ORTHO PAIN MANAGEMENT Flashcards
INPATIENT PAIN MANAGEMENT
- controlled environment: the need for pain control over at least 12 hours
- PCA = patient controlled analgesia
- usually written on pre-printed order sets
o loading dose, PCA dose, lockout interval, and 4hr limit - Choice of morphine, fentanyl, hydromorphone (dilaudid), or meperidine (Demerol)
- Inpatient pain management requires o coherent patient o attentive staff o naloxone (narcan) taped to pump o bowel program
Inpatients that need sporadic pain control adjustments
Toradol IM/IV Morphine IM/IV Dilaudid IM/IV (hydromorphone) Demerol / Phenergan IM - most patients, however, can usually be controlled with oral medications
MANAGEMENT OF ACUTE PAIN
- usually in an ambulatory setting following injury or post-op
- combination of narcotic & non-narcotic medication
- don’t forget the importance of splinting / bracing / immobilization in orthopedic pain management
MANAGEMENT OF CHRONIC PAIN
- ground rules need to be established early; most cases are better dealt with through chronic pain providers
- Need pain contracts: pain med, amount (dose), and time period
- Drug testing (to make sure the pt is actually taking the meds and not selling them)
- Providers (primary & secondary - can’t go to anyone else to get meds)
- Ancillary services such as
behavioral health
biofeedback
PT
OT
hypnosis
Osteopathic manipulation
several narcotics come in combination with
APAP (acetaminophen / Tylenol)
most common narcotics
⦁ Codeine ⦁ Morphine ⦁ Hydrocodone ⦁ Oxycodone (oxycontin) ⦁ Tramadol (ultram); (tramadol + APAP = Ultracet) ⦁ Hydromorphone (dilaudid) ⦁ Meperidine (Demerol) ⦁ Fentanyl
hydrocodone + APAP
vicodin / Norco / lorcet / Lortab = schedule II
codeine + APAP
Tylenol #3 = schedule III
oxycodone + APAP
percocet
hydromorphone also known as
dilaudid
hydromorphone vs hydrocodone - which is combined with APAP?
hydrocodone
hydrocodone + APAP = vicodin
SCHEDULE I DEA DRUGS
⦁ Use = illegal or restricted to research. No accepted medical use
⦁ High potential for abuse
⦁ Lack of accepted safety for use
EXAMPLES
a. Hallucinogens
b. Heroin
c. Peyote
d. Psilocybin Mushrooms
e. Marijuana
illegal or restricted to research; no accepted medical use
high abuse potential
lack of accepted safety for use
schedule I drugs
examples of schedule I drugs
a. Hallucinogens
b. Heroin
c. Peyote
d. Psilocybin Mushrooms
e. Marijuana
SCHEDULE II DRUGS
⦁ Use - requires a prescription
⦁ High abuse potential - psychological or physical dependence risk
⦁ NO REFILLS OR VERBAL ORDERS
EXAMPLES (opioids & some combos)
a. Codeine
b. Hydrocodone
c. Hydromorphone (dilaudid)
d. Morphine
e. Cocaine
f. Fentanyl
g. Methadone
h. Meperidine (Demerol)
⦁ Use - requires a prescription
⦁ High abuse potential - psychological or physical dependence risk
⦁ NO REFILLS OR VERBAL ORDERS
schedule II
examples of schedule II
a. Codeine
b. Hydrocodone
c. Hydromorphone (dilaudid)
d. Morphine
e. Cocaine
f. Fentanyl
g. Methadone
h. Meperidine (Demerol)
also Adderall & ritalin
SCHEDULE III DRUGS
⦁ Use - requires a prescription (like schedule II)
⦁ Moderate abuse potential (less than I and II)
⦁ Max = 5 refills / 6 months (none in schedule II)
⦁ verbal orders allowed (not in schedule II)
⦁ ex = some opioid combos
EXAMPLES
- Stimulants
a. Benzphetamine
b. Clortermine - Depressants
a. Ketamine
b. Pentobarbital
c. Secobarbital
d. Sulfomethane
also Tylenol #3
⦁ Use - requires a prescription (like schedule II)
⦁ Moderate abuse potential (less than I and II)
⦁ Max = 5 refills / 6 months (none in schedule II)
⦁ verbal orders allowed (not in schedule II)
⦁ ex = some opioid combos
schedule III
examples of schedule III
