Pain–Are we wrong in how we

Treat it????

Major Peter Strube CRNA MSNA APNP

ARNP

We Must Start to Think Differently!

We can no longer sit by the wayside, we must make ourselves better.

Think outside the box…..

People don’t learn like we do?

Different Drugs, Different and new USES!

Methylene Blue► Recent evidence (mostly in cardiac surgery) shows that it may be a benefit for

refractory hypotension

► Has been used with liver transplant for hypotension

► Reports of being used for patients on ACE inhibitors for refractory hypotension

► MOA: inhibits guanylate cyclase enzyme with then blocks nitric oxide synthase

► This action blunts Nitric Oxide

► Nitric oxide as a second messenger causes a relaxation of the smooth muscle and this action causes a decrease in peripheral vascular resistance

► What about a patient on Nitro? Nipride? Hydralize?

Think outside the BOX

ZOFRAN EXAMPLE?Heroin? Marinol?

LSD? Nicotine

Understand Receptors

Nicotine??

► Nicotine agonistsNicotine nasal spray dose of 3 mg versus NS nasal spray placebo during closure

► Does not work on smokers as they seem to be desensitized to nicotine from chronic use

► Nicotine patch is even more effective than nasal spray with VAS scores in

Marinol► MARINOL should not be used if you are allergic to dronabinol

or any of its ingredients, including marijuana and sesame oil

► Most patients respond to 5 mg three or four times daily. Dosage may be escalated during a chemotherapy cycle or at subsequent cycles, based upon initial results. Therapy should be initiated at the lowest recommended dosage and titrated to clinical response. Administration of Marinol Capsules with phenothiazines, such as prochlorperazine, has resulted in improved efficacy as compared to either drug alone, without additional toxicity.

► Marinol has been shown to provide increased pain relief when taken in combination with opioid pain relievers, according to ClinicalTrials.gov. The active ingredient in Marinol, THC, is believed to bind with pain receptors to reduce the transmission of pain through the spinal cord and brain

Heroin► Opioid analgesic synthesized from morphine.

► Used to treat severe pain.

► Inhalation (44-61%); Tran mucosal; IV (99%); Oral (<35%); Intranasal; Rectal, Vaginal; IM

► Metabolism; Hepatic► Half-life: <10 minutes► 90% renal as glucuronides rest biliary

► Pain Control---Diamorphine, Diacetylmorphine

LSD—Acid—Steve Jobs

► Lyseric acid diethylamide► Works on Dopamine and Serotonin receptors. The psychedelic

effects are attributed to its strong partial agonist effects at the 5-HT-2A receptor. Exactly how it produces this is still largely unknown. It also works on NMDA receptors.

► Assumption is that it increases glutamate in the cerebral cortex and therefore excitation of this area.

► Routes: Oral, IV, Ocular, intramuscular► Hepatic Metabolism with renal elimination► Half-life: 3-5 hours► Not considered addictive. Due to rapid build up of tolerance

Patient Satisfaction Scores: American Health Care Affordability Act.

► A random sample of patients discharged from hospitals across the country are surveyed and asked questions about their feelings and perceptions about their hospital stay. This measure combines hospital performance on questions that asked patients their levels of satisfaction with some of the following elements of their stay:

► How well nurses communicated with patients► How well doctors communicated with patients► How responsive hospital staff were to patients’ needs► How well caregivers managed patients’ pain► How well caregivers explained patients’ medications to them► How clean and quiet the hospital was► How well caregivers explained the steps patients and families need to take to

care for themselves outside of the hospital (i.e., discharge instructions)

► The survey also asks patients to give an overall satisfaction rating to their hospital stay.

PACU► In spite of receiving anti-nausea drugs during surgery, 26% of patients still

require additional treatment in the Post-Anesthesia Care Unit (PACU), and 40% of patients require additional treatment for PONV following discharge.

► PONV is also associated with poor surgical outcomes, prolonged healing and wound disruption. Commonly used anti-nausea drugs have a sedating effect, which may prolong time to discharge and increase the risk of obstruction for OSA patients.

