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Let’s Discuss…
Benefits & side effects of common analgesics
Impact of patient-related factors on drug selection &
dose bas...
Reality
http://www.consumerreports.org/cro/video-hub/3705124027001/
The Dangers of Painkillers:
A Special Report.
Publishe...
Critical
Techniques
My primary area of work is…
Ambulatory Care Facility
Community Health Agency
Doctor’s Office/Clinic
Home Health
Hospital
N...
My primary specialty area is…
Adult /Geriatric
Pediatric/Neonatal
Family
Women’s Health
Psychiatric
Acute Critical Care
Ed...
Follow the Guidelines
American Academy of Pain Medicine (AAPM)
“Pain is one of the most common reasons people consult a ph...
Physiologic
Psychologic
Behavioral
Social
Cultural
Religious
PAIN is a
Multifaceted
Experience
Agency for Healthcare Research & Quality (AHRQ)
Practice guidelines for chronic pain management.
An updated report by the ...
Agency for Healthcare Research & Quality (AHRQ)
Practice guidelines for chronic pain management.
Pharmacologic interventio...
Which statement about pharmacologic
management IS TRUE according to AHRQ
Practice Guidelines?
A. For selected patients, no...
The American Geriatrics Society (AGS)
Clinical Practice Guideline:
Pharmacological Management of
Persistent Pain in Older ...
Client Selection, Risk Stratification
Prior to initiating COT:
Conduct an H&P and
assessment of risk of substance
abuse, ...
Informed Consent &
Management Plans
Obtain informed consent: goals, expectations,
potential risks, and alternatives
Writte...
Initiation & Titration of COT
Therapeutic trial to determine if opioid is appropriate
Individualize opioid selection, init...
Monitoring
Documentation of pain intensity & level of function
assessments & progress towards achieving
Monitor for aberra...
High-Risk Clients
Restructure therapy if needed
Consider consultation:
Mental health
Addiction specialist
Discontinuation ...
Follow WHO pain ladder
World Health Organization Stepwise
Analgesic Ladder, Focus on
Proper selection, dosing, titration,...
Mild pain 1 - 3 on a 10 point scale
Analgesics include:
Aspirin
Acetaminophen (Tylenol)
Nonsteroidal anti-inflammatory
dru...
Moderate pain 4 - 6 on 10 point scale
Analgesics include:
Codeine
Hydrocodone
Oxycodone
Nonopioid analgesic
Coanalgesics
S...
Severe Pain 7 - 10 on a 10 point scale
Analgesics include:
Morphine
Oxycodone
Hydromorphone
Fentanyl
Nonopioid analgesics
...
Which of the following is TRUE
regarding the WHO pain
ladder?
1.Five concepts include by mouth, by the clock, by the ladde...
Notable Fame: Comedian, Actor
Cause of Death: Overdose, Combination of
Morphine and Cocaine
Drug Category: Mixed
When: 199...
Pain Management
Goals:
Prevention of acute pain
Control of chronic pain
Optimizing function
Improving quality of life
Inte...
Effective Management
Requires the health care providers to be aware
of personal biases surrounding pain and its
management
CHOOSE
WISELY
AND
CONSIDER
COST
Rate your knowledge level of
Beer’s Criteria…
1.Expert
2.Moderate
3.Minimal
4.None
5.I prefer wine over Beer’s
BEER’S CRITERIA
Expert Panel from around the world
Developed list of Medications to Avoid if you are over 65
Recently Upda...
Beer’s List - Pain Rx Decisions
Drug Rationale Recommend
Quality of
Evidence
Strength
Recommend
NSAIDs oral
Aspirin >
325 ...
Notable Fame: Singer, Actress
Cause of Death: Drowning, Complications of
Cocaine, Heart Disease
Flexeril, Marijuana, Xanax...
Topical Agents
Local Anesthetics
Lidocaine and Bupivacaine
Block Na+ influx of voltage-gated ion channels in afferent neur...
Notable Fame: Singer
Cause of Death: Cardiac arrest, Lidocaine,
Propofol, Midazolam,
Diazepam, Lorazepam
Drug Category: Pr...
