Pain Medications Supplemental Slides PDF

Pain Medications SUPPLEMENTAL SLIDES Pain Defined McCaffery defined pain as “whatever the experiencing patient says it is and exists whenever he says it does.” The International Association for the Study of Pain (IASP) has defined pain as “an unpleasant sensory and emotional experience a...

Pain Medications SUPPLEMENTAL SLIDES Pain Defined McCaffery defined pain as “whatever the experiencing patient says it is and exists whenever he says it does.” The International Association for the Study of Pain (IASP) has defined pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage, or both.” Pain Threshold and Tolerance Pain threshold ◦ The point at which that stimulus is experienced as pain ◦ Differs from person to person Pain tolerance ◦ The duration of time or the intensity of pain that a person will endure before taking overt action to relieve the pain ◦ Decreases with repeated exposure to pain ◦ Decreased by fatigue, anger, fear, and sleep deprivation Pediatric Pain Pathways and chemicals associated with pain are functional in preterm and newborn infants. Nociceptor system is functional by 24 weeks’ gestation. Endogenous opioids are released in the human fetus at birth and in response to fetal and neonatal distress. Pain Assessment in Children Behavioral indicators ◦ Vocalizations (crying, whimpering, whining) ◦ Social withdrawal ◦ Changes in sleep pattern ◦ Facial expression ◦ Body posture ◦ Poor feeding Physiological indicators ◦ Alterations in heart rate, oxygen saturation, respiratory rate and pattern that are not sensitive or specific Pediatric Pain (continued) Chronic pain is rarely associated with sympathetic arousal. Early pain stimuli and experiences are remembered. Pain should be adequately controlled in infants and children. Weight-based dosing. Aging and Pain Increase in pain threshold ◦ Peripheral neuropathies ◦ Skin thickness changes Decrease in pain tolerance Alteration in metabolism of drugs and metabolites Older Adults and Pain Chronic pain is a significant problem. ◦ Joint pain and neuralgias ◦ Many older adults see pain as part of getting old. Dementia pain scale ◦ Pain Assessment in Advanced Dementia Scale ◦ Breathing, vocalization, facial expression, body language, consolability The Pain Experience Pain involves the interactions of three major systems: ◦ Sensory/discriminative system ◦ Motivational/affective system ◦ Cognitive/evaluative system Acute Somatic Pain Arises from connective tissue, muscle, bone, and skin Sharp and localized or dull and non-localized Responds best to: ◦ Acetaminophen ◦ Corticosteroids ◦ Nonsteroidal anti-inflammatory drugs (NSAIDs) ◦ Opiates ◦ Local anesthetics ◦ Ice ◦ Massage Acute Visceral Pain Pain in the internal organs and abdomen Poorly localized (C-fibers) Radiates Most responsive to opiates May also use: ◦ Corticosteroids ◦ NSAIDs Drugs for Acute Pain Morphine and other opioid agonists (moderate to severe pain not responding to non-opioids) Centrally acting non-narcotic analgesic ◦ Acetaminophen COX inhibitors ◦ Salicylates: ASA, Indocin [indomethacin]: (primarily COX-1) ◦ NSAIDs: Motrin [ibuprofen] (COX-1 & COX-2) ◦ COX-2 inhibitors (Celebrex [celecoxib], Voltaren [diclofenac]…) Morphine and Opiates Moderate to severe pain Oral vs intravenous vs transdermal forms Use depends on severity of pain ◦ Moderate pain ◦ Codeine or codeine/acetaminophen (Tylenol #3) ◦ Hydrocodone or hydrocodone/acetaminophen (Vicodin) ◦ Severe pain ◦ Morphine ◦ Oxycodone Prescribing Opiates Dose appropriately ◦ Opioid-naive patient vs patient with chronic pain ◦ Children ◦ Older adults Clear instructions ◦ “Do not exceed.” Dispense the right amount. Refills Prescribing Opiates (continued) Patient education ◦ Clear