► Avoid resource utilization costs: Patients who vomit spend an average of 43 minutes longer in the PACU at a cost of $85 for nausea and $138 for vomiting.

► Save the cost of rescue treatment: $283 (minimum) to treat patients who experience PONV

► For surgical centers: PONV delays may result in an ambulance transfer to a hospital costing $300 - $900 and result in an admission costing $1,200 to more than $2,400 per day.

► Perioperative painApproximately 46 million inpatient procedures and 35 million outpatient surgeries were performed in the US in 2006

Despite new treatment standards, guidelines, and educational efforts, acute postoperative pain continues to be undertreated, with up to 75% of patients in the US still failing to receive adequate postoperative pain relief

With the advent of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, patients are now able to make decisions on hospitals based on quality of care, including quality of pain management

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Acute Perioperative Pain

Pain

► Pain is a unpleasant sensory and emotional experience associated with actual or potential tissue damage.

► Pain in whatever the experiencing person says it is

► May not be directly proportional to amount of tissue injury

► Highly subjective, leading to under treatment

PAIN- What is it?►Cardinal Sign of Inflammation

Mechanical deformation - traumaChemical irritation – released by body►Prostaglandin; Bradykinin; Serotonin; Histamine

►Warning Sign►Limits Function►Has psychological/emotional affect

Acute

► Immediate

► Serves as a warning

► Typically easier to treat

► Typically has a end

► Less than 6 months and subsides once the healing process is accomplished.

Chronic Pain► Involves complex processes and pathology. Usually involves altered anatomy

and neural pathways. It is constant and prolonged, lasting longer than 6 months and sometimes for life.

► Last Longer than 3-6 months (most cite 6 months)

► Serves NO purpose

► Typically can not identify a cause

► Leads to pain behaviors: Negative emotions, anxiety, depression, sleep deprivation, May lead to the patient seeking active end of life.

► Very difficult to treat

World Health Oganization

► Mild Pain…non-opioid +/- adjuvant► Moderate…phase 1 and weak opioid► Severe…Phase 1 and 2 plus high narcotics, and blocks

► Preemptive analgesia…Treat the pain before it occurs

► Surgical incision- inflammation at surgical site Peripheral sensitization wind-up central sensitization increase in the patients pain perception.

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The Historical Acute Pain Paradigm

+++Opioids

+Opioids

++Opioids

Mild Pain

Moderate Pain

Severe Pain

STEP 3STEP 2

andHigher doses of opioids

STEP 1Acetaminophen, NSAIDs, or COXIBs

andLocal/regional anesthesia

STEP 2STEP 1

andLow doses of opioids

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Multimodal Approach to Acute Pain Management

Mild Pain

Moderate Pain

Severe Pain

► Multimodal analgesia combines two or more analgesic agents or techniques that act by different mechanisms to provide analgesia

► ASA, WHO, ASPMN, and the Joint Commission recommend use of a multimodal approach

► Opioid dose-sparing effects can be achieved via the use of non-opioid agents and regional blocks

► ASA Task Force recommendations: Unless contraindicated, all patients should receive an around-the-clock regimen of a non-opioid agent

Non-steroidal anti-inflammatory drugs (NSAIDs)Cyclooxygenase-2 specific drugs (COXIBs) Acetaminophen

Consider supplemental regional anesthesia techniques

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Multimodal Techniques for Perioperative Pain Management

Wind Up Pain!Repeated noxious stimulus through C-fibers

stimulates NMDA receptors in dorsal horn neurons in a progressively increasing manner.

Temporal Summation of Second Pain “TSSP”

Neural activity increases in a spontaneous “self-sustaining” manner (wind-up)

Hyper-excitability results Central sensitization

This occurs at spinal and supraspinal levels

Or a Easier Way to Say it!

Pain wind-up is the perceived increase in painintensity over time when a given painful stimulus is delivered repeatedly above a critical rate.

