Pharm Section 6 Flashcards
pain is not a ____, it’s a ______
not a disease, it’s a symptom
people with what hair color are more sensitive to pain?
redheads
chronic pain is classified into what two types?
nocieptive
neuropathic
nociceptive pain
nociceptors (nerves that sense and respond to parts of body suffering from damage) detect irritation or injury and transmit pain signals via peripheral nerves and spinal cord to brain
visceral pain
subtype of nociceptive pain that involves internal organs and is usually poorly localized
neuropathic pain
results from injury or malfunction of PNS or CNS. pain is usually burning, lancinating/stabbing, or electric shock quality. also characterized by persistent allodynia (pain from non painful stimulus)
mainstays for pain treatment include
opioids
NSAIDs
acetaminophen
first-line treatment for mild to moderate acute pain
acetaminophen
first line NSAIDs for mild to moderate acute pain
ibuprofen and naproxen
second-line meds for mild to moderate pain
COX-2 selective NSAIDs
adjunctive for pain associated with nausea
promethazine (Phenergen)
adjunctive for pain associated with inflammation, edema
corticosteroids
adjunctive for pain associated with anxiety
anxiolytics and sedatives
adjunctive for pain associated with muscle spasms
muscle relaxants
adjunctive for pain associated with CNS depression
caffeine
fibromyalgia
chronic disorder mainly affecting women characterized by diffuse musculoskeletal pain, fatigue, IBS, and sleep problems. Treated with variety of meds: analgesics, muscle relaxants, anticonvulsants, antidepressants
what drugs are approved for treating fibromyalgia?
Pregabalin (Lyrica) SNRI dulozetine (Cymbalta) SNRI milnacipran (Savella)*only fibromyalgia*
PDN
painful diabetic neuropathy. pain associated with neuropathy (stabbing, burning, tingling pain). often opioid resistant pain. antidepressants and anticonvulsants commonly used to treat it, as well as gabapentin (Neurontin) and pregabalin (Lyrica)–level A. All drugs used other than pregabalin are level B.
Gabapentin (Neurontin)
Not CS, but can be abused. Used to treat PDN/PHN.
pregabalin (Lyrica)
CS V drug approved to treat PHD, PDN, partial seizures, and fibromyalgia. side effects include: dizziness, drowsiness, difficulty concentrating
chronic pain
lasts longer than 90 days
salicylates
non-narcotic analgesics. two forms: acetylated and non-acetylated
acetylsalicylic acid (Aspirin)
non-narcotic analgesic. acetylated salicylate. originally derived from the bark of the willow tree. Charles Frederick Gerhardt discovered, Felix Hoffman made famous.
diflusinil (Dolobid)
non-acetylated salicylate. non-narcotic analgesic. derivative of, but not metabolized to salicylate
salicylsalicylic acid/salsalate (Dislacid)
non-acetylated salicylate. non-narcotic analgesic.
choline magnesium trisalicylate (Trilisate)
non-acetylated salicylate. non-narcotic analgesic. liquid.
triethanolamine salicylate (Myoflex, Aspercreme)
non-acetylated salicylate. non-narcotic analgesic. topical only.
pharmacological effects of aspirin
analgesia, antipyresis, ant-iinflamatory (large doses only), anti-platelet aggregation, anti-cancer effects
adverse effects of aspirin
most common: GI upset
1st sign toxicity: tinnitus
allergic reactions
dec. excretion of uric acid (worsens gout)
dec. renal blood flow (LT nephrotoxicity)
aspirin in children
don’t use! can cause Reye’s syndrome
explain the analgesic effects of aspirin
inhibits COX 1 and 2, which inhibits production of prostaglandins, which inhibits inflammation and platelet aggregation.
how does aspirin decrease platelet aggregation?
inhibits COX1 for lifetime of platelet, which inhibits the production of thromboxane, which decreases platelet aggregation
what types of cancer has aspirin been shown to reduce the risk for?
colorectal, esophageal, stomach, pancreatic, breast, prostate, and lung. Only reduces cancer risk after 3 years of being on therapy and only reduces cancer mortality after 5.