- Stimulants
a. Benzphetamine
b. Clortermine - Depressants
a. Ketamine
b. Pentobarbital
c. Secobarbital
d. Sulfomethane
benzodiazepines are schedule _______ drugs
IV
and also tramadol
examples of schedule IV drugs
Alprazolam Barbital Clonazepam Lorazepam Midazolam Phenobarbital Diazepam Tramadol
SCHEDULE IV DRUGS
⦁ Use - Requires prescription (just like II & III)
⦁ Lower abuse potential than I / II / III
⦁ Max = 5 refills / 6 months
⦁ verbal orders allowed
⦁ Examples: benzodiazepines, sedatives/hypnotics, and now tramadol
EXAMPLES
a. Alprazolam
b. Barbital
c. Clonazepam
d. Lorazepam
e. Midazolam
f. Phenobarbital
g. Diazepam
h. Tramadol
⦁ Use - Requires prescription (just like II & III)
⦁ Lower abuse potential than I / II / III
⦁ Max = 5 refills / 6 months
⦁ verbal orders allowed
⦁ Examples: benzodiazepines, sedatives/hypnotics, and now tramadol
schedule IV drugs
SCHEDULE V DRUGS
⦁ Use - Requires a prescription (like II / III / IV)
⦁ Lower abuse potential
⦁ currently accepted medical use in treatment
EXAMPLES
a. Robitussin AC (antitussive)
b. Lyrica (anticonvulsant)
c. Lomotil (antidiarrheal)
d. Potiga (anticonvulsant)
EXAMPLES OF SCHEDULE V DRUGS
a. Robitussin AC (antitussive)
b. Lyrica (anticonvulsant)
c. Lomotil (antidiarrheal)
d. Potiga (anticonvulsant)
TYLENOL #3
codeine + APAP
- opioid agonist (binds to opioid receptors)
- 15-60mg / 325mg APAP
- USED AS AN ANTITUSSIVE AS WELL
- schedule III
- good choice for pediatric orthopedic pain
- pretty inexpensive (about $15 for 30 tabs)
opioid combos are schedule
3
Tylenol #3 schedule
3
- USED AS AN ANTITUSSIVE AS WELL
Tylenol #3
good choice for pediatric orthopedic pain
Tylenol #3
hydrocodone + APAP = Vicodin, lorcet, Lortab, Norco = schedule
2
both hydrocodone and Vicodin = schedule II
combos with hydrocodone + APAP (schedule II)
- many combo formulations (vary in APAP) ⦁ Lorcet (10/325) ⦁ Vicodin (5/325) ⦁ Norco (5, 7.5, 10 / 325) ⦁ Lortab (5, 7.5, 10 / 325) - more expensive than tylenol #3 - $55 for 30 tabs (tylenol #3 was $15 for 30 tabs)
codeine is schedule ________
Tylenol #3 is schedule _______
codeine = schedule II
Tylenol #3 = schedule III
oxycodone + ASA
percodan
Percocet =
Percodan =
Percocet = oxycodone (oxycontin) + APAP
Percodan = oxycodone (oxycontin) + ASA
Oxycodone
Oxycontin
Percocet
Percodan
all are schedule
2
OXYODONE
(Oxycontin) = opioid agonist (binds to opioid receptors)
- can be a combo or not: combo = Percocet; Oxycontin = no APAP
- schedule II drug
- Percodan = Oxycodone + ASA (instead of APAP)
- expensive: $100 for 30 tabs
MORPHINE
MS-Contin = oral morphine sulfate
- controlled release formulation for moderate to severe chronic pain
- $100 for 60 tabs of 15mg
SCHEDULE II
tramadol + APAP
ultracet
tramadol = schedule
4
TRAMADOL (ultram)
- Tramadol + APAP = Ultracet
- MOA = unknown - binds to opioid receptors and inhibits NE / serotonin reuptake
- caution with seizure history, and can cause serotonin syndrome
- schedule 4 (along with benzos)
caution with tramadol
- caution with seizure history, and can cause serotonin syndrome
- caution with seizure history, and can cause serotonin syndrome
tramadol
hydromorphone (dilaudid) is schedule
2
need to taper dose to d/c
hydromorphone (dilaudid)
HYDROMORPHONE (DILAUDID)
- opioid agonist - binds to opioid receptors
- high abuse potential & highly sedative
- available in immediate release, ER, IM, IV, PO, or PR
- TAPER DOSE to d/c
- schedule II
*seizure risk over time & dose**
lowers seizure threshold
meperidine (Demerol)
which 2 meds are you concerned about with seizures
tramadol/ultram (seizure hx)
meperidine/Demerol (seizure risk)
lowers seizure threshold
dysphoric effects