Topical Agents
Analgesic Creams, Rubs, and Sprays
Counterirritants - Ingredients such as menthol, methylsalicylate, and ca...
Topical Agents
Capsaicin
Defunctionalizes nerve fiber terminals through multiple mechanisms
Initial reduction in neuronal ...
Topical Prescription
Pain Products
FDA has approved several topical products (Voltaren, Pennsaid, others)
Contain the pres...
NSAIDs
Inhibit conversion of arachidonic acid to prostaglandins catalyzed by COX isozymes
Nonselective NSAIDs inhibit COX-...
Acetaminophen
Included in combination with many prescription opioids
Analgesia is achieved through central inhibition of p...
Anticonvulsant Drugs
Gabapentinoids
Gabapentin, Pregabalin effective wide neuropathic pain
Selective binding/blockade volt...
Anticonvulsant Drugs
Lacosamide
Modulation collapsin-response mediator protein 2
Inhibits the NMDA receptor subunit NR2B
T...
Antidepressants
Tricyclic Antidepressants
Widely used in neuropathic pain, blocking pre-synaptic reuptake norepinephrine/s...
Antidepressants
Serotonin-Norepinephrine Reuptake Inhibitors
Duloxetine, Venlafaxine, and Milnacipran
Duloxetine is used i...
Antidepressants
Mirtazapine
Atypical tetracyclic antidepressant
Inhibition of 5HT-2, 5HT3, H1-a2-hetero, and alpha-2-adren...
Glutamate Antagonists
Dextromethorphan
Oral cough suppressant, NMDA receptor antagonist, a sigma-1 receptor agonist, an N...
Avoiding drugs with strong anticholinergic
properties is imperative in the elderly with
cognitive impairment. Which drug c...
Glutamate Antagonists
Ketamine
Phencyclidine anesthetic given parenterally, neuraxially, nasally, transdermally or orally...
Notable Fame: American golfer (LPGA)
Cause of Death: Asphyxia, Butalbital,
Temazepam, Alprazolam,
Codeine, Hydrocodone,
Tr...
Opioids
Tramadol
Centrally acting, weak mu opioid receptor agonist
Inhibits norepinephrine and serotonin reuptake
Promotes...
Notable Fame: Actor, Musician, Singer
Cause of Death: Heart arrhythmia, possibly
aggravated by multiple
prescriptions - Me...
Morphine & Other Mu Opioid
Receptor Agonists
Analgesia through opioid receptor binding on cell membranes, producing simul...
Notable Fame: Actor
Cause of Death: Combined Toxicity
Oxycodone, Hydrocodone,
Alprazolam, Diazepam,
Temazepam, Doxylamine
...
Alpha-2 Adrenoceptor Agonists
Clonidine and Tizanidine
Antinociceptive activity
Modulating dorsal horn neuron function, ...
Other Agents
Baclofen
Muscle relaxant that induces analgesia
Agonist action on inhibitory GABA-B
receptors
Efficacious for...
Other Agents
Sulfasalazine
Tetrahydrobiopterin
Essential co-factor in producing nitric oxide
and monoamines
FDA-approved a...
Signs & Symptoms of Toxicity
Classic signs of opioid intoxication
Depressed mental status
Decreased tidal volume
Decreased...
Signs & Symptoms of Toxicity
Opioid-Induced Neurotoxicity
A syndrome of neuropsychiatric consequences of opioid administra...
Suspect Opioid-Induced
Neurotoxicity:
1. Painful experience from a source that is not
normally painful.
2. Complaints of :...
Risk
Assessment
Patient reported history
Psychology interview
Risk screening tools:
Screener and Opioid Assessment for Pat...
Red Flags
Medication loss
Frequent telephone calls
Frequent ER visits
Drug hoarding
Doctor shopping
Aggressive demand for ...
Which of the following clinical
interventions can increase risk
of diversion?
1. Attention to patterns of prescription req...
Amphetamines
Barbiturates
Benzodiazepines
Cocaine
Methadone
Opiates
Phencyclidine
Propoxyphene
Tetrahydrocannbinol
UDS 9 U...
