Pain Management_2024.pdf

PAIN MANAGEMENT ELIZABETH COHEN, PHARMD BCPS OBJECTIVES ¡ Understand different types of pain ¡ Compare and contrast classes of pain medications ¡ Explain the role of non-opioid pain medications in pain management ¡ Describe side effects and monitoring parameters in the treatment of pain ¡ Discuss...

PAIN MANAGEMENT ELIZABETH COHEN, PHARMD BCPS OBJECTIVES ¡ Understand different types of pain ¡ Compare and contrast classes of pain medications ¡ Explain the role of non-opioid pain medications in pain management ¡ Describe side effects and monitoring parameters in the treatment of pain ¡ Discuss appropriate patient education as it pertains to pain medications and pain management PAIN: THE 5TH VITAL SIGN Pain is subjective ¡ “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” - ¡ International Association for the Study of Pain ¡ “Whatever the experiencing person says it is, existing whenever s/he says it does.” ¡ Margo McCaffery, 1968 Part III: Pain Terms, A Current List with Definitions and Notes on Usage" (pp 209-214) Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy, edited by H. Merskey and N. Bogduk, IASP Press, Seattle, ©1994. McCaffery, M. (1968). Nursing practice theories related to cognition, bodily pain and main environment interactions. Los Angeles: University of California Los Angeles. CAUSES OF PAIN Indwelling Procedural Surgery Muscle Pain Cancer Catheters Pain Claudication Injury/trauma Infection Fibromyalgia Arthritis Nerve Headache Damage TYPES OF PAIN ¡ Acute ¡ Surgery, acute illness, trauma, labor, procedures ¡ Typically nociceptive ¡ Chronic 3 mode a ¡ Changes in nerve function and transmission over time ¡ Cancer sien ¡ Nociceptive or neuropathic Katzung BG, Trevor AJ. Eds. Basic & Clinical Pharmacology, 13e. New York, NY: McGraw-Hill;2015. TYPES OF ANALGESICS ¡ Non-Opioid Analgesics ¡ Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) ¡ Acetaminophen > not - an NSAIDS ¡ Opioids ¡ Opioid Antagonists - aren't need to treat pain CYCLOOXYGENASE INHIBITORS ¡ Mechanism of action: inhibition of cyclooxygenase (COX), inhibiting prostaglandin (PG) synthesis from arachidonic acid - 1 enzyme of Cox ¡ Two forms of COX enzyme: COX-1 and COX-2 two forme - ¡ COX-1: Present in nearly all tissues and does “housekeeping” à The good COX ¡ COX-2: Produced mainly at sites of tissue injury, brain, kidney, blood vessels and - colon à The bad COX - ¡ Both COX-1 and COX-2 can contribute to inflammation and pain - Brunton LL, Chabner BA, Knollmann BC. eds. Goodman & Gilman's:The Pharmacological Basis of Therapeutics, 12e. New York, NY: McGraw-Hill; 2011.  protecne remostasis proventral in important also funches > - Sidney good protaglading > 20X1 - Lox] commented into , 2 2 makia ite lo contributes to in do need treat To , - there cox, block pret prosgledin https://www.researchgate.net/figure/Mechanism-of-action-of-selective-and-non-selective-NSAID-used-peri-operatively_fig1_305749630 EFFECTS OF COX INHIBITION Harmful Effects Beneficial Effects Harmful Effects Beneficial Effects of Inhibition of of Inhibition of of Inhibition of of Inhibition of COX-1 COX-1 COX-2 COX-2 Protection against MI Kidney Gastric Erosion and and stroke (reduced Suppression of pain Ulceration - Renal impairment and inflammation platelet aggregation) - Promotion of MI and stroke (secondary to Bleeding tendencies Reduction of fever suppression vasodilation) caused phaso constriction Protection against Renal impairment Colorectal Cancer COX INHIBITORS Nonsteroidal anti-inflammatory drugs (NSAIDS) Do not suppress inflammation ¡ First generation ¡ Acetaminophen ¡ Aspirin ↓ G Weat NSAIDS CoX1 , specie to ¡ Ibuprofen Cox2 intubater, does notelammelie ¡ Naproxen supress Ap The brain isspecific e ¡ Second Generation, COX-2 it Selective - ↳ brain ¡ celecoxib -  - meds as you study their should know this - NSAIDS: THERAPEUTIC USE ¡ Anti-inflammatory, antipyretic, and analgesic effects ¡ First-line analgesia for inflammatory musculoskeletal injuries and disorders such as rheumatoid arthritis and osteoarthritis ¡ Useful for treatment of fever in children ¡ Aspirin should not be used in children < 18 due to risk of Reye’s syndrome when patients have influenza or chickenpox ¡ Appropriate for mild-moderate pain or as an adjunct in the treatment of severe pain ¡ Relieves dysmenorrhea (ibuprofen works best) ¡ Aspirin only – Suppression of platelet aggregation ¡ Not typically recommended for chronic use due to adverse effects > - recommend using N Needs for long-time , dont really a NAIBs Topical us oral develop tolerance for dainy , > - Yese systemiceffects al much as opoids Wolfe MM, et al. N Engl J Med. 1999; 340:1888-1899.  ASPIRIN AND PLATELETS antipe permanetly bind toa ¡ Aspirin IRREVERSIBLY inhibits COX-1 which makes TXA2 leading to platelet aggregation mi causes ↳ changethea wa ¡ Platelets can’t make new COX-1, so it lasts the life of the platelet ~ 8 days platelets = can't make new Cox-1 ¡ Daily aspirin for: protects Yy thop = ¡ Ischemic stroke are permanetly ¡ Transient ischemic attackes blocked ¡ Acute MI > - ¡ Previous MI ¡ Chronic stable angina ¡ Unstable angina ¡ Angioplasty and other revascularization ¡ Low-dose (81mg) effectively inhibits platelets  + brand name -genenc exams on pharm but in the name -gener exams bugger https://thenutritionalhealingcenter.com/nsaids-risks-natural-solutions/  NSAID ADVERSE EFFECTS Effects Considerations Gastrointestinal (GI) Effects Consider proton pump inhibitor or histamine receptor epreventing the protection of erosion blocker in patients using long term > - lower acid levels Worse in advanced age, history of peptic ulcer disease, smoking, alcohol use Bleeding High-dose aspirin discontinued a week before major surgeries High blood pressure increases risk of brain bleed can impair money and affect Renal Impairment Decreased blood flow to kidneys à salt and water retention à edema Worse in advanced age, existing renal impairment, hypovolemia, liver cirrhosis, heart failure * Salicylism (for aspirin only) When aspirin levels climb just above therapeutic Tinnitus, sweating, headache, dizziness and acid-base disturbances NSAID PRECAUTIONS AND CONTRAINDICATIONS ¡ N – nursing and pregnancy alsoundstar used in the ¡ Anemia and postpartum hemorrhage shouldn't be hyperten third trimester ¡ Premature closure of ductus arteriosus ¡ S – serious bleeding ¡ Avoid in patients with significant bleeding history ¡ A – Allergy/asthma ¡ Rare hypersensitivity reaction ¡ Worsen acid/base balance ¡ I – impaired renal function ¡ D – drugs (anticoagulants, alcohol, Angiotensin converting enzyme inhibitors [ACEi] and angiotensin receptor blockers [ARB] NSAID DRUG INTERACTIONS Aspirin is giving before ¡ Anticoagulants TNSARD such an Other NSAIDs , ¡ Increased bleeding risk em ¡ Steroids - + NSAED ¡ Increased risk of gastric ulcers Librupuden prevent.brope bindi reversible ¡ Alcohol INSARD are surprevent ¡ Increased gastric bleeding from aspira ¡ Other NSAIDs + NSARD binding ¡ Time aspirin 2 hours before ¡ ACEi/ARBs + NJARD ¡ Increased risk of renal impairment SELECTIVE COX-2 INHIBITOR (CELECOXIB) ¡ Used ideally for short term pain use ¡ Long