Acute - identified event, resolves in days/weeks

Chronic - Cause often not easily identified, multifactorial; indeterminate duration; nociceptive and/or neuropathic 

- Direct stimulation of intact nociceptors, transmits along normal nerves

- Described as sharpe, aching, throbbin, somatic is easy to localize while visceral isn't

- In this, tissue injury is apparent, and we will manage it with opiods and adjuvant/coanalgesics

- From disordered peripheral or central nerves

- Comes from compression, transection, infiltration, ischemia, or metabolic injury

- Varied Types:  Peripheral, deafferentation, complex regional syndromes

- Pain may exceed observable injury

- Burning, tingling, shooting, stabbing, or electrical like pain

- Management with opiods and/or adjuvant/coanalgesics

- Neuronal blockade (sympathetic nerve blocks)

- Neurostimulatory techniques (spinal cord stimulation)

- Intraspinal infusion

- Gabapentin, Carbamazepine, lamotrigine, and new AED's

- Antidepressants

- Opioid analgesics

- Lidocaine (Transdermal, IV, mexiletine)

- Alpha-2 adrenergic agonists

- Visual Analog Scale

- Graphic rating scale (verbal,numerical)

- Numerical Rating Scale (initiate therapy at 3/4)

- Wong-Baker (literally cartoon faces)

- Color (blue is no pain, red is extreme pain)

- Simple Descriptive pain intensity scale (No pain, mild, discomfort, distresssing, horrible, excruciating)

- FLACC (Face, legs, activity, cry, consolability, useful in non-verbal patients, describes behavior in response to pain)

- Easier to prevent than relieve

- Keep pain diary

- Dose meds around the clock

- Long acting for continuous pain, intermediate for breakthrough pain (look for end of dose failure, incident prophylaxis)

- Dose sliding scales and freq. ranges

- APAP

- NSAIDS

- ASA

- Adjuvants

APAP with......

- Codeine

- Hydrocodone

- Oxycodone

- Dihydrocodeine

- Tramadol

- +/- adjuvants

- Morphine

- Hydromorphone

- Methadone

- Levorphanol

- Fentanyl

- Oxycodone

- +/- adjuvants

- APAP and ASA

- Both 325-650 q4-6h or 1000mg tid or qid

- Max dose of 4000mg

- Apap drug of choice, potential liver toxicity

- ASA ADR's could be bleeding, ulcers, stomach upset, tinnitus, intx

- inflammatory disease use or unresponsive APAP therapy

- OTC

- Ceiling effect (wtf is this?)

- Avoid in high risk patients such as elderly and those with heart/renal problems

- Cox 1 inhibition: bleeding, GI, kidney, liver problems

- Cox 2 inhibition:  Decreases inflammation, pain, fever

- Celexicob has same efficacy but less bleeding, ulcers,similar renal effects

- Moderate-severe pain

- Duel mechanism with mu-opioid receptor and then NE and 5-HT reuptake

- Usual dose = 50-100 q4-6h

- Onset is 60 minutes

- Also available with APAP

- ADR's include n/v, dizziness, CNS stimulation, constipation, potential for seizures

• •Phenanthrenes
• –Morphine
• –Codeine
• –Hydromorphone *
• –Levorphanol *
• –Oxycodone *
• –Oxymorphone *
• –Buprenorphine *
• –Nalbuphine
• –Butrorphanol *
•  
• •Benzomorphans
• –Pentazocine
• •Phenylpiperidines
• –Meperidine
• –Fentanyl
• –Alfentanyl
• –Sufentanyl
• •Diphenylheptanes
• –Methadone
• –Propoxyphene

- No ceiling effect

- Titratable

- No irreversible or life-threatening end-organ problems

- Wide variety of formulations,strengths, dosage forms

- Titrate q1-2 days, either by 25%, 25-50%, or 50-100% depending on mild, moderate, or unrelieved severe pain, respectively

- Increase dose when B/T medication used > 3 times/24 hours for 2-3 days

- Conjugated in liver

- Excreted via kidney (90-95%)

- First-order kinetics

- Cmax after 1 hours, 30 minutes, or 6 minutes depending on dosage form

- Half-life at steady state is 3-4 hours

- steady state after 4-5 half-lives or 24 hours

- Duration of effect 3-5 hours with immediate release formulas

- If renal problems decreasing dose or interval (urine problems indicative of this)

Bolus effect: drowsiness 30-60 min. after admin., pain before next dose due, must change up release formula.