Alka-seltzer
effervescent tablet containing aspirin
acetaminophen (Tylenol)
aka paracetamol in Eur. Equal analgesic and antipyretic effects as aspirin, but not anti-inflammatory. MOA not clear.
acetaminophen and OA/RA.
good for reducing pain with OA, but doesn’t affect inflammation so not very useful for RA
adult dose for acetaminophen
325-1000mg every 4-6 hours with max dose 4000 mg/day
pediatric dose for acetaminophen
10-15 mg/kg every 4-6 hours with max 5 doses/day
maximum single dose of acetaminophen in healthy adults
between 7500 and 10,000mg
maximum single dose of acetaminophen in healthy kids
> 150mg/kg
FDA is considering lowering the max single dose to what?
625mg/ dose and 3250mg/day
FDA limit on acetaminphen dose in combo products
limited to 325 mg/dose because so many products contain acetaminohpen
infant drops of acetaminophen are marketed as one strength, which is…?
160 mg/ 5 ml
injectable acetaminophen
OFIRMEV. 15 min infusion q6h with max single dose of 1gm and max daily dose of 4gm.
adverse effects of acetaminophen
hepatotoxic. 1/2 of all liver transplants caused by acetaminophen. Fasting and malnutrition increase toxicity. If survive liver toxicity, may also be nephrotoxic, cause severe skin reactions like SJS/TEN/AGEP.
acetaminophen and pregnancy
worries that it may increase the incidence of ADHD, but need further investigations to determine
what is a source you can use to determine what products contain acetaminophen?
knowyourdose.org
pediatric antipyretic/analgesic: ibuprofen vs. acetaminophen
equal safety, equal analgesic efficacy, ibuprofen may be superior anti-pyretic (also can be dose less frequently b/c longer duration of action.
should you alternate acetaminophen and ibuprofen?
no. try acetaminophen first. alternating can confuse the caregiver and may mix up meds
does treating kids’ fevers help them get better faster?
no, just makes them more comfortable
pediatric dose of ibuprofen
10mg/kg per dose
NSAIDs
non-steroidal anti-inflammatory drugs. most prescribed and OTC purchased drugs in the world. three classes include: non-specific/traditional, preferential, and selective
two biggest safety concerns with NSAIDs
GI toxicity
cardio-renal toxicity
others: hepatotoxicity, clotting, fatal skin reactions, and pregnancy (last 6-8 weeks)
aspirin allergy and NSAIDs
may be cross-allergic reactions between people allergic to aspirin and NSAIDs. COX2 selectives may be safer.
non-specific or traditional NSAIDs
inhibits both COX1 (GI tract, platelets) and COX2 (brain, bone, cartilage, inflammation sites)
ibuprofen (Advil, Motrin, Midol)
non-specific or traditional NSAID. OTC forms limited to 200mg or less. available as pediatric (NeoProfen) and adult (Caldolor) injections. Also available as combo with famotidine (Duexis).
naproxen (Aleve)
OTC non-specific or traditional NSAIDs. Possibility for false positive for THC on drug screen.
diclofenac
non-specific or traditional NSAID. many forms, such as Voltaren (delayed release formulation).
most effective NSAID available for improving pain and function in osteoarthritis(OA) is what? what’s the problem with it?
diclofenac 150mg/day, but also most likely to cause hepatotoxicity
sulindac (Clinoril)
non-specific or traditional NSAID.
tolmetin (Tolectin)
non-specific or traditional NSAID.
indomethacin (Indocin)
non-specific or traditional NSAID. has the most prostaglandin inhibition. used primarily for gout, secondarily for tocolysis (suppresses premature labor). Can be used for PDA in infants.
piroxicam (Feldene)
non-specific or traditional NSAID.
ketorlac (Toradol)
non-specific or traditional NSAID. oral, injectable, nasal spray, and tablets available. NSAID, but used clinically like narcotic. major role: tx for pain associated with kidney stones. inhibits platelet aggregation (like all NSAIDs), so can prolong bleeding time.
carprofen (Rimadyl)
non-specific or traditional NSAID. vet use only.
preferential COX-2 inhibitors (NSAIDs)
at normal doses, have no inhibition of COX-1. Less likely to cause GI bleed, platelet aggregation than traditional NSAIDs.
etodolac (Lodine)
preferential COX-2 inhibiting NSAID
nambumetone (Relafen)
preferential COX-2 inhibiting NSAID
meloxicam (Mobic)
preferential COX-2 inhibiting NSAID
COX-2 specific inhibitors (NSAIDs)
equally as effective as traditional NSAIDs for analgesia and anti-inflammatory effects, but less likely to cause GI complications or inhibit platelet aggregation. NO EFFECT ON PLATELETS.
