Medco CE - Topical Pain Management
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This document summarizes information on pain management strategies including epidemiology, assessment, pharmacology, and treatment options. It discusses the prevalence and costs of pain, definitions of pain, assessment tools, non-pharmacologic and pharmacologic management strategies including the WHO analgesic ladder, and specific drug classes and examples for treating different pain types.
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Medco CE - Topical Pain Management
- 1. Topical Pain Management for Medco Health Solutions Las Vegas, NV 3/13/11 by Joe Crea [email_address] Crea Healthcare Partnering Powell, OH
- 7. Physiologic Effects of Pain
- 13. Pain and the Brain
- 14. Pain Terminology, Classifications, and Pathophysiology
- 23. Pain Assessment and Management
- 54. Agent Pharmacology Efficacy Safety Cost (US$) Topical NSAID Diclofenac gel COX-2 inhibition w/ reduced COX inhibition Penetrates 3-4mm Suitable for OA of knee or hand Effective monotherapy for mild-mod OA of hand or knee Equivalent analgesia to PO NNT for 50% pain reduction: 3 AEs: local Low risk of GI, CV or renal Ses Same Black Box as oral Do not combine w/ other NSAIDs $35-40/100g tube Salicylates Counterirritant – desensitizes pain receptors Modest efficacy in chronic pain No data for OA Adjunct to NSAIDs NNT: 5.3 Excessive use or ingestion can be toxic $6.99 - $8.99/ 57 g tube Capsaicin Counterirritant – desensitizes pain receptors Modest adjunctive tx Minimal as monotx NNT: 8.1 Application site; pain & burning early on $19.99- $22.49/57g tube
- 58. Moving from Peripherally Acting Agents to Centrally Acting: Opioids
- 70. Opioid Adverse Effects Common Uncommon Constipation Bad dreams/hallucinations Dry mouth Dysphoria/delirium N/V Myoclonus/seizures Sedation Pruritus/urticaria Sweating Respiratory depression Urinary retention
- 84. Facts & Comparison 4.0. Accessed May 10, 2009 Fentanyl Dose Conversion Chart – ONLY WHEN CONVERTING ORAL TO PATCH & NOT WHEN CONVERTING PATCH TO ORAL!!) Current Analgesic Daily Dose (mg/day) Oral morphine 60 to 134 135 to 224 225 to 314 315 to 404 IM/IV morphine 10 to 22 23 to 37 38 to 52 53 to 67 Oral oxycodone 30 to 67 67.5 to 112 112.5 to 157 157.5 to 202 IM/IV oxycodone 15 to 33 33.1 to 56 56.1 to 78 78.1 to 101 Oral codeine 150 to 447 448 to 747 748 to 1,047 1,048 to 1,347 Oral hydromorphone 8 to 17 17.1 to 28 28.1 to 39 39.1 to 51 IV hydromorphone 1.5 to 3.4 3.5 to 5.6 5.7 to 7.9 8 to 10 IM meperidine 75 to 165 166 to 278 279 to 390 391 to 503 Oral methadone 20 to 44 45 to 74 75 to 104 105 to 134 IM methadone 10 to 22 23 to 37 38 to 52 53 to 67 Recommended fentanyl transdermal system dose Fentanyl transdermal system 25 mcg/h 50 mcg/h 75 mcg/h 100 mcg/h
Editor's Notes
- Immune: Depressed immune response Developmental: behavioral, physiological responses to pain, higher somatization, addictive behavior, anxiety Cognitive: Reduction in mental function, confusion Future Pain: Debilitating chronic pain syndromes Quality of life: Insomnia, anxiety, fear, hopelessness, depression Endocrine: ACTH, cortisol, ADH, epinephrine, norepinepherine, GH, catacholamines, rennin, angiotensin II, aldosterone; ↓ insulin, testosterone Metabolic: Increased catabolic demands; poor wound healing, weakness, muscle breakdown, hyperglycemia Musculoskeletal: Muscle spasm, fatigue, immobility Cardiovascular: heart rate, cardiac output, increased coronary/peripheral/systemic vascular resistance, hypertension Respiratory: ↓ Flows and volumes = atelectasis; ↓cough = sputum retention, infection Gastrointestinal: ↓ gastric and bowel motility Genitourinary: ↓ urine output, urinary retention
