Analgesics

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Analgesics

  1. 1. Analgesics Opioids (Narcotics) Non-Opioids(NSAIDS) Management of Gout
  2. 2. ABC’s of Pain Treatment Assess pain regulary Believe patients & their families in their reports of pain Choose interventions appropriately Deliver these in a timely fashion Enable/Empower patients & Families to overcome pain no pain mild discomforting horrible excruciating
  3. 3. Non-Drug Pain Management Techniques <ul><li>Distraction </li></ul><ul><ul><li>Ice/Heat </li></ul></ul><ul><ul><li>TV/ read/visiting </li></ul></ul><ul><li>Relaxation </li></ul><ul><ul><li>Breathing, yoga </li></ul></ul><ul><ul><li>Tapes, music </li></ul></ul><ul><li>Massage </li></ul><ul><li>Biofeedback </li></ul><ul><li>Acupuncture </li></ul><ul><li>Imagery </li></ul><ul><ul><li>Pleasant mental picture </li></ul></ul>
  4. 4. Pain Neuro Transmitters Pain Relief Meds <ul><li>Substance P </li></ul><ul><li>Glutamate </li></ul><ul><li>GABA </li></ul><ul><li>Norepinephrine </li></ul><ul><li>Serotonin </li></ul><ul><li>Histamine </li></ul><ul><li>NSAIDS </li></ul><ul><li>Antidepressants </li></ul><ul><li>Anti seizure meds </li></ul><ul><li>Muscle relaxants </li></ul><ul><li>Local salves- capsaicin </li></ul><ul><li>Narcotics </li></ul>
  5. 5. Opioids (God Morpheus of Dreams) Narcotics (Narcosis—stupor) <ul><li>Produce analgesia by binding to opiate receptors in the CNS, brain and spinal cord involved with the transmission of pain impulses. </li></ul><ul><li>Endogenous opioids are present at brain sites </li></ul><ul><ul><li>Released during stress, pain & anticipation of pain </li></ul></ul>
  6. 6. Clinical Indications <ul><li>Analgesia </li></ul><ul><li>Acute Pulmonary Edema </li></ul><ul><li>Cough </li></ul><ul><li>Diarrhea </li></ul><ul><li>Anesthesia </li></ul>
  7. 7. Opioids Narcotics <ul><li>MOA </li></ul><ul><ul><li>Receptors </li></ul></ul><ul><ul><li>Tolerance </li></ul></ul><ul><ul><li>Dependence </li></ul></ul><ul><li>Selected Agents </li></ul><ul><ul><li>Morphine, Fentanyl, </li></ul></ul><ul><ul><li>Codeine, Propoxyphene </li></ul></ul><ul><ul><li>Oxycodone </li></ul></ul>
  8. 8. Organ Effects <ul><li>CNS </li></ul><ul><ul><li>Analgesia </li></ul></ul><ul><ul><li>Euphoria </li></ul></ul><ul><ul><li>Sedation </li></ul></ul><ul><ul><li>Respiratory depression </li></ul></ul><ul><ul><li>Cough </li></ul></ul><ul><ul><li>Miosis </li></ul></ul><ul><ul><li>Truncal rigidity </li></ul></ul><ul><ul><li>Nausea & vomiting </li></ul></ul><ul><li>Peripheral </li></ul><ul><ul><li>Cardiovascular </li></ul></ul><ul><ul><li>Genito-urinary </li></ul></ul><ul><ul><li>Bilary </li></ul></ul><ul><ul><li>Gastrointestinal tract </li></ul></ul><ul><ul><li>Uterus </li></ul></ul><ul><ul><li>Other </li></ul></ul>
  9. 9. Common Opioid Side Effects <ul><li>Constipation </li></ul><ul><li>Mental clouding, fatigue </li></ul><ul><li>Nausea, vomiting </li></ul><ul><li>Itch </li></ul><ul><li>Euphoria, Dysphoria </li></ul><ul><li>Sweating </li></ul><ul><li>Urinary retention </li></ul>
  10. 10. Toxicity Opioid Antagonists <ul><li>Tolerance </li></ul><ul><li>Dependence </li></ul><ul><ul><li>Physical </li></ul></ul><ul><ul><li>Psychological </li></ul></ul><ul><li>Overdose </li></ul><ul><li>Drug Interactions </li></ul><ul><li>Contraindications </li></ul><ul><li>Agents </li></ul><ul><ul><li>Naloxone </li></ul></ul><ul><ul><li>Naltrexone </li></ul></ul><ul><li>MOA </li></ul><ul><li>Indications </li></ul><ul><li>Abstinence Syndrome </li></ul><ul><ul><li>Gooseflesh, rhinorrhea, chills </li></ul></ul>
