NOCICEPTIVE PAIN

Responsive to non-opioids and opioids

NEUROPATHIC PAIN
Treatment includes adjuvant analgesic

Increased catabolic demand
Poor wound healing, weakness, muscle
breakdown
Decreased limb movement
Increased risk of thrombolytic events
Respiratory effects
Shallow breathing, tachypnea, cough
suppression leading to pneumonia
Tachycardia and elevated blood
pressure

Non-opioids
Opioids
Adjuvants

Acetaminophen & NSAIDs
agonists & mixed agonist-antagonists
Multipurpose & specific to type of pain
Schedule 1
What Controlled substances are more
likely to be abused and include
Codeine, Morphine, Fentanyl,
Meperidine, Hydromorphone,
Oxycodone, Levorphanol, Methadone
What controlled substances are Safer,
less likely to be abused and inculde
Combination products w/ APAP or ASA-
hydrocodone, codeine
What controlled substances are Proven
to be as effective as acetaminophen
and include propoxyphene products,
benzodiazepines (lorazepam, diazepam,
oxazepam)
What Controlled substances Might help
a cough in include Expectorants w/
codeine
Narcotics
There is none
Acute and chronic
Meperidine
morphine
meperidine, fentanyl, methadone
Relieves pain and induces euphoria by
binding to opioid receptors (mu, delta &
kappa) in the brian
Binding to these receptors mimics the
release of the euphoric compounds
(enkephalins, dynorphins & endorphins)

Poppies
Constipation:
Puritis
N&V
Sedation
Respiratory Depression
Inhibition of cough reflex
Confusion/ Hallucinations
Dysphoria/ euphoria
Prolonged Labor
Urinary Retention
Miosis (pupil constrict)

Give stool softener + stimulant
docusate + senna
Puritis do to Histamine release

Respiratory depression
local & generalized flushing & itching
give diphenhydramine
Other CNS depressants; EtOH
Mathadone has CYP4503A4 interaction

Yawning & muscle aches
Naloxone ( Narcan)
Mu= partial
Kappa= full
Precipitate withdrawal
Buprenorphine (Buprenex)
Butorphanol (Stadol)
Nalbuphine (nabain)
Pentazocine (Talwin)

An Mixed Opioid Agonist-Antagoinst
used to treat opioid addiction
Buprenorphine/ Naloxone= Subaxone
Adjunctive Analgesics & Co-Analgesics
NSAIDs, Antidepressants, Anticonvulsants,
Corticosteroids, Benzodiazepines &
Muscle Relaxers
Morphine
MS Contin (CR tabs)
MSIR (IR caps)
Avinza (CR caps)
Kadian (CR caps)
Hydromorphone (Dilaudid)
MS Contin (CR tabs)?
Long Acting
MSIR (IR caps)
Immediate release
Avinza (CR caps)
Long Acting
Kadian (CR caps)
Long Acting
Hydromorphone (Dilaudid)
Immediate Release

MSIR (IR caps)
Hydromorphone (Dilaudid)


Avinza (CR caps)

What types of morphine can be emptied
onto food but NOT chewed- because it
alters drug delivery OD? & death
OxyCONtin (CR tab)
OxyIR (IR caps)
Roxicodone (solution)
Percocet
Roxicet
Percodan
OxyCONtin (CR tab)
Long acting Chronic
OxyIR (IR caps)
Short Acting Acute
Roxicodone (solution)
Short Acting Acute
Percocet
Long acting chronic
Roxicet
Long acting chronic
Percodan
Long acting Chronic

OxyCONtin (CR tab)
Percocet & Roxicet
Percodan
Fentanyl (Sublimaze)
Fentanyl Patch (Duragesic)
Fentanyl Lozenge (Actiq)
Fentanyl Patch (Duragesic)
Fentanyl (Sublimaze)
Fentanyl Lozenge (Actiq)
What type of fentanyl is more of an
anesthetic drug, used extensively
perioperative & may be tolerated in
morphine allergic?