How Many Times Have You Looked Up a Client
on the Prescription Access in Texas (PAT)
System?
1.Never
2.1-5 times
3.5-10 ti...
Consultation & Referral
Be willing to refer:
When pain problems remain intractable, unremitting
To obtain other approaches...
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria...
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria...
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria...
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria...
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria...
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria...
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria...
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria...
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria...
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria...
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria...
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria...
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria...
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria...
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria...
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria...
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria...
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Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria Included.

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Michelle Peck | Geriatric Nurse Practitioner | Health Care Consultant | Professional Speaker | Nursing Faculty| Legal Nurse Consultant | Mindful Geriatrics

In collaboration with Dr. Linh Nguyen, Supportive Medicine at UTHealth Medical School, we have created this slide deck for Advanced Practice Nurses.

Our mission is to simplify the pharmacologic basics of good pain prescribing. We have not provided very much detail about schedule II controlled substances due to the current limitations on Texas Nurse Practitioner prescribing in primary care.

This lecture is designed to meet our Advanced Practice Nursing audience where they are at and provide tools, knowledge and practical tips. Areas where we detect mastery with our polling questions are briefly touched upon and more time and examples are given are to areas of audience identified needs. Prescribing pain medication for Advanced Practice Nurses is dynamic, complex and ever changing

We have also included a special focus (our passion) for pain prescribing in the geriatric population. Beer’s Criteria medications, to be used with caution or avoid completely in geriatrics are mentioned throughout this presentation.

This presentation starts with the audience writing down their biggest fear about pain prescribing. We then categorize these fears, so that throughout our lecture we can give special focus and alleviate fears with practical tips, guidelines and real life examples.

Our objectives are to discuss:
1. Benefits and side effects of common analgesics
2. The impact of patient-related factors on drug selection & dose based on knowledge of patient related changes
3. Medications to avoid, use with caution, explain why
4. Management of pain based on client care goals

We hope you Learn it-Live it-Love it!

Published in: Health & Medicine
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Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanced Practice Nurses. Geriatric Beer's Criteria Included.

  1. 1. Let’s Discuss… Benefits & side effects of common analgesics Impact of patient-related factors on drug selection & dose based on knowledge of patient related changes Medications to avoid, use with caution, explain why Management of pain based on client care goals
  2. 2. Reality http://www.consumerreports.org/cro/video-hub/3705124027001/ The Dangers of Painkillers: A Special Report. Published: July 2014
  3. 3. Critical Techniques
  4. 4. My primary area of work is… Ambulatory Care Facility Community Health Agency Doctor’s Office/Clinic Home Health Hospital Nursing Facility/Rehab Nursing School/Education Surgical Center Other
  5. 5. My primary specialty area is… Adult /Geriatric Pediatric/Neonatal Family Women’s Health Psychiatric Acute Critical Care Education Hospice Other
  6. 6. Follow the Guidelines American Academy of Pain Medicine (AAPM) “Pain is one of the most common reasons people consult a physician. Yet it frequently is inappropriately treated.” AAPM believes pain should be diagnosed and treated in a comprehensive, systematic, collaborative, patient-centered fashion http://www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf
  7. 7. Physiologic Psychologic Behavioral Social Cultural Religious PAIN is a Multifaceted Experience
  8. 8. Agency for Healthcare Research & Quality (AHRQ) Practice guidelines for chronic pain management. An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Optimize pain control, recognizing that a pain-free state may not be attainable Enhance functional abilities and physical and psychological well-being Enhance the quality of life of patients Minimize adverse outcomes Target population http://www.guideline.gov/content.aspx?id=23845
  9. 9. Agency for Healthcare Research & Quality (AHRQ) Practice guidelines for chronic pain management. Pharmacologic interventions Anticonvulsants Alpha-2-delta calcium channel antagonists Sodium channel blockers Membrane-stabilizing drugs Antidepressants Tricyclic antidepressants Selective serotonin–norepi reuptake inhibitors Selective serotonin reuptake inhibitors Benzodiazepines N-methyl-D-aspartate (NMDA) receptor antagonists Nonsteroidal anti-inflammatory drugs (NSAIDs) Opioid therapy Sustained or controlled-release opioids Tramadol Skeletal muscle relaxants Topical agents Capsaicin Lidocaine Ketamine
  10. 10. Which statement about pharmacologic management IS TRUE according to AHRQ Practice Guidelines? A. For selected patients, nonsteroidal anti-inflammatory drugs, and topical agents may be used. B. Anticonvulsants should be used as part of a multimodal strategy for patients with visceral pain. C. Selective serotonin reuptake inhibitors should be avoided for patients with diabetic neuropathy. D.A strategy for monitoring and managing side effects, adverse effects, and compliance should be considered for selected patients undergoing any long- term pharmacologic therapy.
