Pain Management PDF

Pain Number one reason people take medication Generally is related to some type of tissue damage and serves as a warning signal  25 million people suffer acute pain related to surgery or injury. Chronic pain affects 250 million Americans Is a multibillion dolla...

Pain Number one reason people take medication Generally is related to some type of tissue damage and serves as a warning signal  25 million people suffer acute pain related to surgery or injury. Chronic pain affects 250 million Americans Is a multibillion dollar industry. Opioid receptors—binding sites not only for endogenous opiates but also for opioid analgesics to relieve pain. Several types of receptors: Mu, Kappa, Delta, Epsilon and Sigma.  Location: CNS incl. brainstem, limbic system, dorsal horn of spinal cord Morphine sulfate and morphine  Narcotic Analgesics Can be given orally, IM, sub q, IV or even transdermally Orally are metabolized by liver, excreted by kidney—caution if compromised Morphine and meperidine produce metabolites Widespread effects: CNS, Resp., GI  Narcotics—Mechanisms of Action Bind to opioid receptors in brain and SC and even in periphery acting on receptors located on neuronal cell membranes. The presynaptic action of opioids to inhibit neurotransmitter release is considered.  Indications for Use Before and during surgery Before and during invasive diagnostic procedures During labor and delivery Tx acute pulmonary edema Treating severe, nonproductive cough  Contraindications to Use Respiratory depression Chronic lung disease Chronic liver or kidney disease BPH Increased intracranial pressure Hypersensitivity reactions  Management Considerations age-specific considerations Morphine often drug of choice Use non-narcotic when able Combinations may work by different mechanisms thus greater efficacy  Route selections Oral preferred IV most rapid Epidural, or local injection Can use rectal suppositories  Scheduling Give narcotics before encouraging turning, coughing and deep breathing in post-surgical patients Automatic stop orders after 72h In acute pain, narcotic analgesics are most effective when given parenterally and at start of pain  Cancer Give on a regular schedule Oral, rectal and transdermal are preferred over IV  Management of Withdrawal Symptoms Methadone Clonidine (norepinephrine) Gradually decrease dosing so not to cause withdrawal  NSAIDs on-steroidal anti-inflammatory drugs (NSAIDs) are medicines that are widely used to relieve pain, reduce inflammation, and bring down a high temperature The main types of NSAIDs include: ibuprofen naproxen diclofenac  Peptic ulcers and gastrointestinal bleeding Long-term or high-dose use of NSAIDs could also lead to ulcers developing peptic ulcers  Toradol (ketoralac) is used only for pain. Is the only NSAID that can be given by injection. Use limited to 5 days as can cause bleeding.  Effects of Nonsteroidals on Other Drugs Decrease effects, beta blockers and diuretics Affect sodium and water retention  Acetaminophen Poisoning Toxicity occurs with 20g or more. Treatment—gastric lavage, charcoal, antidote is Mucomyst (acetylcysteine  dosaging Acetaminophen (paracetamol) 325 to 500 mg orally every 4 hours or 500 to 1000 mg every 6 to 8 hours (maximum 3 g per day) Tramadol Start with 25 mg orally once daily May increase daily dose by 25 to 50 mg after 3 to 7 days; give in 3 or 4 divided doses Age ≤75 years: Maximum 400 mg daily Age >75 years: Maximum 300 mg daily  Morphine Start with 2.5 to 10 mg orally every 4 hours as needed (an oral solution is available for initial low doses; lowest tablet strength available in the United States is 15 mg) After 3 to 7 days, determine 24-hour