Rogers Pain Part 1 Flashcards
Role of pharmacists in treatment of pain
-Assessment of pain
-Recommend OTC medications
-Refer patients to prescribers
-Recommend initial prescription analgesics to providers
-Educate patients on analgesic therapy
-Evaluate safe and effective use (abuse, side effects, etc.)
-Adjust medication therapy based on response
What questions would you want to ask to subjectively assess a patient’s pain?
-Palliative or precipitating factors
-Quality of pain
-Region of pain location
-Severity
-Time-related nature of pain
-Impact of pain on you
-What have you tried to control the pain?
Objective information to assess pain
-Behavioral changes
-Physiological changes
Examples of physiological changes when someone is in pain
-Dilated pupils
-Paleness
-Sweating
-Tachycardia
-Tachypnea
What are the different pain intensity scales?
-Verbal
-Numeric
-Visual
-Wong-Baker
Types of pain
-Acute (less than 3 months)
-Chronic (more than 3 months)
Types of chronic pain
-Nociceptive (tissue)
-Neuropathic (nerve)
-Mixed (tissue and nerve)
Goals of therapy
-Correct underlying cause of pain if possible
-Minimize pain and symptoms from pain/injury (may not be possible to be free of pain)
-Improve quality of life (QOL) and activities of daily living (ADLs)
-Limit pharmacotherapy side effects
Patient factors to consider when selecting an analgesic
-Hepatic/renal function
-Past medical history
-Previous analgesic therapy
-Routes for medication administration
-Type of pain (neuropathic vs nociceptive)
-Severity of pain
Medication factors to consider when selecting an analgesic
-Allergies
-Cost
-Drug-drug interactions
-Duration of action/dosing frequency
-Potency
-Routes of administration
-Side effects
Types of non-pharmacologic therapy
-Physical manipulation
-Heat or ice
-Massage
-Acupuncture
-Exercise
Step 1 of the WHO analgesic treatment ladder
-Non-opioid
-+/- adjuvant analgesic
Step 2 of the WHO analgesic treatment ladder
-Opioid for mild-moderate pain
-+ non-opioid
-+/- adjuvant analgesic
Step 3 of the WHO analgesic treatment ladder
-Opioid for moderate-severe pain
-+ non-opioid
-+/- adjuvant analgesic
When do you move up the WHO analgesic treatment ladder?
Step up if pain is persisting or increasing
When do you step down the WHO analgesic treatment ladder?
Step down if pain is resolving or toxicity occurs
What non-opioid analgesics are used as primary treatment?
-Acetaminophen
-NSAIDs
What non-opioid analgesics are used as adjunct treatment?
-Gabapentinoids
-Serotonin-norepinephrine reuptake inhibitors (SNRIs)
-Tricyclic antidepressants (TCAs)
-Skeletal muscle relaxants
-Antiepileptics
-Topical agents
What properties does acetaminophen have?
Analgesic and antipyretic
Available formulations of acetaminophen
-Tablet
-Capsule
-Chewable tablet
-Liquid/gel
-IV solution
-Suppository
Recommended dosing for acetaminophen for adults
-325-1000mg PO Q4-6H PRN
-Max dose: 3-4g/day
Recommended dosing for acetaminophen for pediatrics
-10-15mg/kg PO Q4H PRN
-Max dose: 75mg/kg/day or 3-4 g/day
Side effects of acetaminophen
Hepatotoxicity (acute liver failure most likely 10g or more dose)
What is the strength of a regular acetaminophen tablet?
325mg
What is the strength of an extra strength acetaminophen tablet?
500mg
What is the strength of an acetaminophen tablet used for arthritis?
650mg ER
What is the strength of an acetaminophen chewable tablet?
80 or 160mg
Acetaminophen clinical pearls
-Gold standard for osteoarthritis due to fewer side effects in geriatric patients than NSAIDs
-Educate patients about max daily doses, including combination products
-Injection is expensive (often restricted use)
What properties do NSAIDs have?
-Analgesic
-Antipyretic
-Anti-inflammatory
NSAID side effects
-GI bleeding (black box warning)
-Nephrotoxicity
-Fluid retention
-Increase CV events (black box warning)
NSAID clinical pearls
-Take with food
-Caution use in geriatric patients due to increased side effects (Beer’s list)
-Avoid systemic NSAIDs in patients with cardiac history (can use topical NSAIDs)
-Avoid in severe liver disease or chronic kidney disease
Aspirin available formulations
-Chewable tablet
-Tablet
-EC tablet
-Capsule
-ER capsule
-Suppository
Recommended dosing for adults taking aspirin
-325-1000mg PO q4-6h PRN
-Max 4g/day
Recommended dosing for pediatric patients taking aspirin
Avoid (Reye’s syndrome)
Aspirin clinical pearls
-Avoid using for pain in patients taking blood thinners or antiplatelets
-Some formulations available OTC
What Reye’s syndrome
-Rare but serious condition that causes swelling in the brain and liver
-Associated with children/teens using aspirin when they have viral infections such as flu or chickenpox (with or without fever)
Ibuprofen available formulations
-Capsule
-Tablet
-Chewable tablet
-Suspension
-IV solution
What is the strength of a regular ibuprofen tablet?
200mg
Recommended dosing for an adult taking ibuprofen
-200-800mg PO q6-8h PRN
-Max: 3200mg/day
Recommended dosing for a pediatric patient over 6 months old taking ibuprofen
-5-10mg/kg PO q4-6h PRN
-Max: 40mg/kg/day or 2400mg, whichever is less
Ibuprofen clinical pearls
Some formulations available OTC
Diclofenac available formulations
-Capsule
-Tablet
-IV solution
-Suppository
-Topical gel (Voltaren 1% gel)
-Topical solution
-Ophthalmic solution
-Patch
Recommended dosing for adults taking diclofenac
50mg PO q8h or 2-4g applied topically 4 times/day
Diclofenac clinical pearls
-Minimal systemic side effects with topical gel
-Some formulations available OTC
Naproxen available formulations
-Capsule
-Tablet
-DR/ER tablet
-Suspension
Recommended dosing for adults taking naproxen
-220-500mg PO q6-12h
-Max 1000mg/day
Naproxen clinical pearls
Some formulations available OTC
Ketorolac available formulations
-Tablet
-IV/IM solution
-Nasal spray
-Ophthalmic solution
Ketorolac recommended dosing for adults
-15-30mg IV/IV q6h prn
-10mg PO q6h prn
Ketorolac recommended dosing for pediatric patients
0.5mg/kg/dose IM/IV q6h prn
Ketorolac clinical pearls
-Maximum duration is 5 days (parenteral + oral)
-Increased risk of GI bleeds when used for more than 5 days
-Oral dosing is intended as a continuation of IM or IV therapy
Celecoxib available formulations
-Capsule
-Oral solution (less common)
Celecoxib recommended dosing for adults
200mg PO BID
Celecoxib clinical pearls
COX 2 selective- less GI toxicity
Aspirin brand name
Bayer
Acetaminophen brand name
Tylenol
Ibuprofen brand name
Advil, motrin
Diclofenac brand name
Voltaren
Naproxen brand name
Aleve, Naprosyn
Ketorolac brand name
Toradol
Celecoxib brand name
Celebrex
