Download A 35 Year-Old Woman with Spontaneous Iliac Artery Rupture

A Primer on Pain
Medications
Howard P. Levy, M.D., Ph.D.
Assistant Professor,
Johns Hopkins University
July 21-22, 2011
Ehlers Danlos National Foundation
2011 National Learning Conference
Baltimore, MD
Pain
Miracle Chocolate Pill
•
•
•
•
Brings you back from almost dead
Take as needed
Works fast
No side effects
“You can’t always get
want you want”
-Mick Jagger, 1969
“But if you try sometimes,
you might find,
you get what you need”
-Mick Jagger, 1969
Pain Med Principles
• Easier to prevent than get rid of pain
 Scheduled, preventive medication more
effective than as-needed
• Goal is to limit, not eliminate pain
• Cocktail of multiple medications
 Incremental benefits
 Synergies
 Maximize safer meds
 Minimize riskier meds
Tylenol® (acetaminophen)
• Relatively weak by itself
• Can provide incremental pain reduction
• Augments other meds
• Regular standing dose, not just as
needed
• Very well tolerated, few side effects
Tylenol® (acetaminophen)
• OTC: 3 strengths
 Regular = 325 mg (3 tabs = 975 mg)
 Extra = 500 mg (2 tabs = 1000 mg)
 Arthritis = 650 mg (2 tabs = 1300 mg)
• Max safe dose 4000 mg/day
 975 mg or 1000 mg 4 times/day
 1300 mg 3 times/day
Tylenol® (acetaminophen)
I thought 2000 mg was the max?
• White lies: up to 4000 mg/day is safe
• Found in many OTC meds
• Accidental overdose is too common
• READ ALL LABELS




acetaminophen
APAP
paracetamol
“non-aspirin”
NSAIDs
• Non-Steroidal Anti-Inflammatory Drugs
• Reduce pain (incremental effect)
• Reduce inflammation
• Regular standing dose, not just as
needed
NSAIDs
Side effects
• Gastritis:
 Take w/food and/or antacids
• Bruising: Usually just cosmetic
 Rarely significant bleeding
• Blocks cardiac benefit of aspirin
 Wait 2 hours
• Heart attack, kidney disease
 Rare, mainly w/high dose & prolonged use
NSAIDs
Generic name
ibuprofen (OTC)
Brand name
Advil®, Motrin®
ibuprofen (Rx)
naproxen (OTC)
Typical Adult Dosing
200-800 mg 4 times/day
600-800 mg 4 times/day
Aleve®
naproxen (Rx)
220-440 mg 3 times/day
500 mg 3 times/day
meloxicam (Rx)
Mobic®
7.5 mg twice daily OR
15 mg once daily
nabumetone (Rx)
Relafen®
500 mg 3 times/day OR
750 mg twice daily
diclofenac (Rx)
Flector® Patch
1 patch twice daily
Cox-2 Inhibitor
• CycloOXygenase 2 inhibitor
 More targeted than NSAIDs
• Reduce pain (incremental effect)
• Reduce inflammation
• Regular standing dose, not just as
needed
• No stronger or weaker than NSAIDs
• Different side effect profile
Cox-2 Inhibitor
Side effects
• Gastritis: Less common than NSAIDs
• Bruising: Less common than NSAIDs
• Blocks cardiac benefit of aspirin
 Wait 2 hours
• Heart attack
 More common than NSAIDs, but still rare
 Mainly w/high dose & prolonged use
Cox-2 Inhibitor
Generic name
celecoxib(Rx)
Brand name
Celebrex®
Typical Adult Dosing
100-200 mg 1-2 times/day
Topical Lidocaine
(Lidoderm®)
• Anesthetic: local pain control
• Few side effects
 Local rash/skin irritation
• Up to 12 hours/day
• Up to 3 patches at a time
• Can cut patches
Skeletal Muscle Relaxers
• Reduce spasm
 Less pain
 Possible  laxity
• Sedation is most common side effect
 metaxolone may be least sedating
• Standing or as-needed dosing
 Especially bedtime
Skeletal Muscle Relaxers
Generic name
Brand name
Typical Adult Dosing
metaxolone (Rx)
Skelaxin®
400-800 mg 1-3 times/day
cyclobenzaprine (Rx)
Flexeril®
5-10 mg 1-3 times/day
orphenadrine (Rx)
Norflex®
100 mg twice daily
baclofen (Rx)
Lioresal®
5-10 mg 1-3 times/day
carisoprodol (Rx)
Soma®
350 mg 3-4 times/day
Neuropathic Pain
• Antiseizure medications
• Tricyclic (& tetracyclic) antidepressants
• SNRI antidepressants
Antiseizure Medications
• Suppress undesired nerve signaling
• Can prevent/reduce migraines
• Side effects
 Sedation
 Dizziness
 GI upset
• Gradual dose increase minimizes side
effects
• Regular standing dose