It is caused by repeated stimulation of group C peripheral nerve fibers, leading to progressively increasing electrical response in the corresponding spinal cord (posterior horn) neurons!!!!

Reduction of pain and suffering with consequent improvement in function.

Seems like a very straight forward goal?

Pain assessment► Each person brings unique perspective of pain.

► Listen to patient—most indicators very nonspecific

► Many factors influence patient pain experience: CulturePrevious pain experience(s)Religion/spiritualityCurrent medicationsCoping skillsPhysical aspectsBehavior

Consequences of poorly managed acute post-operative/trauma pain

►The HospitalIncreased costs $$$Poor staff moraleReputation/Standing in the Community, NationallyAccreditationLitigation

►The Healthcare professionalMoraleComplaints to CollegeLitigation

Pain… we are late when treated in the OR……

► When we treat the pain the OR…. The receptors and the transmitters are already being fired….. Why not treat prior to that?

► The study of Pain is a new issue… we have only really cared for the last few years… why should YOU care?

► Cost.. Money and patient satisfaction…

► “Patients who are pretreated with pain meds, anxiolytic or NSAIDS prior to surgery” –”have a greater decrease in postoperative pain” ---“decrease in postoperative anxiety”

► Olurunto 2006; Managing the spectrum of Surgical Pain.

Fiber Size and Function► α: (dia 12-20um; cond vel 70-120m/s) largest, afferent to and efferent from muscles

and joints. Actions: motor function, proprioception, reflex activity.

► β: (dia 5-12um; 30-70m/s) large as A-alpha, afferent to and efferent from muscles and joints. Actions: motor proprioception, touch, pressure, touch and pressure.

► δ: (dia 2-5um; 12-30m/s) thinnest, pain and temperature. Signal tissue damage.

► B fibers: (dia – 2-5um) Myelinated preganglionic autonomic. Innervate vascular smooth muscle. Though myelinated, they are more readily blocked by LA than C fibers.

► C fibers: (dia 0.4-1.2 um) Nonmyelinated, very small nerves. Smallest nerve fibers, slow transmission. Transmit dull pain and temperature, post-ganglionic autonomic.

► * Both A-d and C fibers transmit pain and are blocked by the same concentration of LA.

Neuropathic Pain► Abnormal processing of the impulse either by the peripheral or central nervous

system.

► May be caused by injury, scar tissue from surgery (back surgery has the highest risk) Nerve entrapment, or damaged nerves (diabetic neuropathy) is I this burning, electric, searing tingling and migrating or traveling pain.

► Unclear why depolarization and transmission of pain impulse are spontaneous and repetitive.

► Very complex condition that may evolve from unmanaged nociceptive pain.

► May Present without any physical findings or definable cause. It can then be maintained by multiple mechanisms

Neuropathic pain is pain transmitted over damaged nerves.

So Why Should we Treat Pain?► Increased catabolic demands: poor wound healing, weakness, muscle breakdown. INCREASED

RISK OF INFECTION

► Decreased Limb Movement: increased risk of DVT/PE, muscle spasm immobility

► Respiratory effects: shallow breathing, tachypnea, couch suppression increasing the risk of pneumonia and atelectasis

► Increased Sodium and water retention

► Decreased gastrointestinal mobility, Illeus, Nausea and vomiting

► Urinary retention

► Endocrine: increased catabolic hormones with increase in blood glucose

► Tachycardia and elevated blood pressure

So Why Should we Treat Pain?► Immunological effects: Decreased natural killer cell counts

► May exacerbate co-morbid conditions i.e. increase risk of MI in the patient with CAD…,

► Dozens of physiological needs to treat pain….

► Increased hospital stay and cost

► Decrease patient satisfaction

► Increased Catecholamine; tachycardia, hypertension, increased cardiac workload, increased myocardial oxygen consumption.

► Psychological: FEAR, ANXIETY, INSOMNIA<<<< fear of healthcare

So what can we do?