  11. 11. Analgesic Ladder <ul><li>Mild to moderate pain </li></ul><ul><ul><li>NSAID (ASA) </li></ul></ul><ul><ul><li>Adjuvant analgesic (APAP, antihist) </li></ul></ul><ul><li>No adequate relief </li></ul><ul><ul><li>Non-narcotic analgesic (NSAID) </li></ul></ul><ul><ul><li>Weak opioid (Codeine, propoxyphene) </li></ul></ul><ul><li>Strong opioid (Fentanyl or Morphine) with adjuvant analgesic </li></ul>
  12. 12. Opioid Drug Interactions <ul><li>Other CNS depressants  respiratory depression </li></ul><ul><li>Etoh  liver, respiration </li></ul><ul><li>MOA inhibitors  induce excitability, hypotension or HTN (reduce opioid dose by ¼ and use as test dose) </li></ul>
  13. 13. Oxycontin Abuse <ul><li>Formulations </li></ul><ul><ul><li>IR or SA </li></ul></ul><ul><li>When tablets are crushed, snorted or extracted & injected. </li></ul><ul><li>Effective, less toxic, well-tolerated medication. </li></ul><ul><li>Backlash ‘war on drugs’ challenges legitimate users </li></ul>
  14. 14. Non-Opioid Agents Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) <ul><li>Aspirin (prototype) </li></ul><ul><li>Indications </li></ul><ul><ul><ul><li>Anti-inflammatory </li></ul></ul></ul><ul><ul><ul><li>Analgesic </li></ul></ul></ul><ul><ul><ul><li>Anti-pyretic </li></ul></ul></ul><ul><ul><ul><li>Anti-platelet </li></ul></ul></ul><ul><li>Toxicity </li></ul><ul><ul><li>RF, RespirFailure </li></ul></ul><ul><li>Selected Agents </li></ul><ul><ul><li>Diclofenac,Etodolac </li></ul></ul><ul><ul><li>Ibuprofen,Ketorolac </li></ul></ul><ul><ul><li>Naproxen </li></ul></ul><ul><li>COX-2 Inhibitors </li></ul><ul><ul><li>Celecoxib </li></ul></ul><ul><ul><li>Mobic </li></ul></ul><ul><li>MOA </li></ul><ul><li>Toxicity </li></ul>
  15. 15. NSAIDS Drug Interactions <ul><li>Anticoagulants  increase bled risk </li></ul><ul><li>Diuretics  decrease diuretic effect </li></ul><ul><li>Herbals (feverfew, garlic, ginger, ginkgo)  GI distress & anti-platelet effects </li></ul><ul><li>Methotrexate  result in MTX toxicity, adjust dose per serum levels & patient’s renal function </li></ul>
  16. 16. DMARDs- Disease Modifying Anti-Rheumatic Drugs <ul><li>Azathioprine </li></ul><ul><li>Cyclophosphamide </li></ul><ul><li>Hydroxychloroquine </li></ul><ul><li>Leflunomide (Arava) </li></ul><ul><li>Methotrexate </li></ul><ul><li>Penicillamine </li></ul><ul><li>Gold salts </li></ul>
  17. 17. Biological –DMARDs (TNF) <ul><li>Etanercept (Enbrel) </li></ul><ul><li>Infliximab (Remicade) </li></ul><ul><li>Anakinra (Kineret) </li></ul>
  18. 18. Corticosteroids <ul><li>Inhibit inflammation </li></ul><ul><ul><li>Cause leukocytes to be sluggish </li></ul></ul><ul><li>Complications with long term use </li></ul><ul><li>Rebound deterioration </li></ul><ul><li>Importance of Taper </li></ul><ul><li>Sample Agents </li></ul><ul><ul><li>Prednisone, prednisolone, dexamethasone </li></ul></ul>
  19. 19. Glucocorticoids Adverse Effects <ul><li>CV </li></ul><ul><ul><li>Na retention </li></ul></ul><ul><li>GI </li></ul><ul><ul><li>PUD </li></ul></ul><ul><li>Metabolic </li></ul><ul><ul><li>Redistribution of fat, hyperglycemia </li></ul></ul><ul><li>Immune </li></ul><ul><ul><li>infections </li></ul></ul><ul><li>Dematologic </li></ul><ul><ul><li>Impair wound healing </li></ul></ul><ul><li>Musculoskeletal </li></ul><ul><ul><li>Osteoporosis </li></ul></ul><ul><ul><li>Bone fractures </li></ul></ul><ul><li>Neuropsychiatric </li></ul><ul><ul><li>Psychosis/mood </li></ul></ul><ul><li>Opthalmic </li></ul><ul><ul><li>Cataracts/glaucoma </li></ul></ul>
  20. 20. What is Gout?