Antiseizure Medications
Generic name
Brand name
Typical Adult Dosing
gabapentin (Rx)
Neurontin®
300-1200 mg 3 times/day
pregabalin (Rx)
Lyrica®
25-100 mg 2-3 times/day
topiramate (Rx)
Topamax®
25-100 mg 1-2 times/day
lamotrigine (Rx)
Lamictal®
25-100 mg 1-2 times/day
Tricyclic Antidepressants
• Reduce nerve pain
• Can prevent/reduce migraines
• Helps treat stress, anxiety, depression
• Regular standing dose or as-needed
• Sedation is common
 Can help treat insomnia
 Take at bedtime
• Other side effects:
 constipation, dry mouth
Tricyclic Antidepressants
Generic name
Brand name
Typical Adult Dosing
trazodone (Rx)
Desyrel®
25-150 mg at bedtime
nortriptyline (Rx)
Pamelor®
25-100 mg at bedtime
amitriptyline (Rx)
Elavil®
10-75 mg at bedtime
• Listed in order of increasing likelihood
of side effects
• These doses are less than used for
primary treatment of depression
SNRI Antidepressants
• Serotonin-Neurepinephrine Reuptake
Inhibitors
• Cousins of SSRIs
 (e.g. fluoxetine/Prozac®)
• Also treat stress, anxiety, depression
 Full antidepressant dosing
• May also help prevent migraines
• Regular standing dose
SNRI Antidepressants
Side Effects (most common)
• Increased appetite
• Sexual dysfunction
• May increase suicide risk, esp in teens
Venlafaxine (Effexor®):
• Requires higher doses for pain benefit
• May  blood pressure (good for NMH?)
• Only one currently available as generic
SNRI Antidepressants
Generic name
Brand name
Typical Adult Dosing
venlafaxine (Rx)
Effexor XR®
150-225 mg daily
desvenlafaxine (Rx)
Pristiq®
50 mg daily
duloxetine (Rx)
Cymbalta®
30-90 mg daily
milnacipran (Rx)
Savella®
25-100 mg twice daily
Opioids (narcotics)
• Most potent painkillers available
• Treat both myofascial & neuropathic
• Many risks & side effects
• Best to minimize use
 1st maximize cocktail of all other meds
 Add occasional opioids as-needed
• If daily doses required, switch to long-
acting form
 Use short-acting version of same drug for
breakthrough pain
Opioids (narcotics)
Side Effects
• Severe sedation
• Clouded thinking
• Disrupted sleep
• Urinary retention
• Dry mouth
• Dizziness
“Mostly Dead”
• Itching, sweating
• Constipation, nausea (worsens IBS)
Opioids (narcotics)
• Tramadol works the same way, with
fewer side effects & problems
• Available in combination with
acetaminophen (Ultracet®)
• Caution when combining with TCA or
SNRI antidepressants
Generic name
Brand name
Typical Adult Dosing
tramadol(Rx)
Ultram®
50-100 mg 1-3 times/day
tramadol(Rx)
Ultram ER®
100-300 mg daily
Opioids (narcotics)
• If tramadol fails, switch to true opioid
• Short acting form as needed
 available in combination with
acetaminophen
• Use long acting forms if taking daily
 Add short acting version of same drug as
needed for breakthrough pain
Opioids (narcotics)
Generic
Short/Long
Typical Adult Dosing
oxycodone
short
5-15 mg 3-4 times daily
oxycodone
long-Oxycontin®
10-60 mg twice daily
morphine
short
10-30 mg 4-5 times daily
morphine
long-MS contin®
15-100+ mg twice daily
morphine
long-Avinza®, Kadian®
10-100+ mg once daily
fentanyl
short-Actiq®
0.2-0.6+ mg 4-5 times daily
fentanyl patch
long-Duragesic®
12-100 mcg/hr every 3 days
Opioids (narcotics)
Other problems
• Stigma/suspicion of abuse
• Target of crime
• Written Rx only
• Narcotic bowel syndrome
 Pain stimulation exceeds pain reduction
 Especially abdominal, possibly other areas
 Hard to distinguish from IBS/other GI prob’s
Opioids (narcotics)
Addiction?
• Tolerance: need  dose for same effect
• Dependency: withdrawal sx’s if stopped
• Addiction:
 take for reasons other than pain
(“I just feel better”)
 modify actions to get more drug
Summary
• Cocktail of multiple meds
• Incremental effects
• Maximize safer, less potent drugs
• Regular schedule to keep pain controlled
• Use opioids as last resort & try to limit
use to no more than a few years