- Acute: treatment outcome predictable. Resolves in days to weeks. Chronic: treatment outcome unpredictable
- American Pain Society and American College of Rheumatology Capsaicin and methylsalicylate not considered proven to provide much relief vs OA But… Current American Rheumatology guidelines were created prior to the approval of topical NSAID availability in the US
- Voltaren 1% gel Solaraze 3% gel – only approved for AK actinic keratosis Flector transdermal patch 1.3%
- Discuss the limitations of those old studies done regarding salicylates and OA Methyl salicylate (BenGay, IcyHot)
- “ reversible” – nerve fibers re-innervate over a 6 wk period in one small study Zostrix
- Of note: some nerve regenaration might be irreversible. Some studies of patients who have lost their ability to sense cold
- Magnesium sacilyate (Doan’s, DeWitt’s, Momentum)- po only Choline magnesium trisalicylate – combo salicylates – po only F&C For external use only: Avoid contact with eyes, eyelids, and mucous membranes. Apply to affected parts only: Do not apply to irritated skin; discontinue use if excessive irritation develops. Consult a physician if pain persists for longer than 7 to 10 days, or if redness is present, or in conditions affecting children younger than 10 years of age. Heat therapy: Do not use an external source of high heat (eg, heating pad) with these agents because irritation and burning of the skin may occur. Protective covering: Applying a tight bandage or wrap over these agents is not recommended because increased absorption may occur. Product List Print this section RUBS AND LINIMENTSTrade nameDoseform Analgesic Balm-GRXBalm : 14% methyl salicylate, 6% menthol Icy HotBalm : 29% methyl salicylate, 7.6% menthol, white petrolatum EpidermBalm : Isopropyl alcohol, parabens, ureas, menthol, EDTA JointFlexCream : 3.1% camphor, lanolin, aloe, urea, EDTA, glycerin, peppermint oil Capzasin-PCream : 0.035% capsaicin. Alcohols, petrolatum. ArthriCare for Women Silky DryCream : 0.025% capsaicin, parabens, mineral oil ArthriCare for Women Extra MoisturizingCream : 0.025% capsaicin, aloe vera gel, cetyl and stearyl alcohol, parabens ArthriCare for Women Multi-ActionCream : 0.025% capsaicin, 1.25% menthol, 0.25% methyl nicotinate, aloe vera gel, cetyl alcohol, parabens Capzasin-HPCream : 0.1% capsaicin. Alcohols, petrolatum. ArthriCare for Women Ultra StrengthCream : 0.075% capsaicin, 2% menthol, aloe vera gel, cetyl and stearyl alcohol, parabens AxsainCream : 0.25% capsaicin in an emollient base. Lidocaine, benzyl alcohol, cetyl alcohol, white petrolatum. Vicks VapoRubCream : 2.8% menthol, 5.2% camphor, 1.2% eucalyptus oil, cedarleaf oil, cetyl and stearyl alcohol, EDTA, glycerin, urea, parabens, turpentine oil Arthritic HotCream : Methyl salicylate, menthol ZiksCream : 12% methyl salicylate, 1% menthol, 0.025% capsaicin, cetyl alcohol, urea Thera-GesicCream : 15% methyl salicylate, 1% menthol, glycerin, parabens Bengay GreaselessCream : 15% methyl salicylate, 10% menthol, cetyl alcohol, glycerin Pain Bust-R IICream : 17% methyl salicylate, 12% menthol, cetyl and stearyl alcohol ArthriCare for Women NighttimeCream : 30% methyl salicylate, 1.25% menthol, 0.25% methyl nicotinate, glycerin, isopropyl alcohol Arthritis Formula BengayCream : 