term can still have gastroduodenal ulceration mcrease cardiovascular celecoxib , centivy - portant ¡ Increased cardiovascular events anvited up heart pleasing sease. ¡ Avoid in patients with existing heart disease and undergoing coronary artery bypass graft (CABG) surgery most commen * D P pertent > - bactis , history it has ¡ Avoid in patients with a sulfa allergy a herdisease , not ¡ Interacts with warfarin so corned unless occing on. As ACETAMINOPHEN ¡ Weakly inhibits COX-1 and COX-2 exclusively in the CNS, not the periphery ¡ No anti-inflammatory properties - ¡ No gastric ulceration or renal impairment - -  urcause - ALCOHOL AND ACETAMINOPHEN me dis need un ever failre Major pathway Acetaminophen Nontoxic metabolite Depleted by Alcohol and Acetaminophen overdose - Minor pathway: - Glutathione O P450 & - Toxic Nontoxic metabolite more unzyme mat induced Induced by metabolite med o have muntoxic metaso be alonol , In acetaminophen overdose, more is processed through the minor pathway by toxie metabolite 6 Alcohol tre up deree so liver Overdose: all causes which failure Nausea, vomiting, diarrhea, sweating, abdominal discomfort. à hepatic failure (jaundice and increased liver enzymes), coma, death -- Treatment with acetylcysteine which replaces depleted glutathione N yellowe eye helps of overdose ACETAMINOPHEN ADVERSE EFFECTS I acctaminophire US NSARD ¡ Liver injury -- instr inflammation epain es due to ¡ Doses > 4000mg/day eng/day - Blood condition, hematologer ¡ Concurrent use of alcohol conditiont disease : Acetaminaphere ¡ Anaphylaxis & hidney to diseas, better ¡ Swelling of the face, mouth, and throat - m ever at lowers dose. sue deltammophene ¡ Skin related adverse effects – painful rash, blistering of skin and membranes, detatchment ¡ Stevens-Johnson syndrome (SJS) our asprtine ¡ Acute generalize exanthematous pustulosis (AGEP) acctammphie ¡ Toxic epidermal necrolysis (TEN) Ibrypaper - ADDITIONAL PATIENT EDUCATION ¡ Administration ¡ Take oral NSAIDS with food, milk, or a glass of water to reduce gastric upset ¡ Do not crush or chew enteric-coated or sustained-release formulations ¡ Do not consume alcohol ¡ Side Effects ¡ Salicylism ¡ Liver injury OPIOIDS ENDOGENOUS OPIOID RECEPTORS ⑳us Response Mu Receptors Kappa ¡ Endogenous opioid peptides are in the central nervous system (CNS) and in peripheral tissues Receptors Analgesia X X ¡ Mu are the most important, weak activation of kappa Respiratory X depression ¡ Additional effects Sedation X X ¡ Cough suppression ¡ Emesis : patients can vomit Euphoria X blood ¡ Orthostatic hypotension : change position Physical X pressuredrops ¡ Miosis dependence ¡ Biliary colic Decreased GI X X mobility OPIOID AGONISTS -need really small doses compared to other - re to the in so. us https://www.hcplive.com/view/equianalgesic-opioid-dosing-calculation-isnt-simple-math OPIOIDS: THERAPEUTIC USES -most effecture at ¡ Post-op pain treating pain , have all the but They ¡ Pain of labor and delivery issues ¡ More effective against dull, ¡ Chronic pain caused by cancer or constant pain than sharp, - others intermittent pain - ¡ Pre-operative sedation and - reduction of anxiety - - ADVERSE EFFECTS ¡ H – hypotension ¡ M – miosis (pinpoint pupi) - ¡ Vasodilation and release of histamine > can - calle hypotention - ¡ O – out of it (sedation) - ¡ Stand up slowly ¡ R – respiratory depression ¡ I – infrequency (constipation, urinary retention) ¡ Main cause of death ¡ Physical activity and use of stool softener (docusate) and laxative (senna) ¡ Assess RR prior to administration, monitor oxygen, Urinary