The Use of Parenteral Nalbuphine Nubain to Treat Adults with Sickle Pain Episodes

1
The Use of Parenteral Nalbuphine (Nubain) to
Treat Adults with Sickle Pain Episodes

• Allan Platt, PA-C, Richard Mbonzo, PA-C, James
  Eckman, M.D.
• The Georgia N.I.H. Comprehensive Sickle Cell
  Center
• Emory University School of Medicine and Grady
  Health System
• Atlanta, Georgia

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Treatment of Pain Episodes

• Step wise approach oral to parenteral agents
• Evaluate to determine cause of pain
• Bed rest, heat, quiet environment
• Hydration IV or oral
• Analgesics
• NSAIAs
• Agonist Narcotics
• Agonist-Antagonist Narcotics

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Agonist - Antagonist Analgesic Agents

• Agonist/Antagonist analgesics not widely used
• Reports in children not adults with sickle cell
  pain episodes
• Ceiling effect Analgesic and Respiratory
• Psychomimetic effects
• Opiate withdrawal in narcotic dependant patients

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Nalbuphine HCL (Nubain - DuPont Pharmaceuticals)

• Related to Naloxone and Oxymorphone
• Potency similar to morphine
• Onset in 2 - 3 minutes given I.V. slow push
• Onset in 15 minutes given I.M.
• Respiratory depression similar to morphine up to
  0.15 mg/kg, then ceiling.
• Analgesic ceiling at 0.30 mg/kg (20 mg for 70 kg
  patient)

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The Comprehensive Sickle Cell Center at Grady

• 24 hour emergency care
• Consistent and dedicated staff of PAs, NPs, RNs,
  and MDs
• Pain assessment with Visual Analog Scale (VAS) at
  check in/out
• Rapid patient assessment and treatment
• Multimodal pain treatment

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Study Design

• Retrospective database review 1/91 - 8/97
• 11,088 Pain episodes in 537 adults over 16
• Nubain used in 7,076 (64) episodes at a dose of
  20 mg IM or IV every 3 hours
• Hydroxizine (Vistaril) at 25 mg every 6 hours
  used as antiemetic
• NSAID such as Ketorolac or Ibuprofen used in 24
  as a second analgesic

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Analgesics Used in 11,088 Pain Episodes in 537
Adults
Nubain was used in 64 of pain episodes
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Pain Relief Results of 2,681 Nubain Treated
Episodes

• Average beginning pain score 8.05 (over 10)
  S.D. 1.70, Var 2.90
• Average ending pain score 3.43 (over 10) S.D.
  2.89, Var 8.33
• Average pain decrease equals 4.62 S.D. 2.90, Var
  8.45
• Average time of treatment 8 hours, average total
  dosage 60 mg

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Need for admission in 7,076 pain Episodes treated
with Nubain
17 Admitted, 83 went home
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Safety Profile

• Pulse oximetry measured at checkin and checkout
  in 4,467 episodes
• Beginning SaO2 94.88, S.D 4.1, Var 17.30
• Ending SaO2 95.14, S.D. 4.1, Var 17.07
• Very rare dysphoric effects
• One patient with evidence of Nubain dependence
• Good patient satisfaction

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Conclusions

• Nalbuphine is an effective and safe analgesic for
  most sickle pain episodes
• Remember the ceiling effect and use agonist
  narcotic agents for severe pain
• Do not use in narcotic dependant patients