►What have we thought about?► PT, OT, stretching and strengthening►Nutrition,,, loose weight►General conditioning► Physical methods like Ice and Heat, massage►Cognitive behavioral therapy►Acupuncture►Tens►Relaxation, imagery, herbals

► Joint Commission Sentinel Event Alert Entitled “Safe use of opioids in hospitals” (08-Aug-12)

Focus on the need for assessing and managing pain to help avoid accidental opioid overdose among hospital inpatientsProvides a number of actions that can be taken to avoid the unintended consequences

► Recommendations include advising clinicians who prescribe pain medications to use both non-pharmacologic and pharmacologic alternatives

Non-pharmacologic therapies: physical therapy, acupuncture, manipulation or massage, ice, etc.Pharmacologic treatment: non-opioid analgesics, such as acetaminophen, NSAIDs, antidepressants, anticonvulsants, and muscle relaxants, can be used before prescribing an opioidWhen used in combination with opioids, these non-opioid pharmacologic treatments may reduce the dose of opioids required to effectively manage pain

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The Joint Commission Sentinel Event Alert

First Step.. Do we really do a good Pre-op related to pain

► Discuss the history of acute and chronic pain

► Identify the history of pain and their meds

► Ask “what had worked”

► How long have they been on meds?

► Allergies…. What really happens?

► Differentiate between tolerance and physical dependence

►Discuss pain management –sound familiar??

► Special attention to patients with Multiple back surgeries

► Abdominal surgeries, i.e. Crohn's disease

► Cancer pain

► Chronic Joint Pain

► Standard is a bad term….

► ASK direct questions>>> talk about the pain…. Don’t avoid the subject.

► Talk about the post operative pain control plan

Act Early…► Prevent sensitization or stimulation of peripheral receptors…

► Antihistamines and sedatives

► NSAIDS—blocks the inflow of the pain signal from the site of injury. Use with caution.

► Local anesthetics. Blocks inflow of pain signals

► Others……

► Your Goal should be to treat the pain BEFORE it is perceived by the patient… BEFORE

► “A preemptive treatment that prevents the establishment of altered central processing of afferent input, which them amplifies post op pain” This leads to a decrease in incidence of hyperalgesia and allodynia post-operatively”

Hydromorphone $0.89/1mgHydromorphone was first synthesized in Germany in 1924

Hydromorphone, a semi-synthetic μ-opioid agonist, is a hydrogenated ketone of morphine

0.015mg/kg dosing

Compared to morphine: Except 5-7 times as potentSlightly less water soluble Slightly faster onset Slightly shorter duration of action

Associated with fewer adverse effects (pruritis, sedation, nausea, vomiting)

Onset 10 minutes, Peak 30 minutes, Duration 3 hoursSemisynthetic opioid – 4 to 6 times potency of morphine

Hydromorphone

Major effects on the central nervous system and gastrointestinal tract.

► These include analgesia, drowsiness, mental clouding, changes in mood, euphoria or dysphoria, respiratory depression, cough suppression, decreased gastrointestinal motility, nausea, vomiting, increased cerebrospinal fluid pressure, increased biliary pressure, pinpoint constriction of the pupils,

► Increased parasympathetic activity and transient hyperglycemia.

►Amazing For Epidural and Spinal Procedures: ► Epidural Dose: 10mcg/ml with local► Spinal Dose: 0.002 milligram per kilogram

TYLENOLNOW AVAILABLE IN THE US>>> OFIRMEV-- Cadence► Very limited side effects (hepatic in high doses)► NO antiplatelet effects► NO gastric damage to the mucosa (high doses can get GI upset)► NO effect on wound healing or bones► Does not affect major organs in small doses

► NO real reason why it works?? Mechanism of action is poorly understood -- It may be working on a COX—3 route

► This is a safe weak to moderate analgesic that is quickly absorbed

► www.knowyourdose.org

OFIRMEV► IV acetaminophen injection: Cadence Pharm

► Minimum dosing interval is every 4 hours

► No change when going from IV to Oral

► Administer over 15 min…..well….??

