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Overview of Selected Pain Medications

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Overview of Selected Pain Medications. Doug Carroll, PharmD, ... Tramadol (Ultram ) Also available combo with APAP (Ultracet ) MOA. NOT a CONTROLLED SUBSTANCE ... – PowerPoint PPT presentation

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Title: Overview of Selected Pain Medications


1
Overview of Selected Pain Medications
  • Doug Carroll, PharmD, BCPS
  • Clinical Associate Professor
  • Harrison School of Pharmacy

2
IV Medicationsfor Severe Pain
3
Morphine
  • GOLD STANDARD!!
  • Advantages
  • Sedating
  • No analgesic ceiling
  • Less expensive
  • Nursing staff comfort
  • Disadvantages
  • Slower onset
  • Histamine release
  • Accumulation of metabolite

4
Morphine
  • Adverse Effects
  • Pruritis
  • N/V
  • Constipation
  • Respiratory depression

5
Fentanyl
  • Advantages
  • More rapid onset
  • NO active metabolites
  • Renal and hepatic dsfxn
  • Pregnancy
  • Less sedating
  • Very young
  • Very old
  • Disadvantages
  • Shorter duration
  • Expensive
  • Potential for tachyphylaxis
  • Nursing staff less familiar

6
Fentanyl
  • AEs same as with morphine
  • Special note
  • MINIMAL to NO EUPHORIA associated with its use
  • Patients perceptions
  • Lower potential for abuse
  • POTENCY
  • Ordered in micrograms

7
Hydromorphone (Dilaudid)
  • Advantages
  • Onset b/w morphine and fentanyl
  • Less sedating
  • Disadvantages
  • Most expensive
  • HIGH POTENTIAL for ABUSE (but not as high as with
    the other D)
  • AEs same as with morphine

8
Ketorolac (Toradol)
  • Good for musculoskeletal pain
  • DO NOT use greater than 5 days
  • DO NOT use in patients with RI, active bleeding,
    or an ASA/ NSAID allergy
  • CAUTIOUSLY use in patients with hepatic dsfxn,
    thrombocytopenia, anticoagulants, and peptic
    ulcer disease

9
DO NOT USE DEMEROL !!!!
  • But why????????????????

10
Why NOT use Meperidine (Demerol)?
  • Active metabolite.normeperidine
  • Metabolized in the liver
  • Eliminated by the kidneys
  • ½ analgesic potency of meperidine
  • 2x the toxicity of meperidine
  • Accumulates in patients with RI and elderly
  • Toxicity manifests as SEIZURES, IRRITABILITY,
    TREMORS, MYOCLONUS, etc

11
Why NOT use Meperidine (Demerol)?
  • VERY EUPHORIC (especially if given with
    phenergan)
  • Confusion of euphoria and analgesia
  • Promotes Drug Seeking Behavior
  • NO advantage over morphine or fentanyl

12
What about Oddi?
  • Current literature does NOT support the use of
    Demerol over Morphine
  • No basis for myth that meperidine is preferred
    over morphine for pancreatitis
  • Equianalgesic doses, meperidine raised common
    bile duct pressure more than morphine
  • Morphine controls pain for a longer duration of
    time
  • Repeated doses of meperidine lead to
    normeperidine accumulation

Arch Int Med November 1998158(21)2399.
13
Morphine vs. Meperidine
  • Meperidine or morphine in acute pancreatitis? Am
    Fam Physician Jul200164(2)219-20.
  • Meperidine vs morphine in pancreatitis and
    cholecystitis. Arch Int Med Nov
    1998158(21)2399.
  • Narcotic analgesic effects on the sphincter of
    Oddi. Am J Gastroent Apr200196(4)1266-72.

