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Appropriate therapy for somatic pain
- Cold packs
- Tactile stimulation
- Topical anesthetics
Appropriate therapy for visceral pain
- Intraspinal local anesthetics
Appropriate therapy for neuropathic pain
- Tricyclic antidepressants
Analgesic ladder - Severe
- Severe pain 7-10: Strong opioids/adjuvants
- Fentanyl transdermal
Analgesic ladder - Moderate
- Moderate pain 4-6: Weak opioids/adjuvents
- Hydrocodone bilatrate
- Oxycodone and acetominaphen combos
Analgesic ladder - Mild
- Mild pain 1-3: nonopioids
- 1st generation: COX-1/COX-2 inhibitors - causes increased bleeding
- Advil, Motrin (Ibuprofen)
- Naprosyn (Naproxen)Toradol (Ketoralc) -Nonnarcotic injectable
- 2nd generation: Selective COX-2 inhibitor - causes increased cardiovascular eventsCelebrex (Celecoxib)
- Bextra (Valdecoxib)
- Inhibits prostaglandin formation
- When aspirsins are taken they increase the level of nitrous oxide in the blood make the transport of WBC to the injury site easier.
- Uses: Suppress inflammation, Analgesia for mild to moderate pain, Reduction of fever
Prostaglandins & Cyclooxygenase (COX)
- COX is responsible for formation of prostanoids (prostaglandins, prostacyclin, and thromboxane)
- A prostaglandin is a messanger resulting in increased inflammatory response.
- Inhibition of COX can provide relief from the symptoms of inflammation and pain.
- COX-1 inhibition results in decreased platelet aggregation therefore more bleeding
- COX-2 inhibition results in decreased inflammation but no bleeding
NSAIDs Watch out
- Do not give COX-1 to anyone with:
- clotting/bleeding disorders
- liver/kidney disease
- viral disease in children
- or taking anticoagulants or steroids
- Do not give COX-2 to anyone with:
- Hx of cardiovascular disease
- liver/kidney disease
- seizure disorders
- Toxic additive effect: taking ASA with another NSAID
- Toradol (Ketoralac) no more than 5 days!!
- COX inhibition impairs renal perfusion
- Watch out liver disease
- Caution when patient takes seizure meds, anticoags
- Adults not to exceed 4000 mg in 24 hours
- PEDS not to exceed five doses (50-75 mg/kg) in 24 hours
- Specific Antidote for Overdose Mucomyst (Acetylcysteine)
- Slows the production of prostaglandins
- Uses relieve mild to moderate pain, and to reduce fever
- Given for moderate to severe pain relief
- Most opioids do not have an upper limit of effectiveness
- Pain relief increases as the dose increases
- CNS is primary site of action of morphine and produces: analgesia, sedation, euphoria, mood change, mental cloudiness
- Morphine analgesia changes our reaction and our perception of pain allowing you to tolerate more pain
- Short-acting morphine, such as IV morphine, is used as needed for pain
- Kadian, oral morphine, is an oral extended release that has a longer onset of action and remains in the blood stream longer
- For example – choose Codeine when you want to control a non-productive cough
- because a nice side effect of Codeine is suppression of cough.
- Opioid agonists:
- Demerol (Meperidine), Dolophine(Methadone), Codeine(w/ASA = Empirin #2,3,4 – Tylenol #2,3,4), Vicodin(Hydrocodone), Dilaudid(Hydromorphone), Oxycontin(Oxycodone), Oxycodone combos(w/Tylenol =Percocet, W/ASA= Percodan), Talwin(Pentazocine), Ultram(Tramadol)
- Avoid use with: MAOIs (increases BP; hyperpyretic coma), sedative effect drugs (increase sedation), Anticholinergics (Example: when used with Benadryl will increase sedation), pregnancy (result may be fetal addiction)
- Reduce doses in elderly or with liver disease
- DO NOT USE: Head injury or any condition where increased ICP iould be
- problematic(will increase intracranial pressure)
- Respiratory depression/decreased cough reflex
- Pinpoint pupils (miosis) may be warning sign
- Be alert to bronchocontriction – rare, but can result so if you see an increase in wheezing, you need to be alert and intervene.