► Do not exceed max daily doses.. Adult is 4 grams per day► Pediatric is dosed at 15mg/kg with max of 75 mg/kg/day

► CHEAPPPPPPPP

OFIRMEV► Liver issues is big

► Contraindicated in patients with liver failure/hepatic injury or with known hypersensitivity to acetaminophen…

► What about ETOH?

► Common side effects are: N/V; HA: insomnia; constipation, pruritus and agitation and atelectasis

► Using this drug may mask post surgical fever when used for post-operative pain.

COX 2 inhibitors

► The first of the selective COX 2 inhibitors, celecoxib (Celebrex) is approved by the FDA for the treatment of osteoarthritis, rheumatoid arthritis, and psoriatic arthritis. Dose is 100-200 mg daily

► A second COX 2 inhibitor, rofecoxib (Vioxx), was approved forthe treatment of acute pain and for symptomatic treatment of osteoarthritis. In September 2004, it was removed from the market secondary to significant associated cardiovascular side effects such as acute MI and stroke

► Valdecoxib is used for the above problems, but can be administered in a 40mg dose about 1 hour before surgery and another 40 mg can be given after surgery

► Parecoxib is the only IV form of COX 2 inhibitor that is converted to Valdecoxib in vivo. Dosing is the same as Valdecoxib

► Lack of effects on platelet aggregation and bleeding is the primary advantage of COX 2 inhibitors vs nonselective NSAIDs

Celebrex► Analgesic and anti-inflammatory agent.

► Classified as a Cox-2

► Action is in the periphery as well as the central nervous system

► Stops pain at the site of transmission….noxious system.

► 200-400 mg

► Contraindicated in renal insufficiency and a sulfa allergy

► certain blood pressure medicines called ACE inhibitors

► furosemide, fluconazole or ketoconazole, phenytoin, warfarin, aspirin

Anti-Convulsants

►Gabapentin and Pregabalin

►This class of medications manage the spontaneous firing of sensory neurons associated with neuropathic pain

►Reduces pain with movement and can reduce chronic post surgical pain syndromes by neuronal plasticity.

Pregabalin-lyrica► Pregabalin is a new synthetic molecule and a structural derivative of

the inhibitory neurotransmitter γ-aminobutyric acid.

It has analgesic, anticonvulsant, anxiolytic, and sleep-modulating activities. Pregabalin binds potently to the α2-δ subunit of calcium channels, resulting in a reduction in the release of several neurotransmitters, including glutamate, noradrenaline, serotonin, dopamine, and substance P.

► Anticonvulsants work to decrease the hyperalagesic response from the central nervous system.

► 50, 75, 150 mg

► Dose dependent on procedure and weight

Gabapentin► Gabapentin is typically well tolerated in the correct does:

► Doses range 300-1200 mg single does for anesthesia : max dose is 1200mg TID or max of 3600mg/day

► Higher the dose (smaller the patient) more side effects (keep in mind excretion i.e. renal failure)

► Typically: ► Somnolence► Dizziness► Fatigue► Impaired concentration

► Typically single small does (300-600) little problems► Keep in mind Half life of 5-7 hrs

What about? What in Common?

What about the NMDA Receptor?

►Ketamine►Magnesium►Nitrous►Xenon►Methadone

Ketamine► Produces analgesia via interaction with cholinergic, adrenergic and

serotonergic systems. NMDA non-specific receptor antagonist

► Currently some research also suggests that until you get to very high doses there is no sympathetic response

► The only true single anesthetic drug

► Causes dissociative anesthesia; they only true anesthesia drug we have

► NMDA plays a important role in processing pain via glutamate

► Reduces the need for opioids

20-30mg bolus with additional 8-16 mg/hr infusion. First line for chronic narcotic users… keep dose less than 0.75mg/kg (90kg pt -67.5 mg)

Ketamine the secret agent► Analgesia; 0.1-0.2 mg/kg IV

► At these low levels ; little if any side effects; (cardiovascular and psychological side effects)

► At amnesia and analgesia doses; proper pretreatment with a benzo will help eliminate the psychological effects if any….