30% methyl salicylate, 8% menthol, lanolin Icy HotCream : 30% methyl salicylate, 10% menthol Ultra Strength BengayCream : 30% methyl salicylate, 10% menthol, 4% camphor, EDTA, lanolin Panalgesic GoldCream : 35% methyl salicylate, 4% menthol, lanolin, cetyl and stearyl alcohol, mineral oil MyoflexCream : 10% triethanolamine salicylate, cetyl and stearyl alcohol, EDTA Myoflex Extra , Myoflex ArthriticCream : 15% triethanolamine salicylate SportscremeCream : 10% trolamine salicylate, cetyl alcohol, glycerin, parabens, mineral oil AspercremeCream : 10% trolamine salicylate, aloe vera gel, cetyl alcohol, glycerin, parabens, mineral oil MobisylCream : 10% trolamine salicylate, aloe vera gel, cetyl alcohol, urea, glycerin, parabens, mineral oil, sweet almond oil, EDTA Icy Hot Arthritis TherapyGel : 0.025% capsaicin, aloe vera gel, benzyl alcohol, urea, maleated soybean oil, parabens Flexall Quik GelGel : Menthol, methyl salicylate Blue IceGel : 2% menthol. Isopropyl alcohol. Mineral Freez GelGel : 2% menthol. Alcohol. Vanishing Scent BengayGel : 2.5% menthol, urea, isopropyl alcohol Vicks VapoRubGel : 2.6% menthol, 4.8% camphor, 1.2% eucalyptus oil, cedarleaf oil, nutmeg oil, petrolatum, turpentine oil Flexall 454Gel : 7% menthol, aloe vera gel, eucalyptus oil, glycerin, peppermint oil, thyme oil Maximum Strength Flexall 454Gel : 16% menthol, aloe vera gel, eucalyptus oil, glycerin, peppermint oil, thyme oil Flexall Ultra PlusGel : 16% menthol, 10% methyl salicylate, 3.1% camphor, aloe vera gel, eucalyptus oil, glycerin, peppermint oil, thyme oil Icy Hot Chill StickGel : 30% methyl salicylate, 10% menthol, hydrogenated castor oil, stearyl alcohol Myoflex Ice Cold PlusGel : 15% triethanolamine salicylate Therapy Ice GelGel : 2% menthol. Isopropyl alcohol. Absorbine Jr Arthritis StrengthLiquid : Capsaicin, echinacea, calendula, and wormwood extracts Absorbine JrLiquid : 1.27% menthol, echinacea, calendula, and wormwood extracts, wormwood oil Extra Strength Absorbine JrLiquid : 4% menthol, echinacea, calendula, and wormwood extracts, wormwood oil Yager'sLiniment : Camphor, turpentine oil, clove oil Panalgesic GoldLiniment : 55.01% methyl salicylate, 1.25% menthol, 3.1% camphor, emollient oils, alcohol BanalgLotion : 4.9% methyl salicylate, 1% menthol, 2% camphor, parabens, eucalyptus oil Banalg Hospital StrengthLotion : 14% methyl salicylate, 3% menthol, parabens AspercremeLotion : Trolamine salicylate EucalyptamintOintment : 16% menthol, eucalyptus oil, lanolin, mineral oil Original Formula BengayOintment : 18.3% methyl salicylate, 16% menthol, lanolin Absorbine JrPatch : Menthol, camphor, eucalyptus Absorbine Jr Deep Pain ReliefPatch : Menthol, glucosamine, MSM Pain Relieving Bengay PatchPatch : 1.4% menthol. Regular and large sizes. Icy Hot Back Patch , Icy Hot Pop & Peel PatchPatch : 5% menthol. Glycerin. Ultra Strength Bengay Pain Relieving PatchPatch : 5% menthol. Regular and large sizes. Icy Hot Elbow and Wrist Sleeve , Icy Hot Knee and Ankle Sleeve
- Expected fewer side effects, esp if unable to cross the BBB May be helpful in the repair of damaged skin, as skin activation of the opioid system can influence cell differentiation and apoptosis…
- Extra notes for my reference Meperidine (Demerol ® ) Not recommended Poor oral absorption Normeperidine is a toxic metabolite Longer half-life (6 hours), no analgesia Psychotomimetic adverse effects, myoclonus, seizures If dosing q 3 h for analgesia, normeperidine builds up Accumulates with renal failure