celecoxib (Celebrex)
the only COX-2 specific inhibitor NSAID approved for human use in the US
Upper GI toxicity with NSAIDs
dyspepsia, ulcers, bleeding
some use PPIS, but ulceration due to systemic depletion of prostaglandins, not local effect.
risk factors for GI complications with NSAIDs
older age (>60)
history of PUD or GI bleed
high dose, multiple NSAID use
co-used with prednisone or anticoagulant
cario-renal toxicity with NSAIDs
long-term use can lead to renal papillary records, renal insufficiency, acute renal failure, and the renal injuries. Don’t use in patients with creatinine clearance <50. ALL NSAIDs INC. RISK OF HEART ATTACK AND STROKE. these effects can occur after only a week of therapy.
NSAIDs and Alzheimer’s disease
new research shows they are not beneficial for preventing dementia…actually increase risk for cognitive decline with heavy NSAID use
NSAIDs and bone regrowth
prostaglandin inhibition may lead to delayed bone healing, delayed new bone formation (delays osteoblastic formation of new bone, which require inflammation/prostaglandins for healing).
concomitant ibuprofen and aspirin use?
taking ibuprofen may interfere with anti platelet effects of low-dose aspirin
non-aspirin NSAIDs and cancer protection?
other NSAIDs match aspirin’s anti-cancer effects, especially for colorectal cancer (greatest reduction in COX2 selective inhibitors–Celebrex).
osetoarthritis
most common joint disease. degenerative disorder arising from breakdown of hyaline cartilage in synovial joints (bone on bone pain). symptoms include: deep, achy joint pain exacerbated by extensive use, reduced ROM, crepitus, stiffness during/after rest.
rheumatoid arthritis
chronic systemic inflammatory disease of unknown cause (thought to be triggered by an external source like an infection). Leads to synovial hypertrophy and chronic joint inflammation along with potential for extra-auricular manifestations. inflammatory pain. symptoms: synovitis @ hands and feet, progressive auricular deterioration, extra-auricular involvement, difficulty performing ADLs, constitutional symptoms
hallmark sign of osteoarthritis
deep, achy joint pain exacerbated by use
hallmark sign of rheumatoid arthritis
persistent symmetric poly-arthritis (synovitis) of hands and feet
treatments for osetoarthritis
NSAIDs intra-auricular corticosteroid injections hyaluronic acid injections glucosamine chondroitin
hyaluronic acid
viscous substance in synovial fluid that lubricates and protects joints
are sodium hyaluronate drugs extracted from?
rooster comb (except 1%, which is non-avian and safe for people who are allergic to eggs).
do hyaluronic acid injections work?
conflicting reports. Many organizations recommend against it’s use, but some people find it really beneficial.
glucosamine
amino acid in the body and widely distributed to the connective tissues like cartilage. Said to rebuild joint by strengthening and protecting them.
what is glucosamine derived from?
crab shells or corn
chondroitin
highly hydrophilic, gel-forming polysaccharide macromolecule that helps retain water in cartilage.
what is chondroitin derived from?
shark, pig, or cow cartilage
glucosamine/chondroitin warnings
if effective, if takes weeks to see effects. Caution with shellfish allergies, monitor blood glucose, interacts with warfarin to double INR.
GAIT trial and glucosamine/chondroitin effectiveness?
showed it is effective for knee severe osteoarthritic knee pain, but so was placebo
AAOS (Orthopedic surgeons) glucosamine/chondroitin effectiveness
strongly recommend against use
JOG study and glucosamine/chondroitin effectiveness
no evidence of structural benefits from use
MOVES study glucosamine/chondroitin effectiveness
found that the combo is as safe and effective as Celebrex for knee osteoarthritis
DMARDs
disease-modifying anti-rheumatic drugs. drugs used in place of long-term therapy with NSAIDs or corticosteroids, which can have negative effects if used long term. Biologic and non-biologic/traditional subtypes of these drugs. NOT ANALGESICS.
anchor drug for RA treatment and adjunct recommended with it
methotrexate (Rheumatrex)
folic acid 5-7mg/wk to limit mouth sore, nausea and liver toxic side effects
if anchor drug isn’t enough, what should you do for RA treatment?
add a DMARD. Generally recommend to add a traditional first, but now most people skip directly to the biologic DMARDs. low dose steroids can be added with this for a few months to reduce inflammation until DMARDs start working.