► Keeping doses less than 1 mg/kg with a benzo is the max benefit of both drugs

THEORY OF KETOFOL:

PRO ARGUMENT:

Ketamine preserves respiratory function -> counterbalance the respiratory depression associated with propofol.

Ketofol reduces required amount of propofol -> less respiratory depression.

Less hypotensive episodes with ketofol versus propofol alone (ketamine preserves BP).

Ketofol leads to a reduction in opioid requirements.

Ketofol has fewer side effects (than ketamine)

CON ARGUMENT:Ketofol is nothing more than propofol sedation where fentanyl analgesia is replaced with dissociative ketamine.

Ketofol does not reduce respiratory depression or is a superior sedative as compared to either drug when used alone.

Remifol???

KETOFOL

Magnesium► This is a great electrolyte for pain control ► NMDA antagonist► Need to be careful on dosing

► Hypermagnesemia can impair the release of acetylcholine and decrease motor end plate sensitivity of acetylcholine in the muscle

► Keep levels low; keep dosing low; Magnesium has a very narrow therapeutic index;

► Dose 1-2 grams in a normally healthy patient diluted in 50-100 ccs given over 30 minutes

► Or: 30mg/kg bolus with 500mg/hr infusion for the duration of the case…

► It is easily excreted in the kidneys so those with renal failure will be prone to hyper levels

► Blocks bradykinin release in the local vasculature; works great as a predosing agent in small doses for propofol -- dose this in mmols

Nitrous Oxide

► Very useful has NMDA receptor activity.

► Rapid onset of analgesia and rapid recovery

► In concentrations of 50% is as potent as 10mg of IM morphine.

Methadone► Synthetic Opioid developed in Germany in 1937► Not chemically related to morphine or heroin► Cheap and long acting► Traditionally used with narcotic abuse ► Half life 24-36 hours -- fat soluble► Mu-receptor with limited action on NMDA ► 5 -10 mg single dose decreases the intra and post operative opioid

requirements

► This may be a great adjunct to both the chronic pain patient and the short term surgical patient.

► Additionally this drug does not have the euphoric effects that other narcotics have and this may be of great benefit in those with addictive personalities.

Clonidine► Alpha 2 agonist that works presynaptic centrally by inhibiting negative

feedback and blocking neurotransmitter communication► IT does have peripheral postsynaptic actions (decreased BP)

When administered orally can augment spinally mediated opioid analgesia.

► Can be administered anytime

► Inhibits the release of substance P blocking pain reception► Half life 9-12 hours

► Works great as a anxiolytic with minimal respiratory depression

► Side effects; ► Decrease BP; bradycardia; sedation; dry mouth; orthostatic (fluid

resusitation is important)

► Decreased narcotic requirements and improved analgesia

Ibuprofen-Caldolor

► Think about Ketorolac.. Actions and side effects

► Big differrences… Less action on Cox 1 and more Cox 2 action..

► What does this mean? Less bleeding.. More pain control can give anytime during the surgery… better now that we can give perop

► 400mg/4ml or 800mg/8ml► Dilute and administer over 30 minutes► 400mg-800mg Over 30 min repeat every 6 hours PRN*

► Fluids Fluids Fluids “ well hydrated prior to use”

Ketorolac (toradol)► NO evidence of unwanted sedation, absence of tolerance, reduction in

opioid related side effects.

► This is the only IV NSAID available for use in the US

► Inhibits prostaglandin synthesis

► Prostaglandin synthesis which sensitizes and amplifies norciceptive input

► The use is limited by the dose ? Higher the dose the worse it is.

► Temporary effect on platelets (36 hours) inhibit thromboxane from A-2

► Studies show use of Toradol with mild narcotics decreases hospital stay. Faster return to bowel function.