  11. 11. The American Geriatrics Society (AGS) Clinical Practice Guideline: Pharmacological Management of Persistent Pain in Older Persons Consider Acetaminophen initial & ongoing pharmacotherapy mild to moderate musculoskeletal NSAIDs & COX-2 selective inhibitors considered rarely, with caution, in highly selected individuals Consider for opioid therapy:  Moderate to severe pain  Pain-related functional impairment  Diminished quality of life due to pain http://www.americangeriatrics.org/health_care_professionals/clinical_practice /clinical_guidelines_recommendations/persistent_pain_executive_summary
  12. 12. Client Selection, Risk Stratification Prior to initiating COT: Conduct an H&P and assessment of risk of substance abuse, misuse, or addiction Perform and document a benefit-to-harm evaluation
  13. 13. Informed Consent & Management Plans Obtain informed consent: goals, expectations, potential risks, and alternatives Written opioid management plans/agreements: obtaining opioids from one prescriber filling opioids prescriptions at one pharmacy urine drug screens, pill counts, limited prescriptions
  14. 14. Initiation & Titration of COT Therapeutic trial to determine if opioid is appropriate Individualize opioid selection, initial dosing, and titration
  15. 15. Monitoring Documentation of pain intensity & level of function assessments & progress towards achieving Monitor for aberrant drug-related behaviors Periodic urine drug screens: Low risk: 1-2; Moderate risk:3-4 High risk:>=4, every month, office visit, or every drug refill
  16. 16. High-Risk Clients Restructure therapy if needed Consider consultation: Mental health Addiction specialist Discontinuation of COT
  17. 17. Follow WHO pain ladder World Health Organization Stepwise Analgesic Ladder, Focus on Proper selection, dosing, titration, and administration of analgesics Five concepts: by mouth, by the clock, by the ladder, for the individual, with attention to detail
  18. 18. Mild pain 1 - 3 on a 10 point scale Analgesics include: Aspirin Acetaminophen (Tylenol) Nonsteroidal anti-inflammatory drugs (Elderly need to be cautious) Coanalgesics Step 1
  19. 19. Moderate pain 4 - 6 on 10 point scale Analgesics include: Codeine Hydrocodone Oxycodone Nonopioid analgesic Coanalgesics Step 2
  20. 20. Severe Pain 7 - 10 on a 10 point scale Analgesics include: Morphine Oxycodone Hydromorphone Fentanyl Nonopioid analgesics Coanalgesics Step 3
  21. 21. Which of the following is TRUE regarding the WHO pain ladder? 1.Five concepts include by mouth, by the clock, by the ladder, for the individual, with attention to detail 2.Mild pain 1 - 5 on a 10 point scale analgesics include Aspirin 3.Severe pain 7 - 10 on a 10 point scale analgesics include Oxycodone
  22. 22. Notable Fame: Comedian, Actor Cause of Death: Overdose, Combination of Morphine and Cocaine Drug Category: Mixed When: 1997 Age: 33 Name this Celebrity -Chris Farley
  23. 23. Pain Management Goals: Prevention of acute pain Control of chronic pain Optimizing function Improving quality of life Interdisciplinary team
  24. 24. Effective Management Requires the health care providers to be aware of personal biases surrounding pain and its management
  25. 25. CHOOSE WISELY AND CONSIDER COST
  26. 26. Rate your knowledge level of Beer’s Criteria… 1.Expert 2.Moderate 3.Minimal 4.None 5.I prefer wine over Beer’s
  27. 27. BEER’S CRITERIA Expert Panel from around the world Developed list of Medications to Avoid if you are over 65 Recently Updated in 2012 Severity ratings of medications on High to Low Scale Problems grouped based on Disease Concerns listed independent of Disease
  28. 28. Beer’s List - Pain Rx Decisions Drug Rationale Recommend Quality of Evidence Strength Recommend NSAIDs oral Aspirin > 325 mg/d GI bleeding; Protection with PPIs or misoprostol Avoid chronic use Moderate Strong Skeletal Muscle Relaxants Ineffective at tolerated doses, antichol, falls Avoid Moderate Strong Tertiary TCAs, alone or in combination: Amitriptyline Highly antichol, sedating, and cause orthostatic hypotension Avoid High Strong