14
PCA Order Basics
15
Which agent to use?
  • Morphine 1 mg/ml
  • Fentanyl 10 mcg/ml
  • Hydromorphone 0.2 mg/ml
  • Meperidine

16
PCA dose
  • Morphine
  • 0.02 mg/kg lbw
  • 70 kg 1.4 mg
  • Fentanyl
  • 0.2 mcg/kg lbw
  • 70 kg 14 mcg
  • Dosing is for opioid naïve patients
  • Decrease dose in elderly, debilitated, and obese

17
Loading dose
  • Used to achieve adequate level of analgesia when
    initiating PCA
  • 2 times the calculated PCA dose
  • PCA dose of 1.4 mg LD of 2.8 mg
  • Repeat every 10 minutes as needed to a maximum of
    3 doses

18
Lockout interval
  • Minimum amount of time between PCA doses
  • DO NOT shorten recommended intervals
  • Morphine
  • 8 minutes
  • Fentanyl
  • 6 minutes

19
Continuous (basal) Infusion
  • Opioid tolerant or high utilization patients
  • Do not have to give CI for all patients
  • 1/3 to 2/3 of hourly use determined over extended
    period
  • 12 hours

20
One Hour Maximum Dose
  • Max amount of drug that PCA pump will deliver in
    1 hour
  • Continuous infusion
  • PCA doses
  • Morphine 0.075 mg/kg lbw
  • 70 kg 5.25 mg (round to whole number)
  • Fentanyl 0.75 mcg/kg lbw
  • 70 kg 52.5 mcg
  • May have to remove limit for severe pain

21
Methods to Adjust PCA
  • Increase PCA dose by 25
  • Consider adding a continuous infusion
  • Divide average hourly use by 2 to estimate new
    PCA dose
  • Dont provide PRN doses of opioids around the PCA

22
Transition to Orals
  • Give 2/3 of previous 24 hour morphine
    requirements as OxyContin
  • Maintain PCA dose for prn use
  • Oxycodone for breakthrough
  • D/C continuous infusions

23
Oral Therapies
  • For Moderate to Severe Pain

24
Morphine (CII)
  • Brand name products
  • Immediate Release
  • Roxanol
  • MSIR
  • Controlled Release
  • MS Contin
  • Oramorph
  • Others

25
MS Contin
  • DO NOT USE for ACUTE pain management!
  • Should be used selectively for CHRONIC pain
    management.
  • May need short acting agent for relief of break
    through pain.
  • No maximum dose for morphine

26
Oxycodone (CII)
  • Brand name products
  • Combination products with APAP
  • Roxicet
  • Percocet
  • Tylox
  • Controlled release
  • Oxycontin

27
Oxycodone
  • No maximum dose for oxycodone alone
  • Doses are limited with combination products due
    to the APAP

28
Oxycontin
  • DO NOT USE for ACUTE pain management!
  • Should be selectively used for CHRONIC pain
    management!
  • May need short acting agent for relief of
    breakthrough pain.

29
Methadone (CII)
  • NOT for ACUTE pain!
  • Peak effects in 4 to 10 days, eliminated in 4 to
    10 days
  • Doses do accumulate
  • May need to decrease dose in 3 to 5 days to
    prevent toxicity
  • Recognized for heroin addiction

30
Fentanyl transdermal (CII)
  • NOT for ACUTE pain!
  • 24 hr for peak effect after initial application
    (will need to cover w/ short acting agent)
  • Levels remain up to 18 hr after patch removal
  • Absorption can be erratic
  • May need short acting agent for breakthrough pain
  • Rash may develop where patch is placed
  • Inhaled steroids to application site???