Tofacitinib (Xeljanz)
Biologic DMARD. Janus kinase (JAK) inhibitor. Should only be used in severe RA that does’t respond to methotrexate or other DMARDs. Very expensive. Being investigated for tx of psoriasis, IBD, and organ transplant rejection.
biologic DMARDs and vaccines
DO NOT GIVE LIFE VACCINES TO PEOPLE ON DMARDs because they are immunosuppressed. Okay to give them attenuated/inactivated vaccines. May not respond well.
methotrexate (Rheumatrex)
anchor drug. standard of care for initiating DMARD (non-biologic) therapy in RA patients. antidotal that is toxic to rapidly dividing cells (chemotherapy in higher doses). 1x/week or 3x/week formulations…CAREFUL. not 3x/day…chemotherapy levels if overdose. toxic.
cautions with methotrexate
dosing (3x/week, not day)
use carefully with NSAIDs (inc. blood levels)
contraindicated with pregnancy (abortions)
folate levels (should replace)
lefluonomide (Arava)
non-bioogic DMARD. oral pyrimidine synthesis inhibitor (suppresses pyrimidine production in lymphocytes)
lefluonomide (Arava) warnings
don’t use with pregnancy (category D). discontinue several months before conception
associated with severe, sometimes fatal, infections/sepsis and severe liver injury
gold sodium thiomalate (Myochrysine)
non-biologic DMARD gold compounds. adverse reactions include: ulcers, rash, vasomotor s/s, rare leukopenia so periodic CBC monitoring
auranofun (Ridaura)
non-biologic DMARD gold compounds. adverse reactions include: GI side effects (diarrhea) that usually subside after 3-4 wks
hydroxychloroquine (Plaquenil)
non-biologic DMARD with ophthalmic warnings for retinopathy regardless of dose or length…eye exams regularly, more often with higher doses.
d-penicillamine (Cuprimine)
non-biologic DMARD that’s a chelating agent for removing copper (Wilson’s disease). toxicities, seldom used today. NOT RELATED TO PENICILLIN. NOT CONTRAINDICATED IN PATIENTS WITH PENICILLIN ALLERGY, but SALAD drug.
Sulfasalazine (Azulfidine)
non-biologic DMARD approved for IBS and now RA. as effective, but safer than gold, penicillamine, and hydroxychloroquine. May cause leukopenia, so CBC regularly to monitor. Sulfapyridine is active agent in RA.
TNF inhibitors
TNF is a cytokine that causes inflammation. TNF inhibitors are biologic DMARDs that bind to TNF and inhibit inflammation. Very expensive ($20K/yr)
adverse effects of TNF inhibitors
injection site pain, local reaction
Black box warning for TB, fungal infections, legionella/listeria infections, lymphoma
demyelinating diseases exacerbated
testing required before can get DMARD drugs?
tuberculosis test
etanercept (Enbrel)
biologic DMARD TNF inhibitor. rapid onset and short 1/2 life. 1st approved DMARD.
infliximab (Remicade)
biologic DMARD TNF inhibitor
adalimumab (Humira)
biologic DMARD TNF inhibitor. also approved for uveitis
certolizumab pegol (Cimiza)
biologic DMARD TNF inhibitor. first pegylated TNF inhibitor. Stays in body longer.
Golimumab (Simponi)
biologic DMARD TNF inhibitor. first patient administered TNF inhibitor. 1x/mo treatment.
differences/efficacy for TNF inhibitors
all work equally as well.
differences mainly cost, convenience, dosing
all are expensive ($1500-3000/mo)
non-TNF inhibitors
biologic DMARDs. also suppress immune system. DO NOT combine with TNF inhibiting biologic DMARDs.
rituximab (Rituxan)
non-TNF biologic DMARD. CD20 monoclonal antibody.
tocilizumab (Actemra)
non-TNF biologic DMARD. 1x/mo injection that dec. IL-6 activity to reduce inflammation.
abatacept (Orenica)
non-TNF biologic DMARD IV infusion. upstream T-cell suppressor.
anakinra (Kineret)
non-TNF biologic DMARD IL-1 inhibitor to reduce inflammation. LEAST EFFECTIVE biologic DMARD for RA. Not recommended.
canakinumab (Ilaris)
non-TNF biologic DMARD. IL-1beta inhibitor to reduce inflammation. approved for juvenile idiopathic arthritis in kids 2 or older.
minocycline (Minocin) for RA
tetracycline antibiotic found to induce remission in RA patients. MOA unclear.
