Transcript PTP 546 Module 14 Pharmacology of Pain Management

PTP 546
Module 14 & 15
Pharmacology of Pain Management:
Acute and Chronic
Jayne Hansche Lobert, MS, RN, ACNS-BC, NP
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Pharmacology of Pain Management
Opioid Analgesia
• Opioid Agonists: Treatment of Severe to Moderate Pain
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Ex: Morphine (Astromorph, Duramorph)
Ex: Fentanyl (Sublimaze; Duragesic )
Ex: Hydromorphone (Dilaudid)
Ex: Methadone (Dolophine)
• Opioid Agonists: Treatment of Moderate to Mild Pain
– Ex: Codeine; Codeine/Tylenol (T#3, T#4)
– Ex: Hydrocodone (Hycodan);
Hydrocodone/Acetaminophen ( Vicodin)
– Ex: Oxycodone (Oxycontin);
Oxycodone/Acetaminophen (Percocet)
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Pharmacology of Pain Management
Opioid Analgesia
• Prototype Opioid Agonist: Morphine
• Gold-standard: 30mL is used to evaluate all other pain meds.
– Action: binds with both mu & kappa receptor sites
– Therapeutic Effect: treatment of severe pain provides analgesia
and euphoria
– Side Effects: sedation, dizziness, hypotension, itching (switch to
different), nausea, constipation (if long term, will always
decrease GI mobility), respiratory depression (doctors worry,
but really need to look out for sedation as always 1st) ,
constriction of pupils
– Note: multiple routes multiple half lives to consider; addictive
potential physical & psychological dependence
– Note: opioid antagonist is Naloxone (Narcan)=used to STOP, to
reverse drug overdose.
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Pharmacology of Pain Management
Opioid Analgesia
• Treatment Considerations
– Route
• Oral; Transmucosal-Lollipop (used for children-expensive)
• Intravenous: Patient Controlled Analgesia Pumps, Continuous IV, Bolus IV
• Epidural: Epidural Pumps- usually at home; Intrathecal (into brian) - Subcutaneous,
Transdermal
• Rectal or suppository
– Half Life
• Impacted by route of administration
• Impacted by formulation: ex: sustained release
– High Alert Medications
• Controlled substances
• Require special precautions
• Addictive potential
– Equianalgesia
• All pain meds judged in relation to morphine
• Charts are available
– Adjunctive Meds and Treatments
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Pharmacology of Pain Management
• Prototype Opioid Antagonist: Nalaxone (Narcan)
– Action: blocks both mu and kappa receptors
– Therapeutic Effect: complete or partial reversal of
opioid effects
– Side Effects: rapid loss of analgesia
hypertension, hyperventilation, pain
– Note: administered when opioid overdose is
suspected; IV administration reversal in minutes
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Pharmacology of Pain Management
• Other Pain Management Medications
– NSAIDS
• Inflammation is what causes the pain so NSAID (antiinflamatory) used to decrease pain.
• ASA, Motrin, Toradol, etc.
– Centrally Acting Drugs
• Tramadol (Ultram)
– Miscellaneous Agents/Classes
• Acetaminophen (Tylenol)
• Antidepressants
– Elavil
• Anticonvulsants
– Neurotin, Dilantin
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Pharmacology of Pain Management
• Other Pain Management Medications
• NSAID’s
– Ex: Acetylsalicylic Acid(Aspirin/ASA)
– Ex: Ibuprofen(Motrin)
– Ex: Ketorolac (Toradol)
– Treatment Issues & Considerations
• Used for anti-inflamatory effect that will decrease pain.
– Side Effects: Gi bleeding, peptic ulcer, dyspepsia,
Kidney dysfunction.
• No Aspirin/Motrin if h(x) of GI bleeds from NSAID’s
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Pharmacology of Pain Management
• Other Pain Management Medications
– Centrally Acting Drugs: Tramadol (Ultram)
• Action: weak binding of mu receptors but also relieves
pain by inhibition of norepinephrine and serotonin
reuptake
• Therapeutic Effect: treatment of moderate pain,
chronic pain.
