This document summarizes key points about pain management in dementia and new developments in opioid use. It discusses the high prevalence of pain in older adults and undertreatment of pain in dementia patients. Cognitive impairment makes pain assessment challenging, requiring evaluation of behaviors, medical history and empirical trials. General factors like reduced liver and kidney function in older adults affect drug absorption and elimination. The document reviews guidelines for opioid use in dementia, emphasizing hydromorphone, oxycodone, fentanyl and methadone. It also discusses new opioids like tapentadol and tramadol, as well as transdermal patches and modified release formulations.
Recent advances in the management of Parkinson's Disease (PD)Sudhir Kumar
Parkinson's disease is a neurodegenerative disease causing severe disability. In the past 10-15 years, a lot of new medicines and treatments have become successful in helping patients with PD. The current review focuses in all approved treatments for PD
This presentation deals with buprenorphine drug profile, from a clinical pharmacist perspective.
Summarized version of drug, including chief ADRs, interactions, and patient and health-care professional counselling tips have been mentioned.
Recent advances in the management of Parkinson's Disease (PD)Sudhir Kumar
Parkinson's disease is a neurodegenerative disease causing severe disability. In the past 10-15 years, a lot of new medicines and treatments have become successful in helping patients with PD. The current review focuses in all approved treatments for PD
This presentation deals with buprenorphine drug profile, from a clinical pharmacist perspective.
Summarized version of drug, including chief ADRs, interactions, and patient and health-care professional counselling tips have been mentioned.
Zonisamide is among the newer broad spectrum anti-epileptic drugs, effective against focal and generalized epilepsies. It can be taken once daily and is well tolerated. The current article focuses on clinical efficacy and safety of zonisamide in epilepsy (as add on or as monotherapy). There is long term data as well as comparative studies against carbamazepine.
Treatment Strategies for Women and Families with Substance AbuseErikaAGoyer
NATIONAL PERINATAL ASSOCIATION 2014 CONFERENCE
Treatment Strategies for Women and Families with
Substance Abuse: The participant will be able to:
Interpret the term “opioid use disorder,” explain the
benefits of Methadone Assisted Treatment (MAT) and
identify the characteristics of Neonatal Abstinence
Syndrome.
Zonisamide is among the newer broad spectrum anti-epileptic drugs, effective against focal and generalized epilepsies. It can be taken once daily and is well tolerated. The current article focuses on clinical efficacy and safety of zonisamide in epilepsy (as add on or as monotherapy). There is long term data as well as comparative studies against carbamazepine.
Treatment Strategies for Women and Families with Substance AbuseErikaAGoyer
NATIONAL PERINATAL ASSOCIATION 2014 CONFERENCE
Treatment Strategies for Women and Families with
Substance Abuse: The participant will be able to:
Interpret the term “opioid use disorder,” explain the
benefits of Methadone Assisted Treatment (MAT) and
identify the characteristics of Neonatal Abstinence
Syndrome.
Better analgesic with opioid is our priority for cancer pain
Inadequate analgesia or intolerable side effect was the reason for opioid rotation
Many factors should be considered in opioid rotation because of individualize analgesic response
Topical pain medications another approach to pain, wound and scar management...Valuecare pharmacy
Struggling through chronic pain or the side effects of pain medication does not have to be a daily activity. Pharmacy compounding offers patients customized options for pain medication. Compounding is the art and science of preparing customized medications for patients. It provides valuable benefits to those for whom pain management has become a way of life.
Every individual is unique, and the types of pain experienced can be equally diverse. By working with a compounding pharmacist, your healthcare provider can prescribe treatments tailored specifically for your pain management needs.
Brief overview of the categories of pain
Review opioid pharmacology
Review the available treatment modalities and alternative options for pain management
Discuss alternative options for wound treatment
Discuss alternative options for scaring
Many patients experience stomach irritation or other unpleasant side effects from taking pain medication. Some have difficulty taking the medication in its commercially available form. Pharmacy compounding can provide alternate methods of delivery to make the process easier. Instead of a capsule or tablet, pain medications often can be compounded as dosage forms such as:
A topical gel, cream or spray form that can be applied directly to the site of the pain and absorbed through the skin.
A custom-flavored troche that dissolves under the tongue, a nasal spray, or a suppository.
Such dosage forms may bypass the gastrointestinal tract, providing optimal results with less GI irritation, and help patients who have difficulty swallowing pills, removing yet another source of aggravation.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
1. Pain Management in
Dementia: what’s new in
opioids?
Romayne Gallagher MD, CCFP
Division of Palliative Care
Providence Health Care
2. Objectives
Basics of pain in dementia
NOUG – is it useful for pain in dementia?
