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NOCICEPTIVE PAIN

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Responsive to non-opioids and opioids

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NEUROPATHIC PAIN

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Treatment includes adjuvant analgesic

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Increased catabolic demand Poor wound healing, weakness, muscle

breakdown Decreased limb movement Increased risk of thrombolytic eventsRespiratory effects

Shallow breathing, tachypnea, coughsuppression leading to pneumoniaTachycardia and elevated bloodpressure

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Non-opioidsOpioids

Adjuvants

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Acetaminophen & NSAIDs

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agonists & mixed agonist-antagonists

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Multipurpose & specific to type of pain

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Schedule 1

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What Controlled substances are morelikely to be abused and include

Codeine, Morphine, Fentanyl,Meperidine, Hydromorphone,Oxycodone, Levorphanol, Methadone

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What controlled substances are Safer,less likely to be abused and inculde

Combination products w/ APAP or ASA-hydrocodone, codeine

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What Controlled substances Might helpa cough in include Expectorants w/

codeine

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Narcotics

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There is none

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Acute and chronic

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Meperidine

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morphine

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meperidine, fentanyl, methadone

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Poppies

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Constipation:PuritisN&V

SedationRespiratory DepressionInhibition of cough reflexConfusion/ Hallucinations

Dysphoria/ euphoriaProlonged LaborUrinary RetentionMiosis (pupil constrict)

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Give stool softener + stimulant docusate + senna

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Puritis do to Histamine release

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Respiratory depression

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local & generalized flushing & itchinggive diphenhydramine

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Other CNS depressants; EtOHMathadone has CYP4503A4 interaction

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Yawning & muscle aches

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Naloxone ( Narcan)

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Precipitate withdrawal

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Buprenorphine (Buprenex) Butorphanol (Stadol)

Nalbuphine (nabain) Pentazocine (Talwin)

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Adjunctive Analgesics & Co-Analgesics

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NSAIDs, Antidepressants, Anticonvulsants,Corticosteroids, Benzodiazepines &

Muscle Relaxers

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MS Contin (CR tabs)MSIR (IR caps)

Avinza (CR caps)Kadian (CR caps)Hydromorphone (Dilaudid)

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MS Contin (CR tabs)? Long Acting

MSIR (IR caps) Immediate release

Avinza (CR caps) Long Acting

Kadian (CR caps) Long ActingHydromorphone (Dilaudid)

Immediate Release

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MSIR (IR caps)Hydromorphone (Dilaudid)

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Avinza (CR caps)

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What types of morphine can be emptiedonto food but NOT chewed- because italters drug delivery OD? & death

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OxyCONtin (CR tab) Long acting Chronic

OxyIR (IR caps) Short Acting Acute

Roxicodone (solution) Short Acting Acute

Percocet Long acting chronic

Roxicet Long acting chronic

Percodan Long acting Chronic

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Percocet & Roxicet

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Percodan

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Fentanyl Patch (Duragesic)

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Fentanyl (Sublimaze)

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Fentanyl Lozenge (Actiq)

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Is only used in who? Use for opioid tolerant ONLY

Pt.s on must continue what? Must continue regular OTC opioids

Not for what type of use? Not for short term pain inc. migraines

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Is a _____-philic drug? Lipophilic Drug

What should be avoided? Why? Avoid sun & heat; inc. absorption

What in the body alters its absorption? Peripheral blood flow & subcutaneous fat altersabsorption

Who can it not be given to? No opioid nave

How long does it take for the body to getsignificant levels?

6-12hr for significant levelsWhat is its Black Box Warning?

BLACK BOX= ACUTE PAIN USE

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Acute

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Norco, Vicodin, Lortab

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Vicoprofen

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Who might we give it to? Morphine allergic

What makes it toxic? Its metabolites= normeperidine

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Chronic pain & opioid abuse

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2 phases Alpha phase works as an analgesic: t1/2= 8-

12 hr Beta phase helps with w/drawl: t1/2; 24-36hr

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Tramadol

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Tramadol (Ultram)Tramadol ER

Tramadol + APAP

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Dual action: blocks mu receptors &inhibits uptake of serotonin &norepinephrine

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Lowers seizure threshold

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Who is it used in? Pt. who need strong analgesic (like

oxycodone) but cant tolerate GI sideeffects

What is the MOA? Opioid agonist and norepi reuptake inhibitor

ADRs? Sedation and Seizures

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Oxycodone po? 20mg

hydrocodone po? 20-30mg

methadone po? 3-5mg

morphone po? 7-7.5

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50mg morphine po

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Oxycodone po? 1.5xhydrocodone po?

1.5xmethadone po?

Non-linearmorphone po?

4-7xFentanyl

80x

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APAP 650mg q 4hrAPAP 1,000mg q 6hr

Ibuprofen 600mg q 6hrPain = 3 might use Tramadol or APAP w/codine

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APAP 325mg/codine 60mg (T4) q 4hrTramadol 50mg q 6hr

APAP 325mg/oxycodone 5mg q 4hr

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Morphine 15mg q 4hrHydromorphone 4mg q 4hr

Morphine controlled release 60mg q 8hr

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Give controlled release (CR) or longacting product + something forbreakthrough painGive 10% the total daily dose asbreakthrough managementUse around the clock (ATC) not prn tobreak the pain cycle

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Dependence

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Addiction

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End-result of under-treatment of pain?Appropriate drug-seeking behaviors;

demand dose before scheduled time &drug hoarding, go to more than onedoctor/ pharmacy?