  29. 29. Notable Fame: Singer, Actress Cause of Death: Drowning, Complications of Cocaine, Heart Disease Flexeril, Marijuana, Xanax and Benadryl found in her body Drug Category: Mixed When: 2012 Age: 48 Name this Celebrity -Whitney Houston
  30. 30. Topical Agents Local Anesthetics Lidocaine and Bupivacaine Block Na+ influx of voltage-gated ion channels in afferent neuron terminals Inhibiting depolarization and generation of action potentials Resulting in the transmission of fewer nociceptive impulses to the spinal cord Topical lidocaine is used for neuropathic pain Blocks hyperactive sodium ions in damaged peripheral nerves Inhibit transmission of ectopic impulses to the dorsal horn
  31. 31. Notable Fame: Singer Cause of Death: Cardiac arrest, Lidocaine, Propofol, Midazolam, Diazepam, Lorazepam Drug Category: Prescription drug overdose When: 2009 Age: 50 Name this Celebrity -Michael Jackson
  32. 32. Topical Agents Analgesic Creams, Rubs, and Sprays Counterirritants - Ingredients such as menthol, methylsalicylate, and camphor create a burning or cooling sensation -distracts your mind from the pain (Icy Hot and Biofreeze) Salicylates - Same ingredients that give aspirin its pain-relieving quality , when absorbed into the skin, they may help with pain (Aspercreme and Bengay) appear to be more effective for muscle aches Capsaicin - Main ingredient of hot chili peppers, one of the most effective ingredients for topical pain relief (Capzasin and Zostrix) more often used for pain associated with damaged nerves
  33. 33. Topical Agents Capsaicin Defunctionalizes nerve fiber terminals through multiple mechanisms Initial reduction in neuronal excitability and responsiveness Inactivation voltage-gated Na channels Direct desensitization of plasma membrane TRPV1 receptors Followed by extracellular Ca2+ entry TRPV1, release from intracellular stores overwhelm TRPV1 receptor May initially cause pain -substance P released from nociceptive terminals, gets better over time May need to apply for a few days to a couple of weeks before pain relief noticed
  34. 34. Topical Prescription Pain Products FDA has approved several topical products (Voltaren, Pennsaid, others) Contain the prescription NSAID diclofenac, OA in joints close to the skin's surface Patches containing a numbing medication, such as lidocaine (Lidoderm) Approved in the U.S. to treat a painful complication of shingles May be used for other pain types, insurance may not pay off-label costs
  35. 35. NSAIDs Inhibit conversion of arachidonic acid to prostaglandins catalyzed by COX isozymes Nonselective NSAIDs inhibit COX-1 & 2 and include ibuprofen, aspirin, and naproxen Nonselective action inhibits the formation of gastroprotective mediating prostaglandins and pain-promoting prostaglandins increasing the risk of serious GI complications Selective COX-2 inhibitors, fewer GI side effects, increased risk of cardio-renal morbidities Disease Drug Rationale Recommendation Quality of Evidence Strength Chronic kidney disease Stages IV and V NSAIDs May increase risk of kidney injury Avoid Moderate Strong Hx of gastric, duodenal ulcers Aspirin (>325) Non–COX-2 selective NSAIDs May exacerbate existing ulcers or cause new or additional ulcers Avoid unless other alternatives are not effective & can take gastroprotective agent Moderate Strong Heart Failure NSAIDs and COX-2 inhibitors Potential for fluid retention and exacerbating HF Avoid Moderate Strong
  36. 36. Acetaminophen Included in combination with many prescription opioids Analgesia is achieved through central inhibition of prostaglandin Not anti-inflammatory Side-effect profile is relatively benign with intermittent Long-term or high-dose use can be hepatotoxic Daily dose should never exceed 4000mg Recommended over NSAIDs in patients with GI, renal, or cardiovascular comorbidity http://www.consumerreports.org/cro/video-hub/3907633633001/