Cyclosporine (Sandimmune) for RA
immune suppression. used orally alone or with methotrexate for refractory RA. Nephrotoxic, drug interactions, cost limit use
azathioprine (Imuran)
immunosuppressant sometimes used for refractory RA
lupus
servious, potentially fatal, autoimmune disease. attacks healthy tissues. affects more women. Develops between 15-44. Primary symptom: “butterfly rash”
belimumab (Benlysta)
only drug approved to treat lupus. used in combination with anti-inflammatories. treat with antihistamine prior to infusion. Don’t use live vaccines.
gout
high levels of uric acid. crystals deposit at joint tissues, leading to arthritis and other problems. Crystals form at serum uric acid levels above 7mg/dL or above 6 @ extremities. crystals provoke immune response > PAINFUL and can permanently destroy joints. usually @ big toe
1st line therapy for gout
NSAIDs or corticosteroids
2nd-line treatment for gout
colchicine (Colcrys). max 3 tablets. used off label to treat recurrent pericarditis. can be used for chronic gout with urate-lowering drugs.
xanthine oxidase inhibitors (XOIs)
drugs that lower serum uric levels for chronic gout treatment
allopurinol (Zyloprim)
xanthine oxidase inhibitor for chronic gout. can cause hypersensitivity reaction in those of asian descent (SJS). lower doses in patients with kidney problems
febuxostat (Uloric)
xanthine oxidase inhibitor. safe for patients with kidney problems. lowers uric acid levels more than allopurinol, but more expensive
uricosurics
drugs that increase uric acid secretion to lower seem levels of uric acid
prebenecid (Benemid)
uricosuric drug that increases excretion of uric acid. Must have good renal function to be effective. high risk of nephrolithiasis, so encourage hydration. 2nd line therapy for gout.
pegloticase (Krystexxa)
uricosuric drug approved to treat gout in patients who don’t respond to more traditional therapies. metabolizes/excretes uric acid. Can cause severe allergic reactions…monitor and give corticosteroid or antihistamine before. REMS.
lesinurad (Zurampic)
uricosuric drug used in combo with XOIs. Helps kidneys excrete uric acid by inhibiting reabsorption at kidney. Box warning for acute kidney failure if use too high doses.
opiate MOA
presynaptic reduction of the release of inflammatory neurotransmitters after activation of opioid receptors mu (OP3), kappa (OP2), delta (OP1). increases dopamine levels. inhibit GABA @ substantial gelatinosa.
drug overdoses kill more people than..?
car accidents
NAS
neonatal abstinence syndrom. withdrawal in painkiller-addicted babies. TN leads the nation in NAS.
tolerance
body adaptation where exposure to drug leads to less effect of drug over time…need more to get same effects.
pseudo-tolerance
need for increased dose not because tolerance but because disease progressing/pain worsening, etc.
dependency
manifests with withdrawal symptoms. does not indicate addiction.
addiction
impaired control over drug use, compulsive use, continued use despite harm, and craving
pseudo-addiciton
dramatic increase to painful stimuli, appears to be craving drug, but really just that pain isn’t managed. misinterpreted as addiction. symptoms, behaviors stop with adequate pain relief.
DSM V substance use disorder dx
requires 2-3 symptoms from list of 11
TN addiction treatment act of 2015
can only prescribe buprenorphine for uses recognized by FDA and only by specifically licensed physicians.
morphine sulfate (MS)
CS II narcotic agonist related to morphine. named after greek god of dreams, morpheus. 10mg “normal” IM dose. oral dose 3-6x larger b/c 1st pass metabolism @ liver. no maximum.
morphine and asthma
releases histamine, so can cause brocho-constriction and exacterbate asthma attacks.
hydromorphone (Dilaudid)
CS II narcotic agonist related to morphine. causes less itching and nausea than morphine. oral (4x) and IV (7x) more potent than morphine.
oxymorphone (Opana)
CS II narcotic agonist related to morphine. oral, injection, or crush-resistant formulations.
codeine
CS II/III depending on how formulated. With tylenol is CS III, alone is CS II. Don’t use in young kids or if nursing (codeine intoxication). Metabolized at liver, excrete by kidneys, de-methylated to morphine.
dihydrocodeine (Synalgos-DC)
CS II narcotic agonist related to codeine. formulated in combo with aspirin and caffeine.
hydrocodone
CS II narcotic agonist related to codeine. most prescribed, one of most abused drugs in US. NSAIDs shown to have equal/greater analgesic effects than opioids with acetaminophen.