New opioids
New opioid formulations
3. Prevalence of pain in older adults
Prevalence of any kind of pain is stable
with increasing age
Scudds & Ostbye 2001, Thomas et al 2004
Prevalence of persistent disabling pain
increases with age
Brattberg et al 1996, Mobily et al 1994
4. Pain Homeostenosis
Diminshed ability to effectively respond to the
stress of persistent pain
Decreased cognitive reserves
Decreased opioid receptors, neurotransmitors
Altered pharmacokinetics/pharmacodynamics
Polypharmacy
Medical comorbidity
Social isolation, depression, loneliness
Impairments in ADL
Karp et al. Brit. J. of Anesthesia 2008
5. Cognitive Impairment (CI) & Pain
Management: Nursing Homes
Pain is documented less frequently for CI
residents, even with similar numbers of painful
diagnoses as less impaired residents (Sengstaken &
King, 1993)
Less analgesic is prescribed/administered for CI
residents, despite similar numbers of painful
diagnoses (Horgas & Tsai, 1998)
Only ¼ of demented residents who are identified
as having pain receive any analgesic therapy
(Scherder et al, 1999; Bernabei et al, 1998; Won et al, 1999)
5
6. Ability to self-report pain
Pain Self-Report and Cognitive
Impairment in Dementia Patients
Nonverbal
Cognitive impairment
6
7. Undertreatment of Pain in Patients
With Advanced Dementia
Prospective cohort study of 59 cognitively
intact elderly patients with hip fracture and
38 patients with hip fracture and advanced
dementia
Daily rating of pain by cognitively intact
patients
Comparison of analgesic prescribing
practices
Morrison & Siu, JPSM, 2000
7
8. Analgesic Prescribing in Hip Fracture
Patients with Advanced Dementia
Pre-op
Mg MSO4/Day
76% of cog. intact
patients rated their
average preoperative pain as
moderate-severe
68% of cog. intact
patients rated their
average postoperative pain as
moderate to severe
Post-op
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Cog Intact
Dementia
Morrison & Siu, JPSM, 2000
8
9. Analgesic Prescribing For Dementia Patients
Following Hip Fracture Repair
As Needed
Standing
24%
76%
Morrison & Siu, JPSM, 2000
9
10. Assessment of Pain in Dementia:
Medical Problems - Previous and Current
Concurrent medical problems (esp. hepatic, renal)
Allergies
Past painful conditions
Past medical history
Hospitalizations
Surgery
Serious illness
10
11. Hierarchy of Data Sources
Most reliable
Resident report (if
possible)
Prior pain history
Painful diagnoses
Behavioral indicators
Observer assessment
Response to empirical
therapy
Least reliable
11
12. Empirical Trials
Try pain medicine
Behaviours suggest it
could be pain
Behaviours decrease
It’s probably pain!
12
13. What do I need to know to
be a better prescriber in
older adults?
14. Maintaining drug levels in the
body
drug delivery
Maximum safe
concentration
Minimum effective
concentration
15. General factors affecting absorption, distribution &
elimination - Age
Absorption: Changes in drug absorption tend to be
clinically inconsequential.
Distribution: Lean mass to fat ratio can change with age
resulting in higher concentrations of fat-soluble drugs
Serum albumin decreases so in a patient with
malnutrition, this may enhance drug effects because
serum concentrations of unbound drug are increased.
16. General factors affecting
absorption, distribution & elimination - Age
Hepatic metabolism: mass and blood flow decreases
which can affect hepatic drug elimination.
The hepatic metabolism is reduced and clearance can
fall by 30 to 40%.
However, the rate of drug metabolism can vary greatly
from person to person. The possibility of hepatotoxicity is
generally enhanced in the elderly.
17. General factors affecting
absorption, distribution & elimination - Age
Reduction in hepatic metabolism
Presystemic (first-pass) metabolism of some drugs
given orally (eg, labetalol, propranolol, verapamil) is
decreased, increasing their serum concentration and
bioavailability.
Many drugs produce active metabolites in clinically
relevant concentrations. Examples are some
benzodiazepines, amitriptyline and opioid analgesics
such as morphine.
The accumulation of active metabolites can cause
toxicity in the elderly due to age-related decreases in
renal clearance. Toxicity is likely to be severe in those
with renal disease.
18. General factors affecting
absorption, distribution & elimination - Age
Reduction in renal clearance with age
The renal mass and renal blood flow decreases
significantly Renal physiological changes decrease renal
drug elimination.
