Pain Management Overview Flashcards
What is the first step to pain management?
Self management and optimized treatment of comorbidities
What is the second step to pain management?
Non-pharmacologic options like accupuncture, physical therapy, stretching, yoga, etc. in addition to step 1
What is the third step to pain management?
Non-opioid pharmacotherapy + first 2 options
What is the final option for pain management?
Opioid therapy + first 3 options; this should be the last choice and should be avoided if possible
How should opioids be used in acute pain?
avoided if mild to moderate, limit duration and dose
How should opioids be used in chronic pain?
Avoid initiation of opioid if at all possible; if they are already taking them, discuss continuation vs tapering vs suboxone vs buprenorphine (always keep quality of life in mind)
What is COX1
maintains homeostasis and is always present
What is COX2
For inflammation; mostly only present after cell injury/inflammation
What is released during injury?
Arachidonic acid is released upon injury to phospholipid membrane
What does arachidonic acid do in case of a cut?
Activates Cox1 and Cox2 which activates prostaglandin (Cox2) and leads to fever, pain, and inflammation
What does arachidonic acid do in the GI tract?
Activates Cox1 which ultimately causes increased platelet aggregation and decreased acid production
What does arachidonic acid do in the kidneys?
Activates Cox1 which ultimately increases renal blood flow
What does NSAIDs inhibit?
Cox1 and Cox2
What do NSAIDs increase the risk of
GI bleeds and renal damage
What is the benefit of a Cox2 NSAID?
Does not block Cox1 so less likely to have GI bleed and renal damage
What is the MOA of aspirin?
Irreversible inhibition of Cyclooxygenase
What does aspirin inhibit?
high dose aspirin inhibits Cox2 (325mg)
How can acetaminophen be given?
Oral or IV
What is the max dose of acetaminophen and why?
4 grams per day; Hepatotoxicity
What does Cox1 activate?
Thromboxane A2
What are some examples of Cox1 and Cox2 inhibitors?
Ibuprofen, naproxen, diclofenac, ketorolac, etodolac
What is an NSAID that is a Cox2 inhibitor at low dose but Cox1 at higher doses
Meloxicam
What is a selective Cox2 inhibitor (no Cox-1 inhibition)
Celecoxib
Are all NSAIDs the same with their inhibition?
No; there is a spectrum; Keterolac is most Cox1 selective and Celecoxib is most Cox2 selective
What is a concern with prescribing NSAIDs?
40% of people use prescription and OTC NSAIDs together
What are the three warnings with NSAIDs?
GI, CVD, Renal
What are CI with NSAIDs?
Sulfa allergy with Celecoxib; CABG
What are BBW with NSAIDs?
CVD risk; GI risk
Can NSAIDs be used in pregnancy?
AVOID if at all possible
What are the drug-drug interactions with NSAIDs?
Anticoagulants, antiplatelets, ibuprofen+aspirin
What is a benefit to topical NSAIDs?
Limited systemic absorption, local site, avoid GI/kidneys
What is an example of topical NSAIDs?
Diclofenac gel (Voltaren)
What are some other topical pain relievers??
Lidocaine patches, Capsaicin, Menthol, Methyl Salicylate, Camphor
What is pregabalin mostly used for?
Neuropathic pain, seizures, fibromyalgia
What is gabapentin mostly used for?
PHN, seizures, RLS
What are some adverse effects of gabapentin/pregabalin?
Weight gain/edema, Sedation, suicidal thoughts/behaviors
How should gabapentin/pregabalin be dosed? Why?
START LOW, GO SLOW (300mg/75mg); sleepiness, adverse effects
Does gabapentin have any special dosing?
Yes, renal dosing
Which med is more potent?
Pregabalin is 6x as potent as gabapentin
How can antidepressants be used for chronic pain?
Neuropathic (Duloxetine, TCA); diabetic peripheral neuropathy, chemo induced peripheral neuropathy
What is the difference between opioid/opiate?
Opiate = naturally occurring: Morphine, Codeine, Metabolites
Opioids = any substance that binds to theh opioid receptor
What are the naturally occurring opioids?
Morphine and codeine
What is the breakdown of codeine?
Codeine to morphine/hydrocodone then both to hydromorphine
How is heroin different than morphine?
Heroin breaks down into 6-MAM then into morphine
What are the synthetic opioids?
Methadone (breaks down to EDDP) and fentanyl (breaks down to norfentanyl)
What substances will people likely also be allergic to if allergic to morphine?
Hydrocodone, Oxycodone, Buprenorphine (could potentially prescribe fentanyl or meperidine)
What is the receptor for opioids?
Mu receptorWh
What is the benefit of buprenorphine?
Binds more strongly to Mu receptor than morphine/oxycodone/hydrocodone and will “steal” the binding site - better pain relief
What is the MOA of opioids?
Interact with mu, delta, kappa opioid receptors which relieve pain; causes sedation, anxiety reduction, and euphoria
What are some things to remember with opioids?
Action depends on location of receptors; increases dopamine receptors; tolerance eventually occurs
Explain the tolerance development of opioids
Your body creates more pain receptors so it maintains the ability to feel pain. It takes more opioid to achieve pain relief and block all of the new receptors. If dose is increased, cycle begins again
What makes Buprenorphine better than opioids?
Tolerance does not build; doors remain slightly opened
How should you approach opioid conversions?
Assess the patient, calculate total daily dose use of opioids, determine which opioid planning to switch to, individualize dose, follow-up and reassess
What are the conversion calculation steps?
- Calculate the 24-hour current dose
- Use equianalgesic ratio
- Calculate new dose using ratio
- Reduce dose 50% for cross tolerance
What to remember when initiating opioid therapy?
Avoid if possible; Immediate release opioids preferred with initiation
What is a concern with initiating with extended release opioids?
Increased risk of overdose at initiation
What are the FDA recommendations for extended-release opioids?
- Pain severe enough that require around the clock treatment
- Patients requiring long term opioid therapy
- DO NOT USE as PRN therapy!
What to keep in mind with opioid dosing?
Use lowest effective dose, do not make dose adjustments until steady state is reached (5 half lives)
Who to give naloxone?
Dispense with new opioid starts and dispense to patients with opioid use disorder or opioid use disorder in remission
What is a concern with naloxone?
When it wears off opioid may rebind and cause more issues; get person to hospital after administering naloxone
What should be avoided with opioids?
Sedated meds - alcohol and ESP BENZOS
What are some warnings of tramadol
Seizures disorders - do not use!!!
What is left to review
Last few slides/summary