31
Fentanyl transdermal dose based on daily morphine
equivalence dose
32
Fentanyl transdermal
  • Each patch is worn 72hrs
  • Do not adjust the dose more often than every 3
    days
  • Doses greater than 100 mcg/hr.multiple patches
    will need to be used
  • Application sites
  • Chest, arms, abdomen
  • Clean, minimal hair

33
Oral Therapies
  • For Mild to Moderate Pain

34
Acetaminophen (Tylenol)
  • Maximum daily dose 4g/d with less than 10d use
  • Reduce the total daily dose for
  • Elderly (2.4 to 3.2 g/d)
  • Alcoholics (2.4 g/d)
  • Debilitated patients (2.4 g/d)
  • Renal failure patients (2.4 g/d)
  • Contraindicated in hepatic disease

35
NSAIDS
  • Cautiously use in
  • Renal insufficiency
  • Hepatic dysfunction
  • PUD
  • Anticoagulants
  • Thrombocytopenia
  • Contraindicated
  • Renal failure
  • ASA/NSAID allergy

36
NSAIDS
  • Analgesia
  • Ceiling effect
  • Effects are evident in 1-2 hr
  • Administration limited to 1-2 wks
  • Rebound headaches
  • Anti-inflammatory
  • Effects are evident in days to weeks
  • Peak in 2-3 wks
  • If inadequate results, change to another NSAID

37
(No Transcript)
38
COX IIs
  • compared to generic NSAIDS
  • (Celebrex)
  • Recommended for use in patients
  • Age 60
  • Concurrent corticosteroid or anticoagulant tx
    (must check INRs regularly)
  • Documented hx of GI bleed or PUD
  • Post op with risk of significant bleed
  • Heavy consumers of ETOH or cigarettes

39
COX IIs
  • Should not be used in patients
  • Tolerant of NSAIDS
  • Short term therapy (
  • Treat HA or fever
  • Renal failure or ASA/NSAID allergy
  • Celebrex Sulfa allergy

40
Other Issues.
  • Cardiovascular risk
  • Avoid use in patients with CAD history
  • Dose and/or duration dependant???
  • Traditional NSAIDs
  • Diclofenac, indomethacin
  • Low dose aspirin

41
Hydrocodone (CIII)
  • ONLY comes as COMBINATION products
  • Lortab (APAP)
  • Vicoprofen (ibuprofen)
  • Loratab ASA (ASA)
  • Doses are limited by the APAP, ibuprofen, and ASA
    components!

42
Tramadol (Ultram)
  • Also available combo with APAP (Ultracet)
  • MOA
  • NOT a CONTROLLED SUBSTANCE
  • Potential for abuse
  • AEs
  • Hallucinations, seizures, etc

43
Are there any oral agents
  • available that shouldnt be used?

44
YES!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
45
And they are.
  • Codeine (Tylenol 2,3 and 4)
  • Weak analgesic
  • AEs
  • Nausea
  • Vomiting
  • Sedation
  • Propoxyphene (Darvocet Wygesic)
  • Minimal analgesic effects
  • Induces tolerances
  • Withdrawal seizures

46
And they are..
  • Toradol (po)
  • Most ulceragenic potential of any NSAID
  • Demerol (po)
  • Same risks as with IV
  • Same potential for abuse as IV
  • Dilaudid (po)
  • High potential for abuse

47
Things to consider when using opioids
  • Pruritis
  • Benadryl 12.5-50 mg PO or IV (sedation)
  • Narcan 0.5-1.0 mcg/kg/hr continuous infusion (max
    4 mcg/kg/hr)
  • Nalmefene (Revex) 0.5 mcg/kg/dose q6-8 hr SC

48
Other things to consider when using opioids
  • Nausea/ Vomiting
  • Phenergan
  • Compazine
  • Reglan
  • Zofran

49
Other things to consider when using opioids
  • Constipation (adult doses)
  • Docusate Sodium (Colace) 100-200mg BID
  • Senna (Senekot) 2 tabs QD to 4 tabs BID
  • Bisacodyl (Dulcolax) 5-15 mg
  • Enemas

50
Other things to consider when using opioids
  • Sedation
  • Transient, tolerance develops 1wk
  • Change agents
  • Respiratory depression
  • Narcan
  • 1-1.5 mcg/kg may repeat in 3 minutes
  • Chronic pain patients and Narcan administration

51
Conversion table for the Opioids
52
Whew! Im glad hes done!
Me too!!
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