0--no pain

2--hurts a little

4--hurts a little more

6--hurts even more

8--hurts whole lot

10--hurts worst

Can assess children with smiley faces to indicate or people who cannot speak, etc.

• Commonly occurs after trauma, surgery, medical procedures
• resolves in short time frame
• Examples:
•   the above and muscle strains/sprains

• Lasting >6 months OR beyond healing period
• Also non associated with cancer pain
• Examples:
• HA, chronic low back, OA & RA, fibromyalgia

• pain associate with progressive DZ that is potentially life-limiting
• (Cancer or its therapy)
• Can have exacerbations (elements of Acute)
• Cancer/Chemo, AIDS, end stage organ failure

• usually described as a burning, tingling, hypersensitive, electrical shock
• Due to abnormal sensory input or trauma
• Not responding well to traditional therapy
• Examples:
• Diebetes neuropathy, B-12 neuropathy

• Level 1 (pain 1-3)--non-opiod analgesic +/- adjuvant
• Level 2 (pain 4-7)--weak opiod +/- non-opiod +/- adjuvant
• Level 3 (pain 8-10)--stong opiod +/- non-opiod +/- adjuvant

• After the acute period of treatment or for chronic/rehibilitation
• Types of heat genreation: dry/moist/convection/microwave
• Increase blood flow and help remove products of inflammation
• Do not use immediately or with local anesthetics

• creating sensation to hide pain
• may cause vasodilation or so placebo effect
• Cooling agents:Camphor and Menthol
• Rubifacients: Methyl salicylate and Capsaicin

• active ingredient hot chili peppers
• Block synthesis of substance P
• 4 wks to start working
• Indications:
• OA and RA
• post-herpes zoster pain
• neuropathies
• severe itching

• Antipyretic
• Anti-inflammatory

--Ceiling effect

--DO NOT cause tolerance or dependance

• Indications: fever (non-inflam component)
• Advantages: no antiplatlet effect, well tolerated, DOC in kids and renal failure
• Disadvantages:hepatotoxicity (awareness of other drugs with this in it)

• Irrevesibly inhibits platelet action
• Adverse effects: GI, SE, bleeding
• Avoid in children <12 yoa
• Hypersensitivity reaction possible

• Acute pain
• OA
• RA
• Gout
• Bursitis migraines
• Dysmenorrhea
• MANY OTHERS

• Acetominophen
• Aspirin
• Salicylates
• Propionic Acids  (most common)
• Oxicams
• Acetic Acids
• Fenamtes
• Naphthyalkanones

Salicylates

--NSAID's

--non-acetylated salicylates do no interfere wit hplatelet aggregation and rare GI bleeding

EX: Salsalate

       Diflunisal

Onset: 1 hr

Duration: 12 hrs

EX:

fenprofen

Ibuprofen

ketoprofen

Naproxen

Oxaprozin

Flubiprofen (FDA only for OA and RA)

• NSAIDS
• Duration: longer up to 24 hrs

Examples:

Meloxicam--FDA only for RA and OA

Piroxicam--caution in elderly

• NSAIDS
• Onset: 1/2 hr
• Durations: 6-8 hrs

Examples:

Diclofenac

Etodolac

Indomethacin--gout

Ketorolac--not exceed 5 days

Sulindac

Tolmetin

• NSAIDS
• Durations 4-6 hrs

Examples:

Meclofenamate

Mefenamic Acid--not exceed 1 wk

• NSAIDS
• Durations 12-24 hrs

Examples:

Nabumentone--FDA for RA and OA only (be careful with Heart Failure)

• Onset: 1hr
• Duration : 12-24hrs

Celecoxib--only one on market (200mg BID)

• GI
• Renal
• CNS
• Dermatology
• Hematologic
• Hepatic injury
• pulmonary
• pregnancy/lactation

GI toxicity

(NSAIDS)

• GI uses COX-1 receptors to make protective PG
• inhibition--> break down of the GI lining

Risks: >60, high dose, past h/o GI toxicity, use with other NSAIDS, anticoags, etc

Primary and Secondary prevention/treatment of GI side effects

1--misoprostol or PPI (lansoprazole, esomeprazole)

