Microsoft word - pharmacological management of pain 2013.doc

Edward C. Dillon, BA., BSC., BSc (Pharm), RPh., ACPR., PharmD Pharmacotherapy Specialist – Intensive Care Medicine Clinical Professor – Faculty of Pharmaceutical Sciences By the end of the presentation, the listener should be able to: 1) List four treatment options for pain management. 2) List four types of pain. 3) List the three major classes of pain medications & one drug of choice from each class. 4) List three benefits & three concerns for each major class of pain medication. c) Immobilization d) Elevation of pain threshold - analgesics, non-invasive techniques (distraction, relaxation, acupuncture, TENS) i) internal organ damage (visceral) ii) external tissue trauma (somatic) iii) nerve damage (neurogenic) iv) psychological trauma (psychogenic) i) eliminate pain ii) prevent pain iii) remove the memory of pain iv) prevent &/or minimize side effects c) Classes of pain medications (analgesics) ii) opioid (agonists, agonist-antagonist) iv) compliance/ease of administration v) cost DRUG T1/2 EQUIVALENT COST MAX. DAILY
(hr) DOSE(mg) ($)
DOSE (mg)
i) P-aminophenols

ii) Non-Steroidal Anti-inflammatory Drugs (NSAID)
a) Propionic Acid Derivatives
*Ibuprofen (Motrin) 2 1500 0.15
b) Phenylacetic Acid Derivatives Diclofenac (Voltaren) 1.5 100 0.96 c) Indeneacetic Acid Derivatives Sulindac (Clinoril) 18 300 0.92 e) Oxicams Piroxicam (Feldene) 41 20 1.23 f) Anthranilic Acid Derivatives Mefenamic Acid (Ponstan) 2 1200 g) Indoleacetic Acid Derivatives *Indomethacin (Indocid) 7 75 0.81 ADVERSE EFFECTS (due primarily to inhibition of prostaglandin synthesis):
i) Stomach/intestinal: nausea, vomiting, cause ulcers (NSAID) ii) Kidneys: most pronounced in patients that have prostaglandin dependent kidney iii) Blood: altered platelet aggregation (NSAID) iv) Nervous System: ringing in the ears, headaches, visual disturbances (NSAID) HIGH RISK FACTORS FOR STOMACH/INTESTINAL BLEEDS (NSAID):
i) Female ii) Elderly (> 65 years of age) iii) Peptic Ulcer Disease (stomach ulcers) iv) Intestinal Bleeds v) Renal/Kidney insufficiency vi) Alcohol excessive use vii) Indigestion (dyspepsia) viii)Multiple NSAID use
OPIOID ANALGESICS
DRUG T1/2 DURATION
EQUIANALGESIC
DOSE (mg)
i) Phenanthrene Derivatives *Codeine 3 4 – 6 200 130 0.20 *Heroin 0.05 Nalbuphine (A/A) [Nubain] 5 4 – 5 10 Oxycodone 3 4 – 5 30 1.65 ii) Morphinans Butorphanol (A/A) 3 4 – 5 2 [Apo] Tramadol [Ultram] 6 4 - 6 150 iii) Benzomorphans Pentazocine (A/A) 2.5 4 – 5 180 60 0.97 iv) Piperidine Derivatives Fentanyl 3 1 – 2 0.1
v) Diphenylheptanes
Methadone 30 4 – 8 12 6 0.09
ADVERSE EFFECTS OF OPIOIDS
Nervous System - sedation - mood changes - mental clouding - hallucinations/nightmares Stomach & intestinal - nausea/vomiting - constipation Heart & Blood vessels - postural low blood pressure - headache
ADJUVANT ANALGESICS
i)Tricyclic antidepressants: (imipramine [Tofranil], clomipramine [Anafranil], amitriptyline [Elavil], doxepin [Sinequan]) ii) Methotrimeprazine [Nozinan] iii) Carbamazepine [Tegretol] & Phenytoin [Dilantin] iv) Corticosteroids – prednisone [Novo], dexamethasone [Dexasone]] vii) Baclofen (Lioresal) viii) Antiarrhythmics: lidocaine [Xylocaine], mexilitene [Novo]
PRINCIPLES OF DRUG USAGE
i) Assess pain: visceral, somatic, neurogenic, psychogenic; mild vs severe; ii) Treat the patient not the symptom iii) Start with a specific drug for a specific type of pain iv) Reassess effects: make dose adjustments v) Use combinations: add opioid +/- adjuvant after maximizing the effect of the non- vi) Know the pharmacology of the drug used - class of drug - onset, peak, duration - pharmacokinetics (what the body does to the drug) vii) Administer the analgesics regularly for prolonged pain viii)Gear the route of administration to the needs of the patient x) Withdraw opioids/adjuvants slowly xi) Respect individual differences among patients

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