Is only used in who?
Use for opioid tolerant ONLY
Pt.s on must continue what?
Must continue regular OTC opioids
Not for what type of use?
Not for short term pain inc. migraines
Is a _____-philic drug?
Lipophilic Drug
What should be avoided? Why?
Avoid sun & heat; inc. absorption
What in the body alters its absorption?
Peripheral blood flow & subcutaneous fat alters
absorption
Who can it not be given to?
No opioid nave
How long does it take for the body to get
significant levels?
6-12hr for significant levels
What is its Black Box Warning?
BLACK BOX= ACUTE PAIN USE
Acute
Norco, Vicodin, Lortab
Vicoprofen
Who might we give it to?
Morphine allergic
What makes it toxic?
Its metabolites= normeperidine
Chronic pain & opioid abuse
2 phases
Alpha phase works as an analgesic: t1/2= 8-
12 hr
Beta phase helps with w/drawl: t1/2; 24-36hr

Tramadol
Tramadol (Ultram)
Tramadol ER
Tramadol + APAP

Dual action: blocks mu receptors &
inhibits uptake of serotonin &
norepinephrine

Lowers seizure threshold

Who is it used in?
Pt. who need strong analgesic (like
oxycodone) but cant tolerate GI side
effects
What is the MOA?
Opioid agonist and norepi reuptake inhibitor
ADRs?
Sedation and Seizures

Oxycodone po?
20mg
hydrocodone po?
20-30mg
methadone po?
3-5mg
morphone po?
7-7.5
50mg morphine po
Oxycodone po?
1.5x
hydrocodone po?
1.5x
methadone po?
Non-linear
morphone po?
4-7x
Fentanyl
80x

APAP 650mg q 4hr
APAP 1,000mg q 6hr
Ibuprofen 600mg q 6hr
Pain = 3 might use Tramadol or APAP w/
codine

APAP 325mg/codine 60mg (T4) q 4hr
Tramadol 50mg q 6hr
APAP 325mg/oxycodone 5mg q 4hr

Morphine 15mg q 4hr
Hydromorphone 4mg q 4hr
Morphine controlled release 60mg q 8hr

Give controlled release (CR) or long
acting product + something for
breakthrough pain
Give 10% the total daily dose as
breakthrough management
Use around the clock (ATC) not prn to
break the pain cycle

Dependence
Addiction
End-result of under-treatment of pain?
Appropriate drug-seeking behaviors;
demand dose before scheduled time &
drug hoarding, go to more than one
doctor/ pharmacy?

Cured by increasing daily dose and
monitoring pt.
Flushing, itching, hives and or mild
hypotension only or at injection site

Severe hypotension
Skin reaction other then itching, flushing
or hives
Breathing, speaking or swelling difficulty
Swelling of face, lips, mouth, tongue or
larynx

Non-opioid analgesic
Avoid codeine, morphine and
meperidine; opioids most commonly
associated w/ psuedoallergy
Use of more potent opioids less likely to
produce pseudoallergy
Concurrent administration of
antihistamine
Dose reduction

on-opioid analgesic
Opioid in different chemical class then
one reacted to
Phenylpiperidines: meperidine & fentanyl
Diphenylheptanes: methadone
Morphine group

Bone mass and maturity and subsequent
bone loss
Measured by DEXA scan
Diagnosis osteoprosis
minimize bone loss
delay progression of osteoporosis
prevent fracture-related M/M
treatment for life???

Women 50-70?
1,200mg Ca & 600 IU Vit D
Women >70?
1,200mg Ca & 800 IU Vit D
Men 50-70?
1,000mg Ca & 600 IU Vit D
Men >70?
1,200mg Ca & 800 IU Vit D


1,200mg Ca & 800-1000 IU Vit D
1200-1500mg/day
1,200mg/ day
Increased risk of kidney stones and CV
disease
From food
Ca & Fe
In small amounts
Throughout the day
NOT w/ high fiber meal
TUMS
Caltrate
Oscal
What percent elemental Ca?
40%
Requires what for absorption?
Acid
Not a good choice for what patients?
Patients on PPIs or elderly
What is the most common complaint of
people on?
Gas/ Bloating
What percent elemental calcium?
21%
What does it NOT require for absorbtion?
Acid
Does it produce gas symproms?
NO