  37. 37. Anticonvulsant Drugs Gabapentinoids Gabapentin, Pregabalin effective wide neuropathic pain Selective binding/blockade voltage-gated Ca channels brain, dorsal spine Inhibits the release of glutamate, norepinephrine, substance P Decreases spinal cord levels of neurotransmitters, neuropeptides Binding affinity of pregabalin is 6 times greater than gabapentin Gabapentin possesses a shorter half-life and nonlinear absorption Pregabalin is easier to titrate and better tolerated
  38. 38. Anticonvulsant Drugs Lacosamide Modulation collapsin-response mediator protein 2 Inhibits the NMDA receptor subunit NR2B Topiramate Suppression of action potentials Na & Ca channel blockade GABA receptor & AMPA receptor antagonism and kainate inhibition Also a glutamate antagonist
  39. 39. Antidepressants Tricyclic Antidepressants Widely used in neuropathic pain, blocking pre-synaptic reuptake norepinephrine/serotonin Reducing neuronal influx of Ca of Na ions and activity with adenosine and NMDA Secondary amines nortriptyline and desipramine are favored over the tertiary amines amitriptyline and imipramine due to more benign side effect Disease Drug Rationale Recommendation Quality of Evidence Strength Chronic Constipation Tertiary TCAs Can worsen constipation Avoid unless no other alternatives Moderate Weak Syncope Tertiary TCAs Increases risk of orthostatic hypotension or bradycardia Avoid Moderate Strong Delirium All TCAs Avoid in older adults with or at high risk of delirium, taper off Avoid Moderate Strong Hx falls or fractures TCAs SSRIs Ability to produce ataxia, impaired psychomotor function, syncope, falls Avoid unless safer Not available High Strong
  40. 40. Antidepressants Serotonin-Norepinephrine Reuptake Inhibitors Duloxetine, Venlafaxine, and Milnacipran Duloxetine is used in painful diabetic neuropathy efficacy at 60 to 120 mg/day Venlafaxine behaves like a SSRI at doses of ≤150 mg/day and like an SNRI at doses >150 mg/day, dose ≥150 mg/day is often necessary to achieve pain control Milnacipran has the greatest affinity for norepinephrine Duloxetine has the greatest potency in blocking serotonin Venlafaxine selectively binds to the serotonin but not the norepinephrine transporter SNRIs are better tolerated than TCAs because they lack affinity for cholinergic, histaminic, and adrenergic receptors
  41. 41. Antidepressants Mirtazapine Atypical tetracyclic antidepressant Inhibition of 5HT-2, 5HT3, H1-a2-hetero, and alpha-2-adrenergic receptors Beneficial effect in the adjuvant treatment of migraine headache, anxiety, agitation, depression, insomnia, and low appetite H1-receptor antagonism is most prominent at low doses (≤30 mg) Drug Rationale Recommend Quality of Evidence Strength Mirtazapine Serotonin–norepinephrine reuptake inhibitor Selective serotonin reuptake inhibitor Tricyclic antidepressants May exacerbate or cause syndrome of inappropriate antidiuretic hormone secretion or hyponatremia; need to monitor sodium level closely when starting or changing dosages in older adults due to increased risk Use with caution Moderate Strong
  42. 42. Glutamate Antagonists Dextromethorphan Oral cough suppressant, NMDA receptor antagonist, a sigma-1 receptor agonist, an N- type calcium channel antagonist, and a serotonin reuptake transporter antagonist Rapid hepatic metabolism interferes with maintaining plasma concentrations sufficient for analgesia Co-administration of quinidine has been found to maintain therapeutic levels FDA approved dextromethorphan for use in the treatment of pseudobulbar palsy Also used in painful diabetic polyneuropathy