• Side Effects: vertigo, dizziness, headache, lethargy,
nausea and vomiting
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Pharmacology of Pain Management
• Other Pain Management Medication
– Ex: Acetaminophen (Tylenol)
• Action: inhibits synthesis of prostaglandins which
mediate pain and fever
• Therapeutic Effect: analgesia; antipyresis
• Note: No anti-inflammatory properties
• Side Effects: liver failure; hepatoxicity with excessive
intake
• Note: Adult daily max= 3- 4 grams/day; note OTC and
prescribed combination meds with acetaminophen;
dose reduction with alcoholism
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Pharmacology of Pain Management
• Other Pain Management Medications
– Ex: Anticonvulsants
• Gabapentin (Neurotin)
• Topiramate (Topamax)
– SE: fatigue, drowiness
– Ex: Antidepressants
• Amitriptyline Hydrochloride (Elavil)
• Treatment Issues and Considerations?
• Side Effects?
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Pharmacology of Pain Management
• Opioids: Treatment Issues
– Physical & Psychological Dependence
• Incidence: more over-dose on opioids then heroine and cocaine.
• Treatment
– Pharmacological: suppression withdrawal symptoms associated with
detoxification
– Withdrawal Sx: restlessness, anxiety, insomnia, chilled, tremors, and a
high death rate if untreated.
» Methadone: liquid
» Buprenorphine hydrochloride (Bupernex): sublingual
• Maintains drug: lower analgesic potential
» Suboxone: naloxone & buprenorphine (newest)
• Non-Pharmacological: individual and group therapy, use
(methadone) to decrease dependence.
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Pharmacology of Pain Management
• Patient Controlled Analgesia (PCA)
– Self administration of opioids (typically IV) in small
frequent doses using a special pain pump
– Clinical Use: post operative acute pain and chronic
pain management
– Advantages:
• Immediate administration of medications
• Equal or superior analgesia
• Less opioids used therefore less side effect potential
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Pharmacology of Pain Management
• PC A Dosing Strategies
– Loading Dose
• One time initial dose-wake up call in the morning
– Basal Dose/Background Dose
• Hourly continuous dose: 7am to 7pm
– Demand Dose
• Patient administered dose
– Lockout Intervals
• Allowed frequency of demand dose; ex: every 10 minutes, always
have another HCW validate.
– One Hour and Four Hour Max Limit
• Equals basal dose and max demand dose
– Total demand dose attempted versus Total demand dose
successfully delivered
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Pharmacology of Pain Management
• Administration Routes for PCA
– Intravenous
• Short term: peripheral IV access
• Long term: long term venous access
– Epidural
• Short term: external catheter placed in subarachnoid space
• Long term: tunneled subarachnoid catheter is connected to an
internal access port or drug reservoir
– Transdermal
• Long term: external patch with button
– Regional: typically local anesthesia similar to one time blocks
• Short term: catheter placed in joint or wound near peripheral nerves
• Advantages/Complications: local effect, less side effects?
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Pharmacology of Pain Management
• Medications used for PCA
– Opioid
• Morphine
• Hydromorphone (Dilaudid)
• Meperidine (Demerol)-rarely used.
– Side Effects: sedation, hypotension, itching, nausea,
vomiting, respiratory depression
– NonOpioid
• Bupivacaine (Marcaine)-Epidural sometime bad SE.
• Ropivacaine (Naropin)
– Side Effects: sedation, hypotension, itching, nausea,
vomiting, respiratory depression, numbness, tingling,
motor impairments, urinary retention
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Pain Management
• Principles
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Always ask about the presence of pain
Perform a comprehensive pain assessment
Avoid IM injections
Treat persistent pain with scheduled meds
Use shorting acting strong opiates to treat moderate to
server pain
• Morphine, hydromorphone, oxycodone
– Use long acting strong opiates once pain is controlled and
can detect the cycle, so not always “chasing” the pain.
• Ms contin, fentanyl patch, oxycontin
– Mange opioid SE aggressively.
• Ex: constipation will negatively effect adherence.
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Pain Management
• Acute Pain:
– Pharmacological:
• Opioids
• Non-opioids (NASIDS- gi bleeding and Tylenol=liver
damage)
• Antidrepssents, anticonvulsants, local anesthetics.
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Pain Management
• Chronic Pain: > then 3 months
– Chronic Pain: rate pain lower, as they learn to tolerate the
pain.
• How is it affecting your life?
– Pharmacological
• Opioids
• Non-Opioids: NSAIDS and Tylenol
• Adjuvants: anti-depressents, anticonvulsants, local anesthetics.
• Other: PT, heat, cold, E-stem, message, acupuncture, distraction,
imagery, support, other CAM, ablative technique, botulism toxin,
epidural steroids.
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