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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