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Cured by increasing daily dose andmonitoring pt.

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Flushing, itching, hives and or mildhypotension only or at injection site

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Severe hypotensionSkin reaction other then itching, flushing

or hivesBreathing, speaking or swelling difficultySwelling of face, lips, mouth, tongue orlarynx

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Non-opioid analgesicAvoid codeine, morphine and

meperidine; opioids most commonlyassociated w/ psuedoallergyUse of more potent opioids less likely toproduce pseudoallergyConcurrent administration ofantihistamineDose reduction

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Bone mass and maturity and subsequentbone loss

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Measured by DEXA scanDiagnosis osteoprosis

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Women 50-70? 1,200mg Ca & 600 IU Vit D

Women >70? 1,200mg Ca & 800 IU Vit DMen 50-70?

1,000mg Ca & 600 IU Vit D

Men >70? 1,200mg Ca & 800 IU Vit D

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1,200mg Ca & 800-1000 IU Vit D

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1200-1500mg/day

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1,200mg/ day

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Increased risk of kidney stones and CVdisease

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From food

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Ca & Fe

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TUMSCaltrate

Oscal

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What percent elemental Ca? 40%

Requires what for absorption? AcidNot a good choice for what patients?

Patients on PPIs or elderly

What is the most common complaint ofpeople on?

Gas/ Bloating

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What percent elemental calcium? 21%

What does it NOT require for absorbtion? AcidDoes it produce gas symproms?

NO

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Vitamin D

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50,000 IU po once weekly x6-8 weeksRecheck levels in 8 weeks

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Weight-bearing exercise

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Antiresorptive Medications & AnabolicDrugs

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They slow the progression of bone lossthat occurs in the breakdown part of theremodeling cycle; stop loosing bone asquickly and still make new bone at anormal pace

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Increases the rate of bone formation inthe bone remodeling cycle; THIS IS THEONLY DRUG CLASS MARKETED TO DOTHIS!!!

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Approved for the prevention ofosteoporosis in post-menopausal women

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Inhibits bone reabsorption= reducesbone loss, increases bone density inspine and hip and reduces fracture risk

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PremarinEstrace

PremproFemhrt

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Vaginal bleedingWeight gain

Breast tendernessNauseaHA

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Active thromboembolic dzBreast CA

Liver DzUnexplained vaginal bleedingPregnancy

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NOT COMMON!!! It is no longer used

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Prevention and treatment ofosteoporosis in postmenopausal women

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Increases bone density, reduces risk ofspine fractures

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Provide beneficial effects of estrogenw/out potential ADRs

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Estrogen agonist activity in bone with noestrogen-like activity in the breasts oruterus

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Breast Cancer

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65% over 8 years

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MENOPAUSAL SX; hot flashes, legcramps, DVT (black box), swelling , flu-like sx

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Active thromboembolic dz & pregnancy

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Inhibit osteoclast activity, decrease bonereabsorption= decreases bone loss,increases bone density and reduces therisk of spine, hip and other fractures

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Once a week or once a month

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It has a pH sensitive coating that allows itto travel through the stomach andrelease in the small intestine; can betaken after breakfast instead of 30 minbefore

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Ibandronate (Boniva) 4x/yearZoledronic Acid (Reclast) 1x/year

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GI upset in PO (irritation esophagus &esophageal CA)Femur fractures

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Osteonecrosis of the jaw (ONJ) is deathon bone cells or tissue in the jaw95% cases are in CA pt. onBisphosphonatesBisphosphonates inhibit bone turnoverneeded for healing jaw injuriesPt. should receive chlorohexidinegluconate daily and before dentalprocedures

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Hx esophageal dzGastritis

PUDRenal impairmentCant sit upright for 30 min

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First thing in morning w/ 8oz waterSit up or stand for 30min after (Boniva is60 min)Dont eat or drink anything for 30 min

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In fasting states

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Postmenopausal women who are atleast 5 years beyond menopause

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Naturally occurring hormone in calciumregulation and bone metabolismSlows bone loss, increases bone densityin the spine and reduces risk of spinefracture

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Calcimar (SC/IM)Miacalcin (intranasally)

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Target population? Post-menopausal women, men , bone pain

(osteoprosis and CA)

Contraindications? Hypersensitivity to salmon protein

Side Effects? Nausea, HA, nasal dryness, nasal and skin

irritation, allergy, face and hand flushing,bloody nose

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Postmenopausal women withosteoporosis and high fracture risk orintolerant to other osteoporosis therapy(bisphosphonates)

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MOA= human IgG2 monoclonalantibody which inhibits RANK Ligand(RANKL) an essential for osteoclastactivity

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Dosage? 60mg q 6 mos w/ 1000mg Ca & 400 IU Vit D/

day

ADRs? Back pain, musculoskeletal pain, extremity

pain, hypercholesterolemia, cystitis, ONJ, skinreactions, infection

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Is parathyroid hormone, A bone forminganabolic med

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Maximum of 2 years

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MOA? Rebuilds bone

ADRs? Leg cramps & dizziness