Because renal function continues to decline, the dose of
drugs given long-term needs to be reviewed periodically.
Elderly people may also have a reduced rate of
compliance
Disease - Liver and renal disease reduces rate of
elimination
19. Opioid Induced Neurotoxicity
Definition
Neuroexcitability manifested by agitation, confusion,
myoclonus, hallucinations and rarely seizures
Predisposing Factors:
High opioid doses
Prolonged opioid use
Recent rapid dose escalation
Dehydration
Renal failure
Advanced age – lack of cognitive reserve, pharmacokinetics
changes
Other psychoactive drugs
*Daeninck PJ, Bruera E. Acta Anaesthesiol Scand. 1999
20. Opioids and Older Adults
Opioids have been associated with a
higher risk of fracture (so has chronic pain)
Opioids have been associated with
delirium - but so have many other
medications
Most of the studies do not differentiate
between opioids or involve pain as a risk
factor
21. Delirium in Hip Fracture Patients
541 patients, no delirium at entry to study
16% of patients became delirious
Subjects able to self-report pain
Severe pain prior to delirium
OR 9.0 p=0.01
Low doses of opioids (<10 mg of parenteral milligrams of mso4/day)
OR 4.4 p=0.03
Received meperidine (NS)
Increase in opioid dose after pain detected (NS)
Subjects unable to self-report pain
Low doses of opioids (<10 mg of parenteral milligrams of mso4/day)
OR 4.0 p=0.004
Received meperidine
OR 3.4 p=.001
21
Morrison et al, J Gerontol Med Sci, 2003
22. What is new in opioids?
National Opioid Use Guidelines
New opioids available
tapentadol, tramadol
buprenorphine
New formulations of oxycodone & fentanyl
23. National Opioid Use Guidelines
National opioid use group: mostly
regulators
Literature review by researchers who
derived recommendations
National Advisory Panel – Delphi Process
Responses from NAP not made public
24. Opioid Guidelines
Generally very useful and worth following
http://nationalpaincentre.mcmaster.ca/opioid/
The bias is towards the prevention of
opioid abuse and diversion – appropriate
for about 10% of chronic pain population
25. Opioid Guidelines
Opioid suggestions for frail older adults do
not make pharmacokinetic sense
Codeine and tramadol
Short-acting opioids
Both must be metabolized to be active
Codeine metabolized to morphine and active
metabolites accumulate in renal failure
q4hr opioids in residential care is nursing
nightmare
26. Opioid classes
Are all opioids the same?
Opioids bind to three opioid receptors with
differing effects
There are at least two distinct classes of
opioids based on structure
Methadone also targets NMDA receptors
There are two pathways of metabolism for
opioids
Two opioids are lipophilic and the rest are
more hydrophillic
27. Opioids of choice
in frail elderly and renal failure
Hydromorphone
Oxycodone
Fentanyl
Methadone
27
30. Notes about the Fentanyl patch
Takes 12 hours for onset of analgesia
Need adequate subcutaneous tissue for
absorption
Takes 24 hours to reach maximum effect
Change patch every 72 hours
Dosage change after six days on patch
Suitable for stable pain only
31. OxyNeo replaces OxyContin
Oxycodone in a new formulation
Turns to gel on contact with water
not injectable
can’t delay swallowing
Extremely crush resistant
Special authority needed
32. Targin
Oxycodone with core of naloxone
Lower incidence of constipation
Naloxone not absorbed from the gut – no
effect on analgesia
Comes in 10, 20, 40mg oxycodone size
Naloxone core too large for 5mg SR size
so will be phased out
Not covered by Pharmacare
33. Tramadol
Tramadol available in Europe (30 years) and US (12
yrs)
Dual Action
Opioid agonist
Inhibits reuptake of Serotonin and Norepinephrine
Metabolism: like codeine requires metabolism to
become active
View as a weak opioid – ie for moderate pain
Available dosage strengths (CR tramadol, q24h)
150, 200, 300 and 400 mg
150mg q24h is the usual adult starting dose for opioid naïve patients
Not to exceed 400 mg total daily dose
34. Tapentadol
Very similar to tramadol but new
Dual action – mu receptor agonist and
norepinephrine reuptake inhibitor
Short acting formulation only
May be more potent than tramadol
Not covered by Pharmacare
Needs a duplicate prescription pad
35. Buprenorphine
Semi-synthetic derivative of
morphine alkaloid thebaine
Highly lipid-soluble
High affinity for the μ-opioid
receptor
Potent partial agonist action
Thought to dissociate slowly
from the receptor
36. Buprenorphine
Partial agonist of mu receptor
Requires metabolism to become analgesic
Ceiling effect – consider as a weak opioid
Slow onset, highly bound to receptor
Highly lipophilic
37. The BuTrans® Patch
Transdermal delivery eliminates first-pass metabolism
Patch delivers very small amounts of buprenorphine
Low plasma concentrations: levels measured in picograms
(one trillionth of a gram or 10-12 g) per milliliter
Buprenorphine binds and dissociates from the mu-receptor
slowly
May account for the prolonged duration of analgesia and,
in part, for its limited physical dependence potential
Patch provides steady delivery of buprenorphine for up
to 7 days
Steady state concentrations achieved during the first
application after day 3
Clinical significance has not been fully established.
