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Module 2: Part II
Part II:
A. Nonopioid medications for pain
management
B. Opioid medications
C. Management of analgesic side
effects
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ELNEC Attribution Statement
The End-of-Life Nursing Education Consortium (ELNEC)
Project is a national end-of-life educational program
administered by City of Hope National Medical Center
(COH) and the American Association of Colleges of
Nursing (AACN) designed to enhance palliative care in
nursing. The ELNEC Project was originally funded by a
grant from the Robert Wood Johnson Foundation with
additional support from other funding organizations
(Oncology Nursing, Aetna, Archstone, and California
HealthCare Foundations; National Cancer, and Open
Society Institutes). Materials are copyrighted by COH
and AACN and are used with permission.
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Part II A: Nonopioid Medications for
Pain Management
Objectives:
• Discuss types and uses of nonopioid
analgesics
• Describe cautions regarding use of
specific nonopioids in older adults
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Medication Management
Nonopioids
• Acetaminophen (APAP)
• Nonsteroidal anti-inflammatory drugs
(NSAIDs)
• Adjuvants/co-analgesics
• Antidepressants
• Anticonvulsants
• Topicals
• Misc
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Acetaminophen (APAP)
• For mild to moderate pain
• Best for nociceptive pain
• First line therapy particularly in the
frail elderly
• Mode of action not well understood
• Routine dosing up to 2000 – 3000
mg/day maximum in older adults
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Acetaminophen (APAP)
• Scheduled dosing works best for older
adults with constant or daily pain
• Avoid in hepatic compromise
• With renal disease, use
q 6 h dosing rather than q 4h
• Be aware of “hidden” doses of APAP
in combination products
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NSAIDs
• Indicated for pain from
acute inflammatory
process (such as gout),
bone metastases, or pain
refractory to opioids
• Effective for mild to
moderate pain
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Selective and Nonselective NSAIDs
• Examples of nonselective:
ibuprofen (eg, Advil®), naproxen
(eg, Naprosyn®, Aleve®)
• Examples of selective COX-2
inhibitors: Celebrex®
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Selective and Nonselective NSAIDs
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NSAIDs
• Use topical NSAIDs (e.g.
Flector®--new diclofenac patch)
• Use proton pump inhibitor or
nonacetylated NSAIDs (e.g.,
Trilisate®) to reduce GI effects
• Avoid chronic use
• Avoid COX-2 agents in residents
with active cardiovascular or
cerebrovascular disease; use the
nonselective agents cautiously
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Co-analgesics/Adjuvants
• Medications developed and
marketed for another medical
condition (e.g., depression) but
found also to be effective for pain
• Many co-analgesics target
neuropathic pain
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Anticonvulsants
• Act by reducing conduction of pain signals
along damaged nerves
®
• Gabapentin (Neurontin ) is commonly used
for burning, shooting pains
• Other anticonvulsants used for neuropathic
®
pain: Levetiracetam (Keppra ), Tiagibine
®
®
(Gabatril ), Lamotrigine (Lamictal ), and
®
the newest one Pregabalin (Lyrica )
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Anticonvulsants (cont.)
• All these agents can cause unclear
thinking, forgetfulness, and other CNS
side effects
• Slow initiation and taper up is essential
®
– for example, start Neurontin at 100
mg q hs and move up by 100 mg per day
in divided doses once a week
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Tricyclic Antidepressants (TCAs)
• Indicated in neuropathic pain
• Believed to work by blocking chemical
neurotransmitters for pain in the spinal
cord and the brain
• Significant anticholinergic effects
• Causes morning grogginess at higher doses
• Significant postural hypotension in elderly
• Patient education is important!
