as CNP in MA
MA Controlled Substances Registration (MCSR)
At least 1 physical practice in MA
Minimum of 2 CE credits in medical marijuana
YOU ARE NOT PRESCRIBING BUT CERTIFYING A PATIENT
Medical marijuana card holders can save 20% in taxes with medical authorization
In MA, NPs can become Certifying Healthcare Provider with the Massachusetts Medical Use of Marijuana Program