  21. 21. What Causes Gout? <ul><li>Higher than normal levels of Uric Acid can be part of inheritance </li></ul><ul><li>Obesity </li></ul><ul><li>High alcohol intake </li></ul><ul><li>High food intake containing purines </li></ul><ul><li>Some drugs that treat BP </li></ul><ul><li>Long standing kidney disease </li></ul>
  22. 22. Treatment of Gout <ul><li>Avoid red meat </li></ul><ul><li>Avoid organ foods (Offal) liver, kidneys, tripe, sweetbreads, tongue </li></ul><ul><li>Avoid shellfish, scallops, peas, lentils, beans </li></ul><ul><li>Reduce weight & alcohol use </li></ul><ul><li>Review medications </li></ul>
  23. 23. Drug Management of Gout <ul><li>Colchicine </li></ul><ul><ul><li>Acute attack </li></ul></ul><ul><ul><li>Reduces leukocytes </li></ul></ul><ul><ul><li>& uric acid production </li></ul></ul><ul><li>NSAIDS </li></ul><ul><li>Uriosurics </li></ul><ul><ul><li>Probenecid </li></ul></ul><ul><li>Allopurinol </li></ul><ul><ul><li>Preventative </li></ul></ul>
  24. 24. Summary Slide <ul><li>ABC’s of Pain Treatment </li></ul><ul><li>Non-Drug Pain Management Techniques </li></ul><ul><li>Opioid Narcotics </li></ul><ul><li>Common Opioid Side Effects </li></ul><ul><li>Opioid Drug Interactions </li></ul><ul><li>Drug Management of Gout </li></ul>
  25. 25. Case Study Pain Management
  26. 26. <ul><li>OP is a 33-year-old male with degenerative disc disease who is on chronic pain management. He was previously employed as a front-end mechanic. In September he tripped while carrying a tire, fell down a concrete stairway and twisted his back. He developed left leg pain two days later. The patient has not worked since and has been on disability. </li></ul><ul><li>Prior treatments with traction, heat, cortisone injections and NSAIDS were of minimal assistance. A myelogram revealed a herniated disc at L5S1. </li></ul><ul><li>Currently he is maintained on Hydrocodone/APAP 5/500 </li></ul><ul><li>8-10 per day. This medication “ just takes the edge off his pain” and causes him diaphoresis and constipation. </li></ul><ul><li>FH: mother arthritis cigarettes 1 ½ PPD x15yr Father deceased ETOH- 3 beer/day more on weekend </li></ul><ul><li>MEDS: Vicodin 5mg 8-10 per day DSS 100 mg bid </li></ul><ul><li>Valium 5 mg tid prn spasms </li></ul>
  27. 27. Points to Ponder <ul><li>Discuss options for pain management. </li></ul><ul><li>Describe an analgesic ladder. </li></ul><ul><li>Why is “maintenance” Vicodin a potential problem. </li></ul><ul><li>List some patient education issues you may try to address. </li></ul>

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