COX-2 NSAIDs

H2 antagonist

H. pylori status

2--assess patients needs for NSAIDS

Recurrent ulcer--Celecoxib and PPI

• not commonly seen
• more in elderly
• mood and congnition changes
• HA
• Hallucinations
• Siezures

• Pruritis
• Stevens-johnson syndrome
• toxic epidermal necrolysis
• more related to the drug than the class of NSAIDS

• CHF
• uterine bleeding
• platelet dysfunction
• Pregnancy--not recomended

Drug interactions

(NSAIDS)

• just understand that there are alot of drug interactions 
• oral anticoags
• increased [lithium]
• oral hypoglycemics
• phenytoin
• methotrexate
• Digoxin
• Aminoglycosides

• BUN/serume creatine
• signs of bleeding
• rash
• take with food to decrease GI effects

Opioids

(advantages and disadvantages)

Ad:

--moderate to severe pain

--multiple receptor agonist (mu, kappa, delta)

--superior benefit to risk

--NO ceiling effect

DISAD:

--addiction/ dependence

--respiratory depression

--Hypoxia

Possible combination therapy for mild to maderate pain

(mild opioids)

1. Hydrocodone + acetominophen (most common)
2. hydrocodone + ibuprofen
3. Codeine + acetominophen

• moderate to severe pain treatment
• pts. may benefit from using them
• decrease amount of short acting pain meds
• insure analgesia throughout night
• Provide consistant level of pain relief

•Morphine

•Codeine

• Weak agonist reuptake inhibitor
• Mu opioid receptor agonist
• inhibit 5-ht and NE

Additonal risk of seizures

adjust for renal impairment

TENDS not to work as well in people previously on opioid treatment

--Activate Kappa while inhibiting Mu

--Highly addictive

Examples:

Pentazocine

Butorphanol

Nalbuphine

**no respiratory depression**

--should not be used for severe progression of pain

--lack euphoric effect

--lack of evidence for advantage

• Long acting  opioid
• GOLD STANDARD
• Caution with severe renal insufficiency
• accumulation of metabolites can cause aggitation, confusion and delerium
• highest insidence of PRURITIS

Examples:

MS contin--controlled release tablet (BID)

Oramorph SR--sustained release     (BID)

Kadian--sustained release   (BID)

Avinza--once a day dosing

• long acting
• modereate to severe pain
• duration: 12 hrs BID
• Biphasic deliverey systemt

• Long acting
• helps patients with cancer pain
• DO NOT CONSUME WITH ETOH
• DO NOT TAKE WITH FOOD (1 hr b4 or 2 hrs after a meal)

• maintanence therapy in patients with heroin addiction
• Once a day for addiction
• dose frequently for pain management
• 1/2 life not specific (monitor)

• 72 hr effect
• dosing of patch referes to amount every hr
• 12 hrs required fo depot to form

Who should NOT use:

--acute, post-op, intermitant and mild pain

--those not opioid tolerant

Fentanyl

(pt. education)

• put patch o nnon-irritated flat skin surface
• clip but do not shave hair
• DO NOT cut patch
• write date and time of application on patch
• caution using sauna, hot tubes or heated water beds
• NO heat on the patch

1. Morphine
2. oxycodone
3. oxymorphone
4. methadone
5. fentanyl

1. Morphine sulfate
2. Oxycodone
3. Hydromorphone
4. Fentanyl
5. Oxymorphone

**remember that some are the same as long acting but it is dependent on the trade drug and thus the deliverey system**

--pain uccuring on top of the chronic pain

--short acting opioid recomended

--use same product in short as in long acting

--short 10-15% of long acting dose

--2-6 hrs prn

• routes: IM, IV, SQ, tablet, supository, liquid
• Onset: 15-30 minutes
• Peak: 1/2-1hr

--sweetened lozenge on a stick

--only a portion of the drug is absorbed

--15 minute consumption

--peak:5-10min.