- When changing from oral to invasive form, use roughly 1/3 of dose (sig. first pass effect)

- If going from Morphine to Dilaudid divide dose by 4

- If Morphine PO to more invasive form divide by 3

- If Dilaudid PO to more invasive divide by 5

- Could be cross tolerance, so start with 50-75% of equianalgesic dose

- For methadone, start with 10-25% of published equianalgesic dose

- For immediate/intermediate release, tapering is the same as stated before

- For extended release, never chew, may put down feeding tubes, dose q8, 12, or 24h and reassess every 2-4 days when SS is reached

- Methadone adjustment is variable, could be q6-8h, adjust every 4-7 days

- Increase breakthrough dose as ATC dose is increased

 - For PO it is 10-20% of total daily dose q1h

- Parenteral = 50-100% of hourly rate q15 (minutes or hours?)

Morphine - 10-15mg

Oxycodone - 5-10mg

Hydromorphone (Dilaudid) - 2-4mg

*If titrated properly, there is no ceiling dose for these opioids

Repeat dose or titrate upwards by 50-100% q1-2 hours until adequate analgesia is met ( >50% reduction in pain) or side effects are encountered

Available:  Morphine in the form of MS Contin, Oramorph SR, Kadian - starting dose 20-30mg po q12h

Oxycodone in the form of Oxycontin - starting dose 20mg q12h

Steady state reached by 24 hours

Can be titrated every 24 hours for unrelieved pain.  For moderate increase by 25-50% q24h, for severe do 50-100% q24h

- No analgesic effect for 12-24h

- Steady state only after 72 hours - therefore replace or increment q72 hours

- Do NOT use for initial dose titration

- Fentanyl levels decay w/ half-life of 17 hours after removal of patch

- Need "breakthrough" medication

- One 25 microgram/hr patch = 60mg of morphine a day

- Idiopathic/Spontaneous

- Disease progression

- Incident

- End-of-dose failure

- Mild to moderate pain

- Only available in combo

- Onset of actoin 10-20 minutes

- Duration = 3-6 hours

- Dose is 1-2 q4-6h

- Dose is limited by APAP

- Better accepted than codeine

- Mild to moderate pain

- Metabolized into morphine by the body

- Often combined with APAP

- 60 mg of Codeine = 600mg of aspirin

- Usualy dose = 15-60mg q4-6h

- APAP limits overall dose

- ADR's include drowsiness and constipation

- Smoking DECREASES effectiveness

- Mild to moderate pain

- Often combined with APAP or ASA

- Dose is 100mg q4h

- MDD = 600mg

- Active metabolite is Norpropoxyphene, causes pulmonary edema and cardiotoxicity

Drug Profile: Morphine

- Oral, rectal, parental formulations

- LA and immediate release

- Onset = 15-60 minutes

- Duration is 4-6h or 8-12h

- Two main metabolites, M3G and M6G (active)

- Caution in renal impairment

- In combo with APAP or ASA for mild-moderate pain

- Long and short acting oral formulations

- Onset = 10-15 minutes

- Duration = 4-6h

- Oral, parenteral, and transdermal formulations

- Transdermal patch for stable, chronic pain

- Opioid naive should start with 25mcg/hr

- Can use multiple patches at once

- Need to rotate sites

- Make take about 16 hours for analgesia to set in

- Difficult to adjust dose/convert from another opioid

- Absorption increases with heat

- Oral, parenteral, rectal formulations

- No LA formula

- Oral

- Onset = 15-30 minutes

- Duration = 4-6 hours

- More potent than morphine

- Oral, rectal, parenteral dosage forms

- Onset = 30-60 minutes

- Duration = 4-6h (for acute) / >8h for chronic

- Half-life is long and variable (12 to 190 hours)

- Low abuse potential

- Stigma

- Multiple conversion methods

AMDA (American Medical Directors Association) and AGS (American Geriatric Society) have stated that combining low doses of different analgesics may produce pain relief with a lower incidence of side effects (synergistic effect)

- Burning, pins and needles type pain

- Use Tricyclics:  Amitriptyline, Nortriptyline, Imipramine, Desipramine, Doxepin, or Venlafaxine

- Antiarrhythmics

- Use Lidocaine, Mexilitine

- Use anticonvulsants, antihypertensives, or topicals

Drugs:  Gabapentin, Carbamazepine, Valproate, Clonidine, Capsaicin

- Dull and aching feeling

- Use:  NSAIDS, Bisphosphonates, Steroids, Calcitonin

For Muscle Spasms use: 

 - Baclofen

- Carisoprodol

- Methocarbamol

- Orphenadrine

- ATC opioids call for ATC laxatives (stimulants preferred)

- Patients do not develop tolerance for this

- For N/V eat and drink slowly, avoid irritating/fatty foods, sit upright, oral hygiene freq., treat with phenothiazines, metoclopramide, haloperidol, dexamethasone, lorazepam

- For diarrhea, perform good personal hygiene, avoid high reside foods like raisin bran, avoid food temp. extremes, avoid caffeine and replenish fluids.

- For sedation, use stimulants, reduce dose, patients not in pain sleep longer (FYI)

- Anaphylactic rxns common

- Urticaria and Pruritus due to mass cell destabilization, treat with 2nd gen. antihistamines