Lortab, Vicodin
hydrocodone with acetaminophen
Vicoprofen, Reprexain
hydrocodone with ibuprofen
oxycodone
CS II narcotic agonist related to codeine. 1.5x more potent than hydrocodone, 10x more than codeine. Metabolized to oxymorphone.
Percodan
oxycodone plus aspirin
Combunox
oxycodone plus ibuprofen
Percocet
oxycodone plus acetaminophen
OxyContin
oxycodone sustained release. Huge abuse potential because contains more Oxy (up to 80mg/dose). Users can crush and get bigger high, so have created abuse-resistant formulations
abuse resistant forms of oxycontin
OxyContin OP with polyethylene (insoluble in alcohol, harder to crush)
Oxaydo with sodium lauryl sulfate that burns when snorted.
meperidine (Demerol)
CS II synthetic opioid agonist. shorter action than morphine. Diff side effects (dependency, seizures, tremors, mood changs. Used mostly in OB and for shivering (off-label). Many drug interactions (SSRIs, MAOIs). Use when patients allergic to morphine.
methadone (Dolophine)
CS II synthetic opioid agonist. PH warning for death due to resp depression and prolonged QT. Mostly used for addiction treatment/detoxification (swap one for another, can slowly taper methadone)
fentanyl
CS II synthetic opioid agonist. used for anesthesia, acute pain, and chronic pain (patches)
Duragesic
transdermal fentanyl
Actiq
transmucosal fentanyl
Fentora
buccal melt in mouth fentanyl
Onsolis
buccal film fentanyl
Abstral, Subsys
sublingual fentanyl
Lazanda
nasal spray
Ionsys
transdermal ion battery PCA fentanyl
butorphanol (Stadol)
CS IV partial or mixed narcotic agonist/antagonist
pentazocine (Talwin, Talacen)
CS IV partial or mixed narcotic agonist/antagonist
nalbuphine (Nubain)
Not CS partial or mixed narcotic agonist/antagonist. equivalent analgesic to morphine. used for itching with epidurals.
buprenorphine (Buprenex, Subutex)
CS III partial opioid agonist/antagonist. longer acting, more potent than morphine. Combined with naloxone (Narcan) to treat opiate addiction. If abused, narcan brings on opioid withdrawals. MDs must prescribe. Also used for pain, but very controlled.
Probuphine
first FDA approved implant for buprenorphine treatment for opioid addiction.
Belbuca, Butrans
buccal and transdermal buprenorphine formulations for pain treatment
Tramadol (Ultram)
CS IV weak agonist/re-uptake inhibitor. inhibits re-uptake of NE and serotonin. Some analgesic effect. high abuse potential. may cause seizures, convulsions. Narcan will reverse some symptoms, but not all. Warning for suicide risk (similar to SNRI) and hypoglycemia
Tapentadol (Nucynta)
CS II weak agonist/re-uptake inhibitor. centrally acting oral analgesic. stronger than tramadol.
analgesic ceiling
none for pure opioid agonists, but there is a ceiling for mixed agonists-antagonists.
dose limiting toxicities with opioids usually attributed to….?
acetaminophen or ibuprofen in combo formulations
effects of narcotics
analgesia, sedation, euphoria, antitussive, pruritic rashes, allergic reactions, smooth muscle relaxation, seizures, nausea/vomiting, inc. ICP, hypogonadism, serotonin syndrome (rare on own), respiratory depression, physical dependence, tolerance.
SCHINIB (Sleepy, constipation, high, itch, nausea, irritated, buzz)
Naloxone (Narcan)
narcotic antagoinst
methylnaltrexone (Relistor)
narcotic antagoinst
Naltrexone (ReVia)
narcotic antagoinst. prevent narcotic abuse and treatment for alcoholism.
Nalmefene (Revex)
narcotic antagoinst. IV and longer acting than naloxone (Narcan)
Alvimopan (Entereg)
narcotic antagoinst. approved for postoperative ileus.
topical salicylates
topical/local analgesic. don’t use with heating pad.
capsacin
depletes substance P. increases pain initially then analgesia.
benzocaine (Oragel)
topical/local analgesic
lidocaine (Xylocaine)
topical/local analgesic
bupivacaine (Marcaine)
topical/local analgesic
