Pharm Exam 2 Pain

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MLBuonarosa
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106353
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Pharm Exam 2 Pain
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2011-10-05 05:08:56
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Pain meds
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Pain meds
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  1. Unrelived pain
    • causes unecessary suffering
    • stimulates sympathetic respone
    • decreases immune function
    • weakens already debilitated patients
    • increases poor compliance with therapy
    • impinges on work, family, leisure
    • diminishes hope
  2. Assessment of Pain intensity
    • Scales: 0-10
    • Simple descriptor (none, mild, moderate, severe)
    • Faces
    • When? initiation; dose increase;peak of analgesic
  3. Physical dependence
    a pharmacologic property causing the occurrence of withdrawal symptoms with abrupt discontinuation or administration of an antagonist
  4. Tolerance
    the pharmacologic effect in which with repeated administration, increasing doses are necessary to provvide the same effect
  5. Addiction
    psychological dependence, a behavioral syndrome marked by drug craving, compulsie efforts to secure a drug supply, hoarding, and drug-related interference with pyschological, social, or physical function
  6. Mechanisms of action
    Nonopiod analgesics
    • Work in periphery
    • Affect prostaglandin synthesis
  7. Mechanisms of action
    Opiod analgesics
    • Work in CNS
    • Bind to the mu, kappa, and delta receptors
  8. Acetominophen (Tylenol)
    • analgesic
    • antipyretic
    • no anti-inflammatory effects
    • max dose: 4000 mg/day
    • risk of hepatotoxicity with higher doses
    • Ofirmev - IV acetominophen
    • Antidote: acetylcsteine (Mucomyst, Acetadote)
  9. Cyclooxygenase inhibitors
    • COX found in all tissues, encourages synthesis of prostaglandins
    • COX 1: present in all tissues, protects gastric mucosa, supports renal function
    • COX 2: at site of tissue injury & brain; mediates inflammation, pain, fever response
  10. COX 1 inhibition
    • Gastric erosion and ulceration (-)
    • Bleeding tendencies (-)
    • Acute renal failure (-)
    • Protection against myocardial infarction (+)
  11. COX 2 inhibition
    • Suppression of inflammation (+)
    • Alleviation of pain (+)
    • Reduction of fever (+)
  12. Salicylates
    Asprin (acetylsalicyclic acid, ASA)
  13. Salicylates
    • analgesic, antipyretic, antiinflammatory
    • Initial ang effect: 1 hr
    • Max anti-inflammatory effect- in 2 wks
    • ADR: GI upset, bleeding
    • Toxicity: tinnitus, sweating, dizziness
  14. NSAIDs
    • Inhibit both COX1 and COX2
    • Analgesic, antipyretic, anti-inflammatory
    • Initial analgesic effect: 1 hr
    • Maximum anti-inflammatory effect: 2 wks
  15. ibuprofen
    • Vitamin I
    • NSAID
    • Advil, Nuprin, Motrin,
  16. Adjuvants
    • Enhance efficacy of other agents
    • Add analgesia
    • Treat concurrent symptoms
  17. Most common adjuvants
    • to treat neuropathic pain: (gabapentin (Neurontin)
    • to treat fibromyalgia: pregabalin (Lyrica)
    • Others: cyclobenzadrine (Flexaril)
  18. gabapentin
    • adjuvant to treat neuropathic pain
    • Neurontin
  19. pregabalin
    • Adjuvant to treat fibromyalgia
    • Lyrica
  20. cyclobenzadrine
    • Adjuvant
    • Flexaril
  21. Opiod classifications
    • Opioid agonist
    • Opioid agonist/antagonist
    • Opiod antagonist
  22. Opioids
    • Treat moderate to severe pain
    • Bind to mu opioid receptors in CNS
    • No ceiling effect
    • No major organ disfunction
    • Generally manageable side effects
  23. codeine
    • Step 2 opioid
    • more emetogenic and constipating
  24. hydrocodone
    • Step 2 opioid
    • Vicodin, Lorcet, Norco
    • Stronger than codeine
    • available in varying doses, limited by acetaminophen content
  25. oxycodone
    • Step 2 opioid
    • Percocet, Percodan, Tylox
    • also available as a single entity?
  26. Tramadol
    • Ultram
    • Centrally acting nonopioid analgesic
    • Binds to mu opioid receptor
    • Inhibits uptake of serotonin and norepi in the CNS
    • Indicated for moderate to moderately severe pain
    • Equianalgesic to Tylenol with codeine #3
  27. Tramadol cont
    • Ultram
    • dose 50-100 mg q 4-6 hr
    • Onset 1 hr
    • Peak 2-3 hrs
    • similar side effects to opioids
    • May cause seizures with therap doses
  28. morphine
    • Step 3 opioid
    • MSO4, MS, Roxanol, MS Contin, Oramorph, Kadian, Avinza
  29. Meperidine (Demerol)
    • Step 3 opioid
    • Duration: 2-3 hours
    • PO Doses: 1/4 analgesic effect
    • Toxic metabolite: normeperidine (not reversible with Narcan)
    • Do not use for more than 48 hrs or at doses >600 mg/24 hr
  30. Equianalgesic Opioid Doses
    Look up in book
  31. Titrating opioid doses
    • Increase dose 25-50% until there is either a 50% reduction in pain rating or the patient reports satisfactory pain relief
    • A repeat dose can be give at time of peak if previous dose is ineffective and side effects are minimal.