retention worse in benign prostatic ¡ - ¡ P – physical dependency hypertrophy (BPH) ¡ Abstinence syndrome once drug is stopped ¡ N – nausea ¡ Tolerance – larger dose required to get the same - effect ¡ E – euphoria - CONTRAINDICATIONS AND PRECAUTIONS - ¡ Infants and older patients -severe luny cancer ¡ More sensitive to respiratory depression spoid going es -an to have greater a -- patient in ¡ Head injury a affect Anotherless respiratory ¡ Can worsen symptoms reserve ¡ Decreased respiratory reserve DRUG INTERACTIONS ¡ Other CNS Depressants & ¡ Anticholinergic drugs ¡ Hypotensive drugs drying effects , worseaa ¡ Monoamine oxidase inhibitors (MAOI) with meperidine OVERDOSE ¡ Manifestation agonist Methadone ¡ Coma, respiratory depression, and pinpoint pupils ¡ Treatment drugs all are non- > - Mucapa, selectur, ¡ Ventilator support - J ¡ Opioid antagonist à will reverse all effects of opioids ¡ Nalaxone ¡ Naltrexone ¡ Methylnaltrexone – specific mu opioid antagonists in the GI tract - ↳ constipation who have patients severe constipation dueto spoid SPECIFIC OPIOID CONSIDERATIONS ¡ Fentanyl ¡ High milligram potency - ~ Cyp-2D6 ¡ Only used in chronic pain in opioid tolerant - ¡ Codeine patients or induction and maintenance of => surgical anesthesia ¡ 10% is converted to morphine by CYP2D6 - - with genetic variations ¡ Interactions with CYP3A4 multimodal inhibitors/inducers ¡ Combinations with aspirin and /panagement acetaminophen produce greater pain relief ¡ Patches cannot be exposed to direct heat - ¡ Antitussive dose smaller than analgesic dose ¡ Transmucosal only used in breakthrough cancer pain and not interchangeable corrects codeine > - maphine AGONIST-ANTAGONIST & eut more umally then there is agonist ¡ Produce analgesia when given on , their own ¡ Pentazocine, nalbuphine, ¡ Much less effective than pure agonist butorphanol ¡ When given with a pure agonist, ¡ Mu antagonist and kappa agonist these can antagonize analgesia ¡ Buprenorphine - - ¡ Should never be administered to ¡ Mu partial agonist and kappa a person who is physically ↳ antagonist - dependent on pure opioids - the gonna antagonize Oxicodene & USING OPIOIDS ¡ Dosing schedule ¡ Pain assessment ¡ Often PRN (as needed) ¡ Before and 1 hour after - ¡ Scheduled dosing to get ahead of - ¡ Include location and type of pain - pain - ¡ Doses need to be adjusted based - ¡ ie. Post op or chronic on relief, same dose won’t work ¡ Withdraw slowly when given for the same way for everyone long periods of time (> 20 days) to be extending release are going standing PHYSICAL DEPENDENCE VS. MISUSE VS. OPIOID USE DISORDER physical dependence vs. dependence 2 also ¡ Physical dependence ≠ Addiction prychologie will have a ¡ Misuse: drug use that is inconsistent prependence ¡ Physical dependence with short with medical or social norms term use is very rare ¡ Opioid Use Disorder: primary, ¡ Even if physical dependence occurs, chronic disease characterized by an psychological dependence is also individual pathologically pursuing rare rewards and/or relief by substance use and other behaviors PATIENT CONTROLLED ANALGESIA (PCA) ¡ Drug delivery that allows patients to self administer parenteral medication through reliable devices ¡ Programmed for preset boluses with specific lock out times ¡ Rapid pain relief and maintains steady levels à accelerated care after surgery PATIENT EDUCATION ¡ Administration ¡ Don’t increase dosage without consulting provider and don’t abruptly stop ¡ Do not crush or chew sustained release or controlled release products PAIN MANAGEMENT ELIZABETH COHEN, PHARMD BCPS