- Sedation (affects patient safety)
- Decreased GI motility (constipation due to decreased peristalsis of gut)
- Note: opioids will also prolong labor due to decrease tone of muscles
- Vomiting (vomiting due to activation of vomiting center in brain)
- Hypotension (causes vasodilation)
- Be alert to orthostatic hypotension
- This is part of why increased ICP results due to dilation of cerebral arteries
- Urinary retention & decreased urinary output (due to increased tone of detrussor muscle – patients feel the urge but unable to void)
- Seizure (especially meperedine)
- Allergic response (causes histamine release – be alert to itching)
- CODEINE: is 10 times LESS potent than Morphine and drug of choice for cough suppression.
- FENTANYL: is 100 times more potent than its' prototype Morphine
- DEMEROL: for adults do not use more than 600 mg in 24 hours and limit Demerol use to 48 hours.
Administration of opioids
- 1.Take or have recent baseline vital signs for comparison
- 2.Follow controlled substance procedures of the facility.
- 3.Double check doses
- 4.IV push doses should be slow push – 5 minutes
- 5.PCA dose set up – double check
- 6.When switching from PCA, assure adequate PCA dosing prior to discontinuation of PCA
- Beaware: Tolerance does develop over time. Long time opiate users with chronic pain may require higher doses to achieve effect.
- Prototype: Stadol (Butorphanol tartrate)
- WATCH OUT: CNS depressants (increase sedation). Dose reduction needed with liver/renal disease. Cardiovascular disease (increase cardiac workload)
- The side effects are the same as commonly observed with opioid analgesics:
- Somnolence, dizzyness, nausea/vomiting are most common.
- Hypotension within first hour after administration.
- CNS depressants (e.g., alcohol, barbiturates, tranquilizers, antihistamines) may result in increased central nervous system depressant effects
- Drug causes sedation = think safety of patients.
- Not useful for severe pain.
- Not recommended for use in patients dependent on narcotics (i.e., sends them into withdrawal right quick).
- May increase the work of the heart, therefore use in patients with acute myocardial infarction, ventricular dysfunction, or coronary insufficiency should be limited to those situations where the benefits clearly outweigh the risk.
- Prototype: Narcan (Naloxone)
- Treat opioid overdose- Reverse effects of opioids such as respiratory depression
- WATCH OUT: Dose adjustment needed if there is brain tumor or head injury; seizures; heart disease or a heart rhythm disorder; or a history of drug or alcohol addiction
- Depade (Naloxone) should be used with caution in patients with pre-existing cardiac disease or patients who have received potentially cardiotoxic drugs, has special use in rapid detox
- Administration: SQ, IM, IV
- DO NOT GIVE ORALLY!
- Evaluation of effectiveness: is respiratory rate improved? Is sedation improved? Is BP improved?
- Purpose: to enhance the effect of opioids to allow use of lower doses and therefore less side effects from use of opioids
- Some are very useful for neuropathic pain such as cramping, aching, burning
- Tricyclic antidepressants: Amitriptyline (Elavil) Used primarily for neuropathic pain
- Anticonvulsants: Carbamazepine (Tegretol); Gabapentin (Neurontin); Phenytoin (Dilantin) Used primarily for neuropathic pain
- CNS stimulants: Methylphenidate (Ritalin); Dextroamphetamine (Dexedrine) using these drugs with opioids enhances breathing pattern without reducing the effect of the opioid for pain relief.
- Antihistamines: Hydroxyzine (Vistaril) used for their antiemetic effects, can cause sedation therefore increased safety risk.
- Glucocorticoids: Dexamethasone (Decadron); Prednisone (Deltasone) effective in reducing pain due to edema and pressure on nerves
- Bisphophonates: Etidronate (Didronel); Panildronate (Aredia) used for relief of cancer-related bone pain
- Evaluation: was there pain relief
- Anti Gout Medication
- Used for acute or chronic gout
- WATCH OUT patients with serious gastrointestinal, renal, hepatic, cardiac, and blood disorders
- Adverse Events: Bone marrow depression, with long-term therapy, peripheral neuritis, purpura, myopathy, allopecia, reversible azoospermia, N/V/D (Diarrhea is common).
- Inhibits neutrophil motility and activity, leading to a net anti-inflammatory effect. It does not have direct pain reliefproperties nor does it decrease uric acid
- As a preventive, it is taken 3 to 4 times a week – this is an important patient education factoid.