Vitamin D
50,000 IU po once weekly x6-8 weeks
Recheck levels in 8 weeks
Weight-bearing exercise
Antiresorptive Medications & Anabolic
Drugs
Bisphosphonates
Calcitonin
Estrogen
Estrogen agonist/ antagonist
Teriparatido (Forteo)
They slow the progression of bone loss
that occurs in the breakdown part of the
remodeling cycle; stop loosing bone as
quickly and still make new bone at a
normal pace
Increases the rate of bone formation in
the bone remodeling cycle; THIS IS THE
ONLY DRUG CLASS MARKETED TO DO
THIS!!!
Approved for the prevention of
osteoporosis in post-menopausal women

Inhibits bone reabsorption= reduces
bone loss, increases bone density in
spine and hip and reduces fracture risk
Premarin
Estrace
Prempro
Femhrt
Vaginal bleeding
Weight gain
Breast tenderness
Nausea
HA

Active thromboembolic dz
Breast CA
Liver Dz
Unexplained vaginal bleeding
Pregnancy
NOT COMMON!!! It is no longer used
Prevention and treatment of
osteoporosis in postmenopausal women
Increases bone density, reduces risk of
spine fractures

Raloxifene (Evista 60mg)
Provide beneficial effects of estrogen
w/out potential ADRs
Estrogen agonist activity in bone with no
estrogen-like activity in the breasts or
uterus
Breast Cancer
65% over 8 years
MENOPAUSAL SX; hot flashes, leg
cramps, DVT (black box), swelling , flu-
like sx
Active thromboembolic dz & pregnancy
Bisphosphonates
Premenopausal women & treatment in
men
Steroid induced in men and women
Inhibit osteoclast activity, decrease bone
reabsorption= decreases bone loss,
increases bone density and reduces the
risk of spine, hip and other fractures
Alendronate (FOSAMAX)
Ibandronate (Boniva)
Risedronate (Actonel) & (Atelvia- NEW)


Once a week or once a month
It has a pH sensitive coating that allows it
to travel through the stomach and
release in the small intestine; can be
taken after breakfast instead of 30 min
before
Ibandronate (Boniva) 4x/year
Zoledronic Acid (Reclast) 1x/year
GI upset in PO (irritation esophagus &
esophageal CA)
Femur fractures

Osteonecrosis of the jaw (ONJ) is death
on bone cells or tissue in the jaw
95% cases are in CA pt. on
Bisphosphonates
Bisphosphonates inhibit bone turnover
needed for healing jaw injuries
Pt. should receive chlorohexidine
gluconate daily and before dental
procedures
Hx esophageal dz
Gastritis
PUD
Renal impairment
Cant sit upright for 30 min
First thing in morning w/ 8oz water
Sit up or stand for 30min after (Boniva is
60 min)
Dont eat or drink anything for 30 min
In fasting states
5 years
After 5 years take DEXA and assess
fracture risk every 2 ears
Restart if DEXA falls >8% in one year,
>10% in two or > 5% below pretreatment
leveles
Postmenopausal women who are at
least 5 years beyond menopause
Naturally occurring hormone in calcium
regulation and bone metabolism
Slows bone loss, increases bone density
in the spine and reduces risk of spine
fracture
Calcimar (SC/IM)
Miacalcin (intranasally)
Target population?
Post-menopausal women, men , bone pain
(osteoprosis and CA)
Contraindications?
Hypersensitivity to salmon protein
Side Effects?
Nausea, HA, nasal dryness, nasal and skin
irritation, allergy, face and hand flushing,
bloody nose
Postmenopausal women with
osteoporosis and high fracture risk or
intolerant to other osteoporosis therapy
(bisphosphonates)

MOA= human IgG2 monoclonal
antibody which inhibits RANK Ligand
(RANKL) an essential for osteoclast
activity

Dosage?
60mg q 6 mos w/ 1000mg Ca & 400 IU Vit D/
day
ADRs?
Back pain, musculoskeletal pain, extremity
pain, hypercholesterolemia, cystitis, ONJ, skin
reactions, infection
Is parathyroid hormone, A bone forming
anabolic med
Maximum of 2 years
MOA?
Rebuilds bone
ADRs?
Leg cramps & dizziness