  43. 43. Avoiding drugs with strong anticholinergic properties is imperative in the elderly with cognitive impairment. Which drug combination would you NOT prescribe? 1.Skeletal muscle relaxants & Acetylcholinesterase inhibitors 2.Acetylcholinesterase inhibitors & some antidepressants 3.Skeletal muscle relaxants & some antidepressants
  44. 44. Glutamate Antagonists Ketamine Phencyclidine anesthetic given parenterally, neuraxially, nasally, transdermally or orally in subanesthetic doses to alleviate a variety of pain conditions, including severe acute pain, chronic or neuropathic pain, and opioid tolerance by NMDA receptor antagonism. Also has activity on nicotinic, muscarinic, and opioid receptors and exerts both anti- nociceptive and anti-hyperalgesic effects Potentially distressing adverse reactions (psychotomimetic side effects) and unwanted changes in mood, perception, and intellectual performance limit its use in pain control
  45. 45. Notable Fame: American golfer (LPGA) Cause of Death: Asphyxia, Butalbital, Temazepam, Alprazolam, Codeine, Hydrocodone, Tramadol Drug Category: Prescription drug overdose When: 2010 Age: 25 Name this Celebrity -Erica Blasberg
  46. 46. Opioids Tramadol Centrally acting, weak mu opioid receptor agonist Inhibits norepinephrine and serotonin reuptake Promotes serotonin release Peripheral activity absent - no effects on blood pressure, ulcer, heart failure Disease Drug Rationale Recommendation Quality of Evidence Strength Chronic seizures or epilepsy Tramadol Lowers seizure threshold; may be acceptable in patients with well-controlled seizures in whom alternative agents have not been effective Avoid Moderate Strong
  47. 47. Notable Fame: Actor, Musician, Singer Cause of Death: Heart arrhythmia, possibly aggravated by multiple prescriptions - Methadone, Codeine, Barbiturates, Cocaine Drug Category: Mixed When: 1977 Age: 42 Name this Celebrity - Elvis Presley
  48. 48. Morphine & Other Mu Opioid Receptor Agonists Analgesia through opioid receptor binding on cell membranes, producing simultaneous activity at multiple presynaptic, postsynaptic, and nervous system sites Each opioid produces a unique spectrum of effects - analgesia, somnolence, respiratory depression, dysphoria, euphoria, decreased GI motility, altered circulatory dynamics, histamine release, physical dependence Morphine, Codeine, Hydrocodone, and Oxymorphone, have greatest affinity for the mu opioid receptor Presynaptic opioid receptor activation inhibits release of nociceptive neurotransmitters, substance P, glutamate Postsynaptic activation inhibits pain by opening K or Cl channels, hyperpolarize and inhibit neuronal firing Inhibits pain signal transmission from peripheral afferents to ascending spinal cord neurons, activates descending pathway inhibition, and will alter limbic activity, decreasing pain awareness
  49. 49. Notable Fame: Actor Cause of Death: Combined Toxicity Oxycodone, Hydrocodone, Alprazolam, Diazepam, Temazepam, Doxylamine Drug Category: Prescription drug overdose When: 2008 Age: 28 Name this Celebrity - Heath Ledger
  50. 50. Alpha-2 Adrenoceptor Agonists Clonidine and Tizanidine Antinociceptive activity Modulating dorsal horn neuron function, norepinephrine and 5-HT release Potentiating mu-opioid receptors, decreasing neuron excitability - calcium channel modulation Clonidine, transdermal, local use enhances release of endogenous encephalin-like substances Tizanidine is used as a muscle relaxant and antispasticity agent
  51. 51. Other Agents Baclofen Muscle relaxant that induces analgesia Agonist action on inhibitory GABA-B receptors Efficacious for trigeminal neuralgia Anti-spasticity properties of baclofen may induce analgesia Botulinum Toxin Neurotoxic protein synthesized by the bacterium Clostridium botulinum Produces analgesia, blocking neurotransmitter release and TRPV1 receptor signaling in C-fibers Inhibits substance P and CGRP release Reduces neurogenic inflammation Increases heat pain threshold