► Now comes nasal…dose is 15.75 mg each nostril every 6-8hrs

Ketorolac► Very effective analgesic, anti-inflammatory, and antipyretic actions

► Available IM/IV doses are 15, 30 and 60 mg dose

► 30 mg of Ketorolac = 10 mg Morphine=100 mg Meperidine

► After IM injection, peak plasma concentrations in 45-60 minutes

► Half-life of about 6 hours

► Decrease the dose in elderly patients

► Not recommended for preop>inhibits platelet aggregation and may prolong bleeding time

► Contraindications: bronchospasm, angioedema, nasal polyps, concurrent use of other NSAIDs, known allergy or intolerance to aspirin, history of GI bleeding, renal dysfunction, volume-depleted patient

► Nice for certain surgeries, provided there are no contraindications as above: gynecologic surgery (D and C), inguinal hernia repair, breast surgery (biopsy)

Lidocaine

► Amide local anesthetic; acting on sodium channels. Also works on dorsal horn neurons, muscarinic/dopaminergic/k/nicotinic and multiple other tissue receptors.

► Reduces neural response to pain by blockade of inhibition of nerve conduction. This is achieved through suppression of conduction of myelinated A-delta and unmyelinated C nerve fibers.

► Lidocaine is shown to suppress spinal cord sensitization, and inhibit spinal visceromotor neurons.

► Lidocaine is an anti-inflammatory that improves outcomes related to post op pain.

Lidocaine Infusions

► Half-life 8 minutes► 90% hepatic metabolism P450-1A2—renal 10%► Bolus 1-2.5 mg/kg Load► Infusion 1-3 mg/min► Stop infusion 60 minutes post skin closure► Opioid Sparing effect► Improved pain scores—some studies showed this effect for 48-72 hrs► Return to faster bowel function► Decreased length of stay

Lidocaine Patch

►On 12 hours and off 12 hours

►Can leave on 24 hours

►Expensive

Mexiletine

► Oral Conger of Lidocaine: effective for neuropathic pain

► Dose range 150-200 mg once or twice daily

► Max dose is 1200 mg daily

► Best range is 150-300mg TID

Sufentanil $3.52/50mcg

► 5 - 10X more potent than fentanyl► Sufentanil 0.0035 mg = fentanyl 0.05 mg ► Safe therapeutic index: 25,211► Dose: .025 - 30 µg/kg► Analgesic dose: 0.1 - 0.4 µg/kg IV► Maintenance dose: 1µg/kg followed by 0.25-0.5 µg/kg/hr

► High dose: 10 - 30 µg/kg

►New PATCH coming out from Durrect Pharm….New technology all the time… PCA fentanyl patch?

Transdur-Sufentanil Patch

Ending Phase 2 trials, so lets watch this evolve

Fentanyl PatchTransdermal Patch

Technology changing for delivery

Dose starting at 25 mcg/hr

On Demand? : Fentanyl iontophoretic transdermal system provides a 40 mcg dose of fentanyl per activation on-demand

Other fentanyl thoughts: BUCCAL TABLET; BUCCAL SOLUBLE FILM; SUBLINGUAL TABLETS; NASAL SPRAY; SUBLINGUAL SPRAY

CapsaicinIs a new Receptor Born? TRPV 1

Selectively stimulates unmyleninated C fibers afferent neurons and cause release of substance P

This continued release leads to depletion of substance P and decrease in pain

Patch and PO

PO is chili-peppers or Herbal 40,000 H.U.

PO is also in pure form under trials

Could be a benefit? Heart burn? Burning senstaion?

Diclofenac Patch 1%

Topical NSAIDSafe and effectiveCould lead to decreased systemic aborbtion

with a decrease risk of GI and Renal issues12 hour patchMay have limits due to greasy texture and

smell

Nucynta--POTapentadol is used to treat moderate to severe pain that is expected to last for a

short time

Tapentadol is a centrally-acting synthetic analgesic; the exact mechanism of action is unknown.

Although the clinical relevance is unclear, preclinical animal studies have shown that tapentadol is a:

— Mu-opioid agonist.— Norepinephrine reuptake inhibitor

Contraindicated in patients with significant respiratory depression, acute or severe bronchial asthma or hypercapnia or paralytic ileus.