instructions regarding safety and ADRs ◦ Length of treatment ◦ Non-opiate therapy Monitoring ◦ Is pain medication effective? ◦ Is dose being tapered and being discontinued? ◦ If not, reassess cause of pain. Opioid Risk Tool (ORT) Sample Treatment Agreement THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of 16 NURSING Acetaminophen Action: works centrally in the central nervous system (CNS) to inhibit prostaglandin Used for mild to moderate pain Safer than NSAIDs for most Safe in pregnancy Safe in infants Safe in most older adults Prescribing Acetaminophen Dosing appropriately ◦ Mild pain: 325 to 650 mg every 4 to 6 hours ◦ Children: 10 mg/kg ◦ Moderate pain: 500 to 1,000 mg every 4 to 6 hours ◦ Maximum: 4 g/24 hours ◦ Children: 15 mg/kg/dose Clear instructions ◦ “Do not exceed.” Acetaminophen: Clinical Use Drug of choice for mild to moderate pain in: ◦ Pregnancy ◦ Patients with history of GI bleed ◦ Aspirin allergy, blood coagulation disorders, upper GI disease Drug of choice for fever in: ◦ Above adults ◦ Children, infants younger than 6 months of age ◦ Especially children with fever during flu-like illness NSAIDs: Monitoring NSAIDs ◦ Renal function with long-term therapy ◦ GI ulcer or GI bleed ◦ CBC prior to initiation of therapy and annually thereafter Acetaminophen ◦ Dosing for overdosing with self-medication ◦ Liver function if on high-dose or long-term therapy NSAIDs: Patient Education Administration ◦ Take as directed. ◦ Limit alcohol consumption. ◦ Maximum acetaminophen dose is 3 g/24 hours. ADRs ◦ Report GI upset or “coffee ground” emesis. Aspirin: Clinical Use and Dosing Fever ◦ Aspirin is effective antipyretic ◦ Do not use in pregnant patients or children. Mild to moderate pain ◦ Aspirin is gold standard for pain management. Rheumatoid arthritis ◦ Aspirin is the gold standard. ◦ Margin is narrow between a good therapeutic level and toxicity in treating patients with RA. ◦ Juvenile patients with RA take aspirin. Aspirin: Clinical Use and Dosing (continued) Osteoarthritis ◦ Aspirin works well to treat pain. Acute rheumatic fever ◦ Inflammatory manifestations are treated with aspirin. Aspirin Myocardial infarction (MI) prophylaxis ◦ Daily treatment of 81 to 325 mg aspirin in patients with MI has been associated with a 20% reduction in risk of subsequent and nonfatal reinfarction. ◦ At first sign of an MI, patients should take one 325 mg aspirin tablet. Transient ischemic attacks ◦ Aspirin 50 to 325 mg/day for stroke prevention Aspirin: Patient Education Administration ◦ Take with plenty of water, and remain upright for 15 to 30 minutes. ◦ Do not crush or chew enteric-coated tablets. ◦ Tablets with a vinegar-like odor should be discarded. ADRs ◦ GI upset, GI bleed, ulcers ◦ Reye’s syndrome if administered to children with flu-like illness Lifestyle ◦ Rest, heat, exercise Prescribing NSAIDs for Pain Ibuprofen and naproxen work well for acute pain. ◦ Short-acting ◦ Available over the counter (OTC) Ibuprofen dosing ◦ 200 to 800 mg/dose every 6 hours or every 8 hours ◦ Maximum: 3,200 mg/day ◦ Children: 5 to 10 mg/kg/dose (maximum: 40 mg/ day) Prescribing NSAIDs for Pain (continued) Naproxen ◦ 500 mg, then 500 mg every 12 hours or 250 mg every 6 to 8 hours ◦ Maximum: 1,250 mg/day Treatment of Chronic Pain Assessment Trial Long-term treatment Termination of treatment Phase 2: Trial of an Opioid Non-opioid therapy is preferred Prior to initiating therapy ◦ Patient–Provider Agreement (PPA) ◦ Informed consent form Set realistic goals. Start with immediate-release opioid when starting therapy. Start low, and go slow. Consider naloxone prescription. Phase 3: Long-Term Treatment End of trial and on to chronic management ◦ Patient has satisfactory pain relief. ◦ Patient can manage