N/V
meperidine (Demerol)
meperidine (Demerol) causes N/V, so it is given with
phenergan
MEPERIDINE/DEMEROL IS SCHEDULE
2
MEPERIDINE / DEMEROL
- opioid agonist - binds to opioid receptors
- very sedative, but not very good for pain control
- seizure risk over time & dose - lowers seizure threshold
- also has dysphoric effects
- oral route is least effective (also available in IV or IM)
- avoid abrupt cessation
- schedule II
- Often causes N/V - give with phenergan
- not used very much anymore (seizures & dysphoria & N/V)
FOR OPIOID TOLERANT PATIENTS ONLY
FENTANYL (DURAGESIC)
for chronic pain*
FENTANYL IS SCHEDULE
2
FENTANYL (DURAGESIC)
- for chronic pain
- patches - good for 72 hours
- for OPIOID TOLERANT PATIENTS ONLY
- major abuse potential
- need responsible patients and/or caregiver to administer
- schedule II
- risk of respiratory depression
caution with concomitant anticoagulation
NSAIDS
some studies have suggested that NSAIDS may slow down _______________
fracture healing
NSAIDS
- good use in orthopedics
- anti-inflammatory properties
- caution with concomitant anticoagulation
- some studies have suggested that NSAIDS may slow down fracture healing
- all NSAIDS have warnings pertaining to CV risk, GI bleeding, kidney risk
acetic acid group of NSAIDS
- Diclofenac
- Etodolac
- Indomethacin
- Ketorolac
- through to inhibit cyclooxygenase (COX) - reducing prostaglandin & thromboxane synthesis
- usually fairly cheap
- this class is effective for management of arthritis associated pain (RA, OA, Ankylosing spondylitis)
examples of acetic acid NSAIDS
- Diclofenac
- Etodolac
- Indomethacin
- Ketorolac
examples of propionic acid NSAIDS
- Naproxen (Aleve, Naprosyn)
- Ibuprofen (Advil, Motrin)
propionic acid group of NSAIDS
- Naproxen (Aleve, Naprosyn)
- Ibuprofen (Advil, Motrin)
- Most common OTC grouping
- still has black box warnings
- messes with prostaglandins
- can cause GI issues, kidney issues
COX 2 INHIBITORS (SELECTIVE NSAIDS)
- COX- 2 = enzyme responsible for inflammation & pain;
cox 1 & 2 inhibitors (non-selective NSAIDS = inhibit fever / pain / inflammation, but Cox 1 protects stomach/intestinal lining, so by inhibiting Cox 1 = prone to GI bleeding/ulcers,etc)
Cox 2 inhibitors = inhibit fever / pain / inflammation, but still get effect of Cox 1 - protects stomach/intestinal lining
⦁ Celebrex (Celexa)
- Bextra & Vioxx were d/c due to increased risk of heart attacks
- Mobic (Meloxicam) = relatively selective Cox-2 inhbitor; may combine anti-inflammatory efficacy with improved tolerability
- many orthopedic surgeons use Cox 2 inhibitors as an adjunct with narcotics following total joint surgery
- may not interfere with anticoagulation as bad as other NSAIDS, or delay fracture repair (depends on who you talk to)
- ***CI in pts with sulfa allergy
- arguably less of a GI profile
contraindicated in patients with sulfa allergy
Cox 2 inhibitors (NSAIDS)
may not interfere with anticoagulation as bad as other NSAIDS, or delay fracture repair
and less of a GI profile
Cox 2 inhibitors (NSAIDS) = celexa / celecoxib
STEROIDS
o ORAL
- medrol dose pack: methylprednisolone
- Prednisone
- for rheumatologic applications = need longer duration (mostly prednisone); need a taper
o Injectable
- Kenalog
- Celestone - betamethasone
- Depomedrol - Methylprednisolone
aim of muscle relaxants in ortho
- The aim of centrally acting skeletal muscle relaxants is to produce a decrease in muscle tone & involuntary movement without loss of voluntary motor function or consciousness
- alters the balance of synaptic excitation & inhibition that the motor neuron receives
- primarily to elicit varying degrees of skeletal muscle relaxation