  52. 52. Other Agents Sulfasalazine Tetrahydrobiopterin Essential co-factor in producing nitric oxide and monoamines FDA-approved anti-inflammatory agent that inhibits sepiapterin reductase May represent an effective therapy for neuropathic pain Ondansetron 5-HT3 receptor antagonist Anti-nociceptive effects Blocking descending serotonergic facilitatory drive to the dorsal horn laminae
  53. 53. Signs & Symptoms of Toxicity Classic signs of opioid intoxication Depressed mental status Decreased tidal volume Decreased bowel sounds Decreased respiratory rate: best predictor RR < 12 Miotic pupils: normal exam does NOT exclude opioid intoxication
  54. 54. Signs & Symptoms of Toxicity Opioid-Induced Neurotoxicity A syndrome of neuropsychiatric consequences of opioid administration Occurs when active opioid metabolites build up (could be due to dehydration and/or decreasing kidney function) Commonly occurs in response to rapid escalation of opioid medicines Features include cognitive impairment, severe sedation, hallucinosis, delirium, myoclonus, seizure, hyperalgesia, and allodynia
  55. 55. Suspect Opioid-Induced Neurotoxicity: 1. Painful experience from a source that is not normally painful. 2. Complaints of :all over” body pain, or a pain that becomes generalized. 3. Worsening pain, but no worsening of disease. 4. Involuntary muscle twitching. 5. Confusion, hallucinations, disorientation, decreased LOC. 6. Seizures. Treatment: If caused by dehydration giving IVF will reverse. If caused by decrease in kidney function reducing the opioid dose usually will reverse. If caused by rapid escalation of opioid medicine, reducing the dose or rotating to a different opioid will usually reverse.
  56. 56. Risk Assessment Patient reported history Psychology interview Risk screening tools: Screener and Opioid Assessment for Patients with Pain(SOAPP) Opioid Risk Tool(ORT) Pain Medication Questionnaire (PMQ) CAGE Questionnaire Clinical impression Risk Monitoring Prescription monitoring programs Pain medication diaries Pill counts Urine drug testing (UDT) Risk monitoring tools: Current Opioid Misuse Measure (COMM) The Addiction Behavior Checklist (ABC) Behavior patterns “Red Flags”
  57. 57. Red Flags Medication loss Frequent telephone calls Frequent ER visits Drug hoarding Doctor shopping Aggressive demand for more drugs Drug seeking Clinging to specific drugs Use for non-prescribed indications (ex. Anxiety, insomnia)
  58. 58. Which of the following clinical interventions can increase risk of diversion? 1. Attention to patterns of prescription requests 2. Annual review in the prescription monitoring program database 3. Urine and/or blood drug screening & pill counts 4. Frequent follow up and client contact
  59. 59. Amphetamines Barbiturates Benzodiazepines Cocaine Methadone Opiates Phencyclidine Propoxyphene Tetrahydrocannbinol UDS 9 UDS 12 Amphetamines Barbiturates Benzodiazepines Cocaine Methadone Methaqualone Opiates - confirms if Codeine, Hydrocodone, Hydromorphone, Morphine, or Oxycodone Phencyclidine Propoxyphene Tetrahydrocannabinol For Tramadol, Fentanyl, or Buprenorphine: A separate order is needed
  60. 60. How Many Times Have You Looked Up a Client on the Prescription Access in Texas (PAT) System? 1.Never 2.1-5 times 3.5-10 times 4.More than 10 times
  61. 61. Consultation & Referral Be willing to refer: When pain problems remain intractable, unremitting To obtain other approaches to assessment or management To determine if interventional procedures would help relieve pain Psychosocial indications for consultation: History of substance abuse Interpersonal dynamics that seem to complicate the treatment Give special attention to clients risk for Rx misuse, abuse, diversion May be required for psychiatric disorders

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