activities of daily living (ADLs). ◦ There are consistent pain scores on reliable scale. ◦ There are no misuse issues. ◦ There are no legal issues or incarceration. ◦ Patient is not relocating. Chronic Pain Plan Review patient’s history. Develop a treatment plan. Obtain informed consent. Evaluate patient periodically. Refer for additional evaluation, as needed. Document all information. Follow federal and state laws. Rational Drug Selection Use of algorithm Lifestyle modification Medications ◦ NSAIDs ◦ Opiates ◦ Antidepressants ◦ Antiepileptic drugs Substance Abuse Red flags ◦ Claims of lost prescriptions ◦ Using alcohol or street drugs ◦ Repeated requests for early refills ◦ Frequent emergency department or urgent care visits seeking medication ◦ Multiple providers prescribing for patient ◦ Forging prescriptions, buying/selling, or injecting oral or transdermal medications Screening and Monitoring for Substance Abuse CAGE-AID questionnaire (Cut down, Annoyed, Guilty, Eye opener–Adapted to Include Drug use) DAST-20 (Drug Abuse Screening Test-20) screening tool Monitoring of prescriptions Urine drug screens Pain Contracts Recommended by the American Academy of Pain Management Define behavior between patient and provider Agreements outline all aspects of treatment, not just drugs Sample contract at www.aapainmanage.org Don’t Forget… Nonpharmacological measures ◦ Heat ◦ Ice ◦ Massage ◦ Touch ◦ Distraction Don’t Forget… (continued) Alternative therapies ◦ Acupuncture ◦ Transcutaneous electrical nerve stimulation (TENS) ◦ Yoga ◦ Massage Migraine: Treatment Goals of therapy ◦ Minimize impact on quality of life ◦ Avoid medication overuse Rational drug selection ◦ Acute abortive therapy ◦ Prophylactic therapy Migraine: Abortive Therapy Over-the-counter (OTC) analgesics ◦ Work best early in migraine ◦ NSAIDs ◦ Ibuprofen or naproxen ◦ Migraine formulas ◦ Excedrin Migraine or Advil Migraine Migraine: Triptans Serotonin receptor agonists Sumatriptan (Imitrex) and other “triptans” Differ slightly in response Taken at onset of migraine Contraindications ◦ Coronary artery disease , uncontrolled hypertension (HTN), pregnancy Drug interactions ◦ Ergotamines, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors Migraine: Preventive Therapy Considered for patients with more than two migraines per month Goal: 50% reduction in migraines Take time to work (4 weeks minimum) HA diary used to track effectiveness Beta blockers (propranolol, timolol) Antidepressants (amitriptyline, venlafaxine) Antiepileptic drugs (divalproex sodium, sodium valproate, and topiramate) Beta Blockers for Migraine Prevention Propranolol ◦ Start at 60 to 80 mg/day, and slowly increase to 240 mg/day. ◦ Start children at 0.5 mg/kg/day, and increase to 2 to 4 mg/kg/day. ◦ Perform 3 month trial. ◦ Reassess every 6 months. ◦ Taper off slowly. ◦ ADRs are fatigue, lethargy, depression. Failure to respond does not predict response to another beta blocker. Nonpharmacological Treatment of Migraine Identifying triggers ◦ HA diary Alternative therapies ◦ Migranol (feverfew, riboflavin, magnesium, vitamins) ◦ Acupuncture ◦ Aromatherapy ◦ Hypnosis Nonpharmacological Treatment of Migraine (continued) ◦ Reflexology ◦ Massage ◦ Yoga Ice Biofeedback Migraine Monitoring ◦ HA diary ◦ Medication refills ◦ Blood pressure monitoring ◦ If on divalproex, need liver function and complete blood count tested Outcome evaluation ◦ Improved quality of life ◦ HA diary ◦ Avoiding triggers Migraine Education Nonpharmacological measures Medications ◦ Administration, ADRs, interactions, maximum dosages, medication-overuse headache Need for HA diary to measure effectiveness of therapy Expectations of treatment OTC drugs should not be used unless part of treatment plan