Overview of Selected Pain Medications

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Overview of Selected Pain Medications

• Doug Carroll, PharmD, BCPS
• Clinical Associate Professor
• Harrison School of Pharmacy

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IV Medicationsfor Severe Pain
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Morphine

• GOLD STANDARD!!
• Advantages
• Sedating
• No analgesic ceiling
• Less expensive
• Nursing staff comfort

• Disadvantages
• Slower onset
• Histamine release
• Accumulation of metabolite

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Morphine

• Adverse Effects
• Pruritis
• N/V
• Constipation
• Respiratory depression

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Fentanyl

• Advantages
• More rapid onset
• NO active metabolites
• Renal and hepatic dsfxn
• Pregnancy
• Less sedating
• Very young
• Very old

• Disadvantages
• Shorter duration
• Expensive
• Potential for tachyphylaxis
• Nursing staff less familiar

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Fentanyl

• AEs same as with morphine
• Special note
• MINIMAL to NO EUPHORIA associated with its use
• Patients perceptions
• Lower potential for abuse
• POTENCY
• Ordered in micrograms

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Hydromorphone (Dilaudid)

• Advantages
• Onset b/w morphine and fentanyl
• Less sedating

• Disadvantages
• Most expensive
• HIGH POTENTIAL for ABUSE (but not as