INDICATIONS FOR MUSCLE RELAXANTS
- For relief of acute painful musculoskeletal conditions of local origin
- As an adjunct to rest and physical therapy
- For the relief of acute painful musculoskeletal conditions which include: ⦁ muscle spasm secondary to trauma ⦁ radiculopathy ⦁ musculoskeletal strain or sprain ⦁ herniated intervertebral disc ⦁ muscle spasm of osteoarthritis
All muscle relaxants are CNS depressants….so caution with the
ELDERLY
All muscle relaxants are ___________….so caution with the elderly
CNS depressants
- SE of leukopenia, thrombocytopenia, hemolytic anemia, and bleeding agranulocytosis with long term use; no initial or follow up labs are needed, however, unless
symptoms occur
caution of muscle relaxants with ______ & ______ insufficiency
hepatic & renal insufficiency
(and elderly)
and high abuse potential with alcohol / opioids
and need to taper off - can have withdrawals
muscle relaxants are frequently used with ______ or ______ for abusive purposes
alcohol
or
opioids
can have withdrawal symptoms from muscle relaxants, so need to
taper off
MUSCLE RELAXANTS
- not recommended for use in _______
- not recommended for use in ________
- do NOT mix with ______ or_______ - will potentiate the effects
pregnancy
children
alcohol or other CNS depressants
⦁ For patients with anxiety who also can benefit from muscle relaxant
diazepam (valium) = only benzo that is proven to help with both
guidelines for muscle relaxant use
⦁ Combination muscle relaxant and an analgesic agent appear to be preferred
⦁ The most effective therapy should consider drugs in conjunction with various modes of physical therapy**
⦁ All agents have the potential to cause drowsiness, headache, dizziness and blurred vision
⦁ Patients should not be treated with muscle relaxants for protracted periods
- Initial treatment 10-14 days - Evaluation after to determine need for further drug therapy
⦁ NSAIDs may be useful where pain predominates
⦁ For patients with anxiety, in whom sedation is desirable, Diazepam (Valium) should be considered
⦁ Combination muscle relaxants/analgesics are available, equally effective and less costly
- Norgesic (asa/caffeine/orphenadrine)
The most effective therapy should consider drugs in conjunction with various modes of
physical therapy
example of combination muscle relaxant/analgesic
Norgesic = ASA + caffeine + orphenadrine
ADVERSE EFFECTS OF SOMA (CARISOPRODOL)
Drowsiness, dizziness*************** Vertigo, ataxia Nausea and/or vomiting Hiccups Epigastric distress Tremor, agitation Headache, insomnia Tachycardia Postural hypotension Facial flushing
The Soma metabolite name & significance
metabolite = MEPROBAMATE = active as an anxiolytic - the degree to which it contributes to the efficacy of carisoprodol is unknown
CONTRAINDICATIONS TO CARISOPRODOL
PORPHYRIA
PRECAUTIONS WITH CARISOPRODOL
SEIZURES
MOST COMMON SE WITH CYCLOBENZAPRINE (FLEXERIL)
DRY MOUTH ( anticholinergic SE)
- drowsiness
- fatigue
- headache
- Centrally acting skeletal muscle relaxant that does not directly relax tense skeletal muscles (which relaxant)
CARISOPRODOL (SOMA)
relieves skeletal muscle spasm of local origin without interfering with muscle function
CYCLOBENAPRINE (FLEXERIL)
BIGGEST SE OF CONCERN WITH CARISOPRODOL
DIZZINESS, DROWSINESS
cyclobenzaprine (flexeril) is contraindicated with
CV issues
- arrhythmias
- heart block
- acute phase of MI
and also with concurrent use of MAOIs
contraindicated with MAOIs and CV issues (acute phase of MI, arrhythmias, heart block)
cyclobenzaprine (flexeril)
anticholinergic SE
cyclobenzaprine (flexeril)
most common cyclobenzaprine (flexeril) SE
⦁ DROWSINESS