Purdue Pharma Canada. BuTrans® Product Monograph, February 2010.
38. Bu-Trans patch
Experience in other countries is good
Useful for moderate pain
Potential for use in residential care as
would reduce work load of administering
pills
Not covered by Pharmacare
40. Sufentanil for incident pain
Well absorbed through buccal, sublingual
and nasal mucosa
Onset is 5-10 minutes
Cleared in 30 minutes
12.5mcg- 25mcg starting dose
Up to 100mcg per dose
For sublingual use must be able to follow
directions
42. New formulations of fentanyl
Abstral – fentanyl buccal tablets
Onsolis – fentanyl buccal film
More effective than sl or intranasal
sufentanil
pH adjusted
less chance of swallowing and inactivating
medication
Not covered by Pharmacare
43. Topical Opioids
Ischemic ulcers, pressure ulcers,
fungating tumors
Morphine 1% concentration in intra-site
gel
Methadone 1% concentration in inert
wound powder
44. Methadone in older adults
Well tolerated and effective
Starting dose 1mg q12hr
Well absorbed orally and bucally
Titrate once weekly only
Use other short acting opioid for breakthrough
pain while titrating methadone
Use methadone for breakthrough dose bid-tid
once on stable dose
Gallagher Pain Med. 2009
45. Methadone in older adults
Many potential interactions but few are
clinically significant
Clinically significant:
Clarithromycin, rifampin
Carbamazepine, phenytoin
Fluconazole, ketoconazole
QTc prolongation in doses greater than
100-200mg per day
46. Titrating opioids
Increase dose by 15-20% each time if
symptom not controlled
Starting with long acting opioids?
In residential care inadequate staff to do q4hr
opioids
Oxycodone SR 10mg = 3 Tylenol #3
Hydromorphone SR 3mg = 3 Tylenol #3
Methadone 1mg q12 hrs = 2 Tylenol #3
½ 12mcg patch = 5 Tylenol #3
47. Treating side effects
Docusate not useful
Senna helpful but can cause cramps
Lactulose works well but horrible taste
PEG 3350 (Laxaday) works well and can
be mixed with drink of choice
48. Neuropathic Pain Adjuvants
Anticonvulsants not well tolerated in oldest
adults – ie gabapentin, pregabalin,
topiramate
32% withdrawal from study of pregabalin in
neuropathic pain
Dworkin et al Neurology 2003
49. Neuropathic Pain Adjuvants
TCAs have intolerable side effects
In a trial of TCA vs opioids for neuropathic pain both
were effective but patients preferred opioids (54%) to
TCAs(30%) to placebo(10%) p=0.02
Raja et al Neurology 2003
SNRIs are likely the best option for older adults
with neuropathic pain
Study of >80 years old found it safe and efficacious
for depression
Baca et al Int J Geriatr Psychiatry 2006
50. Pain and depression
Study of 524 older adults
Pain hinders recovery from depression
Mavandadi et al JAGS 2007
Disabling chronic low back pain and
depression were independent factors that
increased the prevalence of each other
Meyer et al Spine 2007
Anxiety is also a predictor of pain
Feeney J. Anxiety Disord 2004
51. Interventional pain management
Epidural steroid injections: for spinal
stenosis, facet joint, nerve compression
secondary to OA
Vertebroplasty for lumbar compression
fractures causing uncontrollable
pain/disability
52. Take Home Messages
Older adults with chronic pain are not the
same as younger patients with pain
There is “pain homeostenosis” (less ability
to respond effectively to the stress of
chronic pain)
Older adults are more likely to loose
function with chronic pain if there is a lack
of timely intervention
53. Take Home Messages
Minimize polypharmacy
Opioids are a safer choice in older adults
Opioids with no active metabolites are a
better choice in older adults
If patients with dementia and pain become
drowsy with opioid try reducing
neuroleptics
Analgesic trials while monitoring behaviour
Analgesic trials need to include opioids