Contraindicated in patients currently using or within 14 days of using monoamine oxidase inhibitors (MAOIs) due to potential additive effects on norepinephrine levels, which may result in adverse cardiovascular events

Remoxy

► Remoxy is an oral, long-acting oxycodone gelatin capsule

► Remoxy is intended to meet the needs of physicians who appropriately prescribe opioid painkillers and who seek to minimize risks of drug diversion, abuse or accidental patient misuse. Remoxy resists injection or snorting. Published data also show that freezing, crushing or submerging Remoxy in high-proof alcohol for hours at a time releases just a fraction of oxycodone at time points when abusers presumably expect to get high

Dexamethasone

Steroids are useful as adjuvant therapy for pain

Steroids can directly reduce pain in concert with opioid use and allow for a reduction in dose

Steroids reduce pain by inhibiting prostaglandin synthesis

Steroids have been shown to reduce spontaneous discharge in an injured nerve, which reduces neuropathic pain.

Regional Anesthesia

►Blocks… Do we not use them enough?

►Prime example…

►DPM comes in for a “simple” procedure… why are we not doing Blocks for this?

►Thoughts?

Exparel

Posidur

►New product just like Exparel

►Except Clear…. Could this be trouble?

How they work► Local anesthetics at the nerve axon work to block nerve conduction by

reducing the influx of sodium ions into the nerve cytoplasm.

► If the sodium ions cannot flow into the neuron, then the potassium ions cannot flow out, thus inhibiting the depolarization of the nerve.

► If this process can be inhibited for just a few nodes of Ranvier along the way, then nerve impulses generated downstream from the blocked nodes cannot propagate to the ganglion.

► In order to accomplish this feat, the anesthetic molecules must actually enter through the cell membrane of the nerve. Herein lies the differences in the potency, time of onset and duration of the various local anesthetics.

Regional Question?

►Have we skipped intrathecal narcotics?

►Have we forgot about locals and instilling locals into wounds…

Herbals

►Cobra Spray► Fever Few► St Johns Wort►Glucosamine►White willow bark►Boswellia►Devils Claw►Bromelain►Curcumin

Feverfew► Used to treat headaches, arthritis, as a fever reducer and pain

reliever

► Parthenolide in feverfew inhibits platelet aggregation

► Used for treatment of migraines. With increased duration of use 3.5-8 years there is no difference in ADP or thrombin stimulated platelet aggregation. However serotonin induced platelet aggregation is decreased.

► Some suggestions indicated it may help with chronic inflammation

► This supplement/herbal interacts with antiplatelet and anticoagulants.

Conclusions:

► Sources of Postoperative Pain

► Acute nociceptive pain from incision

► Musculoskeletal pain from abnormal body positioning and immobility during and after surgery

► Neuropathic pain from excessive stretching or direct trauma to peripheral nerves.

Conclusions:

► Not all patients are the same► Not all patients process and perceive pain the same way► Pain is unique► Opioids are not always the best choice► Not all patient react the same way

► Don’t be a cook book provider….

► Opioids are the only group with no ceiling► All others have ceilings for use

Multimodal

► A combination regimen using two or more medications or interventions

► This action may include administration via one or more routes

► Synergistic effects can and do occur

► This action enhances the analgesic effects of each drug

► Using different drugs decreases the dose of each and decreases potential side effects and limits the ceiling

► Treat the whole patient… don’t be a cook book

Additional Thoughts?

►THC►Anti-depressants► Selective Serotonin reuptake inhibitors

(Celexa, Luvox, Prozac, Paxil)► Seratonin norepinephrine reuptate inhibitors

(Cymbalta, Effexor )

Ultram –sometimes called a weak opoiod and narcotic like medicine.

Tramadol, Remoxy…

Pain and Pain Management

This is a evolving field, this is only the tip of the iceberg. Keep learning.

Thank You►Questions???

►pstube3000@yahoo.com

►Cell: 608-469-1750