⦁ DRY MOUTH
⦁ FATIGUE
⦁ HEADACHE
least common cyclobenzaprine (flexeril) SE
⦁ constipation ⦁ abdominal pain ⦁ acid regurgitation ⦁ dizziness ⦁ nausea
depresses muscle excitability indirectly by potentiating the effects of synaptic inhibition medication by GABA
DIAZEPAM (VALIUM)
**Out of all the benzos, ________ = only agent to be approved for treatment of muscle spasms or MSK disorders
DIAZEPAM (valium)
which muscle relaxant is a better choice for elderly patients
METHOCARBAMOL (ROBAXIN)
better choice for elderly pts and pts with cognitive dysfunction / dementia
other muscle relaxants
⦁ Metaxalone (Skelaxin)
⦁ Tizanidine (Zanaflex)
⦁ Baclofen (Lioresal)
treating orthopedic pain
- NSAIDS, muscle relaxants, narcotics, steroids, TCAs, GABA analogues (gabapentin/neurontin, valproic acid, pregabalin/lyrica)
- OTC = glucosamine / chondroitin, Omega 3s
seizures are a precaution in which muscle relaxant
SOMA (CARISOPRODOL)
this class of NSAIDS is effective for management of arthritis associated pain
ACETIC ACID GROUP OF NSAIDS
- indomethacin
- ketorolac
- diclofenac, etc
most common ankle sprain & grades
- Lateral is the most common
- Anterior Talofibular Ligament = most commonly sprained ankle ligament
⦁ Grade I = stretching or slight tear
⦁ Grade II = larger but incomplete tear
⦁ Grade III = complete tear
what should be given for grade I sprain
grade II or III sprain?
Naproxen or Ibuprofen
o for Grade II or III = give NSAIDS (can give acetic acid or propionic acid NSAIDS), or may even consider a short dose of narcotics in conjunction with anti-inflammatories, especially to be able to sleep at night
⦁ Vicodin 5/325: 1-2 po every evening prn pain, #10 (hydrocodone + APAP)
⦁ Percocets are probably a little too strong, but can consider (oxycodone + APAP)
- Man presents with lower back pain after lifting a heavy object; had a sudden sharp, non-radiating LBP
- no bowel or bladder incontinence, no saddle paresthesias (cauda equina)
- no fever, DTRs 2+, no CVA tenderness
Start with an NSAID (Ibuprofen TID or Naproxen BID)
- can combine with a muscle relaxant (Flexeril TID or Robaxin qid)
LBP PEARLS: for acute lower back pain, the combination of an NSAID and a muscle relaxant = provided most effective symptom relief in 1 week
⦁ try no to use opioids - consider Tramadol
⦁ no bedrest - do gentle ROM exercises and PT
low back pain management
NSAID + MUSCLE RELAXANT (combo provides the best symptom relief)
risk factors for fibromyalgia
⦁ genetics
⦁ rheumatic diseases
⦁ hx of physical or emotional trauma
what is fibromyalgia
- widespread MSK pain accompanied by
⦁ fatigue
⦁ sleep
⦁ memory and mood issues - Researchers believe that fibromyalgia amplifies painful sensations (substance P)
- Cause unknown and/or multifactorial
- Trigger points (have diffuse pain in at least 11/18 trigger points > 3 months
- muscle biopsy shows “moth eaten” appearance of type I muscle fibers, and muscle damage
- have diffuse pain, especially in the morning, extreme fatigue, stiffness/tender joints, sleep disturbances, haziness. symptoms may worsen with stress
TX = exercise (swimming preferred - relaxing effect of water); TCAs*, SNRIs or SSRIs, Neurontinn. Pregabalin (Lyrica) = FDA approved for fibromyalgia (schedule V)
MEDICATIONS FOR FIBROMYALGIA
- pain relievers
- anti-depressants
- anti-seizure drugs
PAIN RELIEVERS
⦁ - OTC: Acetaminophen (tylenol), Ibuprofen (motrin / advil), Naproxen (aleve)
⦁ - RX: Tramadol (Ultram)
⦁ - Narcotics NOT advised
ANTI-DEPRESSANTS
⦁ - Amitriptyline (TCA) - start at 10mg qhs, may increase to up to 150mg
⦁ - Duloxetine (Cymbalta) - SNRI - 30mg qd x 1 week, then increase to 60 qd as tolerated