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Tricyclic Antidepressants (con’t)
• Desipramine and nortiptyline are preferred
over amitriptyline or doxepin in the older
adult because they have less severe
anticholinergic effects
• TCAs have significant interactions with
other drugs that can cause blood levels to be
much higher – if suspicious ask the
pharmacist to review the resident’s med list
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Newer Antidepressants
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Greater potency, fewer side effects
Not much data in older adults
Expensive
Particularly effective for residents with pain
and depression
®
• Examples: duloxetine (Cymbalta ) - FDA
approved for neuropathic pain; venlafaxine
®
(Effexor )
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Topical Agents
• Local action with minimal systemic side
effects
• Indicated for neuropathic pain but can be
effective in musculoskeletal pain as well
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Topical Agents: Lidocaine
• Lidocaine 5% patch, ointment
• FDA-approved for post-herpetic
neuralgia
• Clinical trials show effectiveness in other
neuropathic pain syndromes
• Effective adjuvant for osteoarthritis and
back pain
• Local side effects: redness, edema,
abnormal sensations at site
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Topical Agents: Capsaicin
• Active ingredient of hot chili peppers
• Clinical trials show effectiveness for
diabetic neuropathy, osteoarthritis, and
rheumatoid arthritis
• Common adverse effects: burning pain at
application site, sneezing and coughing
• Dosed q 6h, usually takes 2—4 weeks to
achieve therapeutic effect
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Other Adjuvants/Coanalgesics
May be effective in special cases
Use cautiously in older adults
• Corticosteroids, e.g., prednisone,
®
dexamethasone (Decadron )
• Muscle relaxants, e.g., baclofen
®
(Lioresal )
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Interventional Therapies
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Intra-articular steroid injections
Epidural steroid injections
Neurolytic blocks
Neuroablative procedures
Eisenberg, 1995; Furlan, 2001;
Wong et al, 2004
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Cancer Therapies to Relieve Pain
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Radiation
Surgery
Chemotherapy
Hormonal Therapy
Others
Doyle et al., 2001; Dunn et al., 2002;
Janjan et al., 2003; Jeremic, 2001
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Part II B: Opioid Medications
Objectives
• Describe the role of opioids in pain
management
• Discuss the advantages and
disadvantages of opioids
• Address barriers to opioid use
• Describe opioid options
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Key Opioid Issues
• Natural or synthetic drugs
with morphine-like actions;
activate opioid receptors
• Indicated for moderate to
severe pain
• Effective for pain regardless
of pathophysiology
• Safe for older adults when
carefully initiated & titrated
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Advantages of Opioids
• Many choices
• Can be delivered by all routes
• Immediate-release (IR) and
sustained-release (SR) formulations
• No end organ toxicity
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Addressing Barriers to Opioid Use
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Addiction
• Primary, chronic, neurobiologic disease, with
genetic, psychosocial, and environmental
factors influencing its development and
manifestations.
• Characterized by behaviors that include one
or more of the following: impaired control
over drug use, compulsive use, continued use
despite harm, and craving.
AAPM, 2001; APS, 2003; AMDA, 2003
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Tolerance
A state of adaptation in which
exposure to a drug induces changes
that result in a decrease in one or more
of the drug’s effects over time
AAPM, 2001
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Physical Dependence
A state of adaptation that is
manifested by a drug class specific
withdrawal syndrome that can be
produced by abrupt cessation, rapid
dose reduction, decreasing blood level
of the drug, and/or administration of
an antagonist
AAPM, 2001
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Side Effects
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Sedation
Nausea and vomiting
Constipation
Urinary retention
Confusion
Dysphoria, hallucinations
Myoclonus (rare, on low doses)
Respiratory depression (rare)
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Opioids
• Older adults already on daily opioids are
considered “opioid tolerant” - will require
higher or more frequent doses to obtain
relief
• Older adults requiring multiple doses of
SAO/day should have LAO
• Older adults with “predictable” pain should
have scheduled doses of SAO
• PRN not effective approach with cognitively
impaired
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Equianalgesic Dosing
• Methods for switching from one opioid
to another or administration routes
• Use of equianalgesic tables is necessary
but use the data cautiously
• Keep in mind the issue of “incomplete
cross-tolerance”
• Reduce by 30-50% when changing
drugs
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Opioid Choices:
The Long and the Short of It
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Short Acting Opioids
• Hydrocodone/APAP (e.g., Vicodin®,
Lortab®)
• Oxycodone/APAP (Percocet®)
• Oxycodone as a single agent (Roxicodone®)
• Morphine Sulfate (MSIR®, Roxal®)
• Hydromorphone (e.g., Dilaudid®)
• Tramadol (Ultram®)
• Oxymorphone (Opana®)
• Fentanyl transmucosal (Actiq®, Fentora®)
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Long Acting Opioids
• Morphine Sustained Release (MS Contin®,
Kadian®, Avinza®)
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Oxycodone Sustained Release (Oxycontin®)
Transdermal Fentanyl (Duragesic®)