--start the lowest dose

--CAN repeat in 15 min. after 1st dose

• Sugar free
• between cheek and gum
• 50% drug absorption
• other is absorbed in GI tract
• 100mcg; can repeat in 30 min. if needed

Lozenge always has higher dose than buccal

• short deration of action
• Toxic metabolite which can induce tremor, twitching, agitation and covulsions
• Should NOT be given more than 48 hrs for acute pain
• NEVER use with chronic pain

•Constipation

• MOST common opioid side effect
• delay gastic emptying, decrease parastalsis, slow down bowel movement
• Treat with stimulant laxative +/- stool softener
• CAUTION use of bulk forming laxatives

• < 8 breaths per min
• tolerance within days to weeks
• TX: Naloxone
• this will reverse the analgesic effect
• half life 60 min.

• Long acting not recomended
• immediate release prefered
• once stable can switch to long acting
• lowest effective dose

• When patient is nto getting sufficient pain relief
• compaining of adverse reactions
• need for change of method of deleivery

IV = PO dosing for

Morphine

hydrocodone

oxycodone

M  10 = 30 mg

H 1.5 = 7.5mg

O  only PO

• calculate total 24 hr dose of opiods
• use the dose table
• new drug shoudl be reduced 25-50% for cross tolerance

• Morphine
• fentanyl
• hadromorphone

--patient self administering narcotic

--preprogrammed with a lockout period

--most post-op patients after the continuous basal infusion is being tappered (3-5 days post-op)

--Add to any regimen

--Many agents used for neuropathic pain

EX.

Antidepressants

Anticonvulsants

Steroids

• Chronic pain is usually associated with depression
• Considered first line for neuropathic pain

Examples= pregabalin and gabapentin

--increasingly used for cancer pain

sedation or neurotransmitter inpuls block

Muscle Relaxants

1. GABA agonist
2. Carbamate Depressant
3. Antihistamine analog
4. tricyclic agent
5. Direct skeletal relaxer

Baclofen

• GABA-B agonist
• Blocks spinal afferent pathways
• Indications: spasticity and mobility in CNS degeration
• 20-80mg daily

GABA agonist

(precautions)

• Do not stop abruptly (2 wk tapper)
• Renal dosing needed
• ELDERLY
• Psychiatric disorders
• admin...oral or intratracheal
• CNS depression at large dose

• enhances GABE inhibitory neurotransmitter system, specifically GABA-A and DNZ receptor
• Indications:
• spasmodic torticollis
• adjunct or joint dislocation
• neurodegenerative disorders
• MAX 40 mg/day oral

Diazepam

(considerations)

• no more than two weeks for muscle spasms
• tachyphylaxis
• NOT with alcohol
• addictive potential
• NOT for Parkinson's

• Carbamate Depressant
• centrally acting sedative
• use: muscle spasms
• 350mg po 3-4 times/day
• Dependency possible
• additive properties with alcohol
• Can combine with ASA or codein

adverse reactions: drowsiness, sedation, vertigo

• Carbamate Depressant 
• CNS and depressant properties
• Use: Muscle Spasms(short term) and Tetanus
• loading dose

renal and hepatic impairment

LOWER seizure threshhold

NOT <16yoa

• centrally acting agent
• USE: muscle spasm (short term) and analgesic
• monitor liver function
• 500mg TID

• Central Depressant and Sedative
• use: Skeletal Muscle spasms
• NOT < 12 yoa or in the elderly (renal or hepatic impairment)
• CONTRAINDICATIONS: hemolytic anemia

• Antihystamine analog
• anticholenergic, stimulant, local analgesic (not for degenerative disorder)
• Indications: nocturnal leg cramp, muscle spasms, parkinson
• SE: anticholenergic (dry mouth, blurred vision, etc.)

• Tricyclic like agent
• acts at brainstem
• powerful sedative
• long halflife---take at bed time
• use: acute muscle conditions
• start with 10 mg at bed

Side Effects:

--anticholinergic

--not excede 2-3 wks

--LOWER seizure threshold

--accumulation

--not effective for depression

Dantrolene

• directly acts on skeletal muscle
• use: chronic spasticity for neurodegenerative disorders
• LIVER TOX.
• 25 mg QID for 7 days

Muscle relaxers

(contra.)

--pregnancy (C)

--Drowsiness

--driving while on meds

Withdraw: baclofen, carisoprodol, diazepam

• Aspirin
• NSAIDS and COX-2
• Caffeine
• Codeine