***must taper off antidepressant before d/c use - do not abruptly discontinue!
Alternative to Amitriptyline (TCA) = Cyclobenzaprine (Flexeril) - does NOT treat depression
ANTI-CONVULSANTS
⦁ - Gabapentin (Neurontin) - starting dose 300mg
⦁ - Pregabalin (Lyrica) - 75mg bid, may increase to 150 after 1 week
COMBO TREATMENT
- if unresponsive to monotherapy, get BH, PT, physical medicine involved - directed at reducing major symptoms of: chronic widespread pain, fatigue, insomnia, and cognitive dysfunction
related tricyclic antidepressants…..can be used as an alternative to amitriptyline, but does NOT treat depression
Cyclobenzaprine (Flexeril)
SUMMARY OF TREATMENT FOR FIBROMYALGIA
PAIN RELIEF o NSAIDS (ibuprofen or naproxen) o can use tramadol, but not narcotics!
ANTIDEPRESSANTS
o amitriptyline (TCA)
o duloxetine/Cymbalta (SSRI)
- can use cyclobenzaprine (flexeril) as alternative to amitriptyline, but doesn’t help with depression
ANTI-CONVULSANTS o gabapentin (Neurontin) o pregabalin (lyrica)
what is Reflex Sympathetic Dystrophy
(now known as Complex Regional Pain Syndrome
- disorder of a body region - usually the extremities
- characterized by severe pain, swelling, limited ROM, and skin changes
- unknown etiology
- autonomic dysfunction following bone or soft tissue injuries (wrist fracture or post-surgery)
- MC affects upper extremities
⦁ stage I = pain out of proportion to injury. Symptoms of swelling, extremity color changes, increased nail and hair growth
⦁ stage II = waxy, pale skin, brittle nails, loss of hair
⦁ stage III = joint atrophy and contractures
***Vitamin C prophylaxis after fractures may reduce incidence of CRPS
- initial tx = NSAIDS. can do anesthetic blocks, PT, steroids, TCAs, nerve stimulation, etc.
most common inciting event prior to reflex sympathetic dystrophy =
soft tissue injury (40%)
then fracture (25%)
INCITING EVENT ⦁ soft tissue injury (40%) ⦁ fractures (25%) ⦁ MI (12%) ⦁ CVA (3%) - cerebrovascular accident
treatment for reflex sympathetic dystrophy (complex regional pain syndrome)
MEDS
⦁ Capsaicin cream
⦁ Prednisone may be effective (corticosteroids)
⦁ NSAIDS (ibuprofen, naproxen)
⦁ Propranolol (sympathetic blocker) - beta blocker
⦁ Terazosin or Prazosin (alpha 1 blocker)
⦁ opioids may be needed for severe pain
NSAIDS = initial treatment (pance prep)
vitamin C prophylaxis after fractures may help reduce incidence of CRPS
DRUG SEEKING BEHAVIOR
characteristics of patients ⦁ Requests for early refills ⦁ Multisourcing ⦁ Intoxicated behaviors ⦁ Pressuring behaviors
Requests for early refills “I took too many” “Lost the prescription” “Washed it with the laundry” “Spilled it in the toilet” “The pharmacist shorted the count” “My sorry ass brother-in-law stole them”
Multisourcing:
Visiting multiple physicians (“doctor shopping”)
Recruiting surrogates to obtain the medication
Purchasing drugs from illicit drug dealers or over the internet
Intoxicated behaviors:
Slurred or disinhibited calls to the office
Presenting to pharmacy under the influence
Emergency department visits for:
⦁ repeated falls
⦁ other traumatic injuries
⦁ accidental overdose
Pressuring behaviors: Begging or pleading Excessive compliments Breaching boundaries Threats of harm to: ⦁ self ⦁ others ⦁ the provider
***THE MOST COMMON REASON THAT PROVIDERS GET IN TROUBLE WITH OPIOIDS =
inadequate documentation
