Analgesics

Opioids (Narcotics)

Non-Opioids(NSAIDS)

Management of Gout

ABC’s of Pain Treatment

Non-Drug Pain Management Techniques

DistractionIce/Heat

TV/ read/visiting

RelaxationBreathing, yoga

Tapes, music

Massage

Biofeedback

Acupuncture

ImageryPleasant mental picture

Pain NeuroTransmitters Pain Relief Meds

Substance P

Glutamate

GABA

Norepinephrine

Serotonin

Histamine

NSAIDS

Antidepressants

Anti seizure meds

Muscle relaxants

Local salves- capsaicin

Narcotics

Opioids (God Morpheus of Dreams)

Narcotics (Narcosis—stupor)

Produce analgesia by binding to opiate receptors in the CNS, brain and spinal cord involved with the transmission of pain impulses.

Endogenous opioids are present at brain sites

Released during stress, pain & anticipation of pain

Clinical Indications

Analgesia

Acute Pulmonary Edema

Cough

Diarrhea

Anesthesia

OpioidsNarcotics

MOAReceptors

Tolerance

Dependence

Selected AgentsMorphine, Fentanyl,

Codeine, Propoxyphene

Oxycodone

Organ Effects

CNSAnalgesia

Euphoria

Sedation

Respiratory depression

Cough

Miosis

Truncal rigidity

Nausea & vomiting

PeripheralCardiovascular

Genito-urinary

Bilary

Gastrointestinal tract

Uterus

Other

Common Opioid Side Effects

Constipation

Mental clouding, fatigue

Nausea, vomiting

Itch

Euphoria, Dysphoria

Sweating

Urinary retention

Toxicity Opioid Antagonists

Tolerance

DependencePhysical

Psychological

Overdose

Drug Interactions

Contraindications

AgentsNaloxone

Naltrexone

MOA

Indications

Abstinence Syndrome

Gooseflesh, rhinorrhea, chills

Analgesic Ladder

Mild to moderate painNSAID (ASA)Adjuvant analgesic (APAP, antihist)

No adequate reliefNon-narcotic analgesic (NSAID)Weak opioid (Codeine, propoxyphene)

Strong opioid (Fentanyl or Morphine) with adjuvant analgesic

Opioid Drug Interactions

Other CNS depressants respiratory depression

Etoh liver, respiration

MOA inhibitors induce excitability, hypotension or HTN (reduce opioid dose by ¼ and use as test dose)

Oxycontin Abuse

FormulationsIR or SA

When tablets are crushed, snorted or extracted & injected.

Effective, less toxic, well-tolerated medication.

Backlash ‘war on drugs’ challenges legitimate users

Non-Opioid AgentsNon-Steroidal Anti-Inflammatory Drugs (NSAIDS)

Aspirin (prototype)Indications

Anti-inflammatoryAnalgesicAnti-pyreticAnti-platelet

ToxicityRF, RespirFailure

Selected AgentsDiclofenac,EtodolacIbuprofen,KetorolacNaproxen

COX-2 InhibitorsCelecoxibMobic

MOAToxicity

NSAIDS Drug Interactions

Anticoagulants increase bled risk

Diuretics decrease diuretic effect

Herbals (feverfew, garlic, ginger, ginkgo) GI distress & anti-platelet effects

Methotrexate result in MTX toxicity, adjust dose per serum levels & patient’s renal function

DMARDs- Disease Modifying Anti-Rheumatic Drugs

Azathioprine

Cyclophosphamide

Hydroxychloroquine

Leflunomide (Arava)

Methotrexate

Penicillamine

Gold salts

Biological –DMARDs (TNF)

Etanercept (Enbrel)

Infliximab (Remicade)

Anakinra (Kineret)

Corticosteroids

Inhibit inflammationCause leukocytes to be sluggish

Complications with long term useRebound deteriorationImportance of TaperSample Agents

Prednisone, prednisolone, dexamethasone

Glucocorticoids Adverse Effects

CVNa retention

GIPUD

MetabolicRedistribution of fat, hyperglycemia

Immuneinfections

DematologicImpair wound healing

MusculoskeletalOsteoporosis

Bone fractures

NeuropsychiatricPsychosis/mood

OpthalmicCataracts/glaucoma

What is Gout?

What Causes Gout?

Higher than normal levels of Uric Acid can be part of inheritance

Obesity

High alcohol intake

High food intake containing purines

Some drugs that treat BP

Long standing kidney disease

Treatment of Gout

Avoid red meat

Avoid organ foods (Offal) liver, kidneys, tripe, sweetbreads, tongue

Avoid shellfish, scallops, peas, lentils, beans

Reduce weight & alcohol use

Review medications

Drug Management of Gout

ColchicineAcute attackReduces leukocytes

& uric acid production

NSAIDSUriosurics

Probenecid

AllopurinolPreventative

Summary Slide

ABC’s of Pain Treatment

Non-Drug Pain Management Techniques

Opioid Narcotics

Common Opioid Side Effects

Opioid Drug Interactions

Drug Management of Gout

Case Study Pain Management

OP is a 33-year-old male with degenerative disc disease who is on chronic pain management. He was previously employed as a front-end mechanic. In September he tripped while carrying a tire, fell down a concrete stairway and twisted his back. He developed left leg pain two days later. The patient has not worked since and has been on disability.

Prior treatments with traction, heat, cortisone injections and NSAIDS were of minimal assistance. A myelogram revealed a herniated disc at L5S1.

Currently he is maintained on Hydrocodone/APAP 5/5008-10 per day. This medication “ just takes the edge off his pain”

and causes him diaphoresis and constipation.

FH: mother arthritis cigarettes 1 ½ PPD x15yr Father deceased ETOH- 3 beer/day more on weekend

MEDS: Vicodin 5mg 8-10 per day DSS 100 mg bid Valium 5 mg tid prn spasms

Points to Ponder

Discuss options for pain management.

Describe an analgesic ladder.

Why is “maintenance” Vicodin a potential problem.

List some patient education issues you may try to address.