Methadone
Tramadol (Ultram ER®)
Oxymorphone (Opana ER®)
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Low Dose Opioid Options
• Hydrocodone 2.5 mg / 325 mg APAP
– can be split to give a 1.25 mg dose
• Tramadol 37.5 mg / 325 mg APAP
– Can be split to give 18.75 mg dose
• Morphine 10 mg / 5 ml solution
– Can give 2 mg in one ml of solution
• Duragesic 12 mcg patch
• Kadian 20 mg per 24 hour dose
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Opioids to Avoid
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Codeine
Propoxyphene (Darvon®, Darvocet®)
Meperidine (Demerol®)
Mixed opioid receptor agonistantagonists:
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Buprenorphine (Buprenex®)
Butorphanol (Stadol®)
Nalbuphine (Nubain®)
Pentazocine (Talwin®)
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Myths Regarding Nebulized and
Sublingual Opioids
• Nebulized opioids provide no advantage
over other routes of administration for
dyspnea or pain
• Sublingual morphine – only 18%
absorbed through sublingual mucosa
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Buprenorphine
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51%
55%
34%
16%
Coluzzi, 1998; Coyne, 2003;
Dudgeon & Lertzman, 1998
Part II C: Management of
Analgesic Side Effects
Objective:
• Review the prevention, assessment,
and treatment of analgesic side
effects
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Analgesic Side Effects
• More common in older persons
• More common with hepatic or renal
insufficiency
• Commonly occurs:
– With initiation of a new analgesic
– Following an increase in analgesic dose
– When non-analgesic is introduced that
interacts with existing analgesic
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Side Effect Management:
General Approaches
• Decrease dose of analgesic
• Lower the dose and add an analgesic
from a different class
• Switch to different analgesic in the
same class
• Add a medication to treat side effect
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CNS Side Effects
• Drowsiness
• Respiratory
Depression
• Delirium
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Drowsiness
• Very common during initiation or up
titration
• Generally resolves within 72 hours
• Most sensitive indicator of too much
drug
• Mild drowsiness may not be
particularly bothersome
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Drowsiness
• For persistent,
bothersome drowsiness
– Down titrate the analgesic
– Switch to a different
analgesic or
– Start low dose caffeine,
methylphenidate, or
modafinil
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Opioid-induced Respiratory
Depression
• Very rare in opioid tolerant resident
• Higher risk in older adults and those with
pulmonary compromise and sleep apnea
• Clinically significant respiratory
depression does not occur in older adults
who are awake, so must combine
respiratory with sedation assessment
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Respiratory Depression
• RR < 8/min w/ marked sedation (sluggish
response to vigorous stimuli or unresponsive to
painful stimuli)
• Naloxone: after dilution (0.4 mg in 10 ml
saline)- Slowly administer 1.0 ml IV push,
repeat q 3 – 4 minutes until adequate LOC is
achieved
• Monitor resident q15 min for at least 2 h
• Naloxone duration of action (~ 1 h)  may
need to be repeated
WI Pain Patient Care Team, 2006
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Delirium
• Acute time limited episode most often
related to disease or drug effect
• Emphasis is on determining etiology; organ
system failure versus drug effect
• Most often requires drastic reduction or
discontinuation of suspected drug and reevaluation of symptoms
• May require treatment with antipsychotic
drugs or geropsych consult
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Opioid Side Effects
• GI Side Effects
– Nausea
– Constipation
– Dry Mouth
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Nausea
• Common side effect during initiation or up
titration of opioids; generally resolves within
72 hrs
• Persistent bothersome nausea may be treated
by decreasing the opioid, switching opioids, or
adding an antiemetic
• Treat severe analgesic-induced nausea with
antiemetic therapy; this situation will likely
require switching to a different agent
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Constipation
• Nearly universal side
effect of opioids and
other analgesics
• Does not go away
• Must be aggressively
treated prophylactically
• Assess for frequency,
quantity, and quality of
stool
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Constipation
• For decreased amount encourage
fruits, vegetables; avoid bulking
agents
• For hard stool add softeners and
emollients
• For decreased frequency of stools
add laxatives or motility stimulants
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Constipation
ALWAYS consider stool softeners and
laxatives when on opioids
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Dry Mouth
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Can be very bothersome
Access to water
Mouth swabs
Sucking on hard lemon drops or
other candy
• Artificial saliva
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Adjuvant Drug Side Effects
• Gabapentin
– Slowed thinking
– Feeling of “low” energy
– Drowsiness
• Start very low and titrate very
slowly
• Pregabalin (Lyrica®) - may have
fewer side effects & allow faster
titration
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Adjuvant Drug Side Effects
• Tricylic antidepressants
– Morning “hangover”
– Daytime drowsiness
– Postural hypotension
• Again, key is start low and go slow
• Despramine / nortriptyline preferred
• Switch to alternate agents (venlafaxine
or duloxetine) if side effects persist
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Summary
• Prevention and prompt treatment of
side effects is critical to ensuring
effective pain relief.
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