  32. Opioid dosing
    • ATC does more effective than PRN for pain that is expected to continue
    • More effective if given before pain becomes severe
    • Provide analgesic to allow for uninterrupted sleep
  33. Opioids: Routes of administration
    • Noninvasive is best
    • PO is effective if doses are high enough
    • IV route is safest and fastest for titration
    • IM is painful and unreliable: AVOID
    • Transdermal useful for chronic pain
  34. Opioid Agonist Antagonist Analgesics
    • Nor recommended for 1st line therapy
    • Bind to kappa receptors
    • Partial agonist
    • Partial antagonist (may cause withdrawal in physically dependent patients on opioid agonists
    • Greater risk of dysphoric side effects
  35. pentazocine
    • Talwin
    • Opioid Agonist Antagonist
  36. butorphanol
    • Stadol
    • Opioid Agonist Antagonist
  37. nalbuphine
    • Nubain
    • Opioid Agonist Antagonist
  38. buprenorphine
    • Buprenex, Butrans
    • Opioid Agonist Antagonist
  39. buprenorphine transdermal (Butrans)
    • Moderate to severe chronic pain
    • Transdermal patch lasts up to 7 days
    • No alcohol during use
  40. Dosing long-acting opioids
    • Treat patient with immediate-release opioids for 48 hrs to learn average daily dose
    • Approximately 2/3 of estimated daily dose should be used for sustained-release
    • Provide supplemental immediate release opioid for breakthrough pain
  41. Long acting opioids
    • morphine (MS Contin, Oramorph, Avinza, Kadian)
    • oxycodone (Oxycontin)
    • Hydromorphone (Exalgo)
    • fentanyl (Duragesic)
    • oxymorphone (Opana ER)
    • methadone
  42. Sustained-released morphine
    • MS Contin & Oramorph (8-12 hrs): Do not crush or chew; swallow hole
    • Kadian & Avinza (24 hrs): Caps can be opened and sprinkled on soft, moist food
  43. Sustained-release oxycodone
    • Oxycontin (8-12 hrs)
    • Do not crush or chew; swallow whole
  44. Hydromorphone
    • Sustained release (Exalgo)
    • Once every 24 hrs
    • Do not crush or chew; swallow whole
  45. Long-acting opioids: Transdermal Fentanyl
    • gradual increase in serum levels
    • Steady state achieved in 12-24 hrs
    • Duration of action: up to 72 hrs
    • Elimination half life: ~17 hrs
    • Transdermal application bypasses GI tract
  46. Extended-release oxymorphone
    • Opana
    • Titrate on short-acting form
    • Then convert to long-acting form Q 12 hrs
  47. Methadone
    • Inexpensive
    • Accumulates with repeated dosing
  48. Breakthrough pain
    • Reaches max intensity within 3 minutes
    • Lasts an average of 30 min
    • Doses should be equiv to about 10-20% of the 24 hr total dose. Doses may be given every 2 hrs as needed
    • Do not use sustained-release meds for breakthrough pain
  49. Fentanyl buccal
    • Fentora
    • For breakthrough pain
  50. Opioid-induced side effects
    • constipation (give stimulant lax: Senokot)
    • nausea & vomiting
    • sedation
    • respiratory depression
  51. methylnaltrexone
    • Relistor
    • Tx for constipation caused by opioid use
    • Acts peripherally as mu-opioid receptor antagonist-blocks opioid effects in GI tract
    • Blocks GI tract effects without loss of analgesia
    • SQ injection qod
  52. Sedation scale
    • S=sleeping, easily aroused, Requires no action
    • 1=awake and alert. Requires no action
    • 2=occasionally drowsy; easy to arouse. Requires no action
    • 3=frequently drowsy, arousable, drifts off to sleep during conversation. Decrease opioid dose
    • 4=somnolent, minimal or no response to stimuli. Decrease opioid; consider naloxone (Narcan)
  53. Discontinuing opioids
    • Short-acting opioids, taper doses
    • 50% x 2 days
    • 25% every 2 days
    • Discontinue after 2 days at min dose
  54. hydrocodone
    • Step 2 opioid
    • Vicodin, Norco
    • stronger than codeine
    • limited by acetominophen content
  55. Local anesthetics
    • suppress pain by blocking impulse conduction along axons
    • Block Na channels
    • Block all function, both sensory and motor
  56. Classifications: Local anesthetics
    • Esters: procaine (Novocain)
    • Amides: lidocaine (Xylocaine)
  57. lidocaine
    • widely used local anesthetic
    • used with epinephrine
    • control of dysrhythmias
  58. bupivicaine
    • Marcaine, sensorcaine
    • epidural and local
  59. cocaine
    • ester
    • used in EENT procedures
    • topical only
    • do not use with epinephrine
    • produces euphoria
    • physical dependence
    • avoid with cardiac patients
  60. Local anesthetics: Methods of administration
    • topical: mixture of locals (lidocaine/prilocaine)
    • by injection: infiltration, nerve block, IV regional, epidural, spinal
  61. General anesthetics
    • Produce unconsciousness, lack of response to all painful stimuli
    • Two groups: inhalation, IV
  62. Stages of anesthesia
    • Stage I: analgesia
    • Stage II: delirium
    • Stage III: surgical anesthesia
    • Stage IV: medullary paralysis
  63. Propofol (Diprivan)
    IV Anesthetic
  64. sumatriptan
    (Imitrex)
    • Seratonin agonist
    • Migraine treatment
  65. methotrexate (Rheumatrex)
    • Disease-Modifying Antirheumatic Drug (DMARD)
    • Treatment of RA
  66. etanercept (Enbrel)
    • DMARD
    • Tumor necrosis factor blocker
  67. gout
    • deposit of uric acid crystals in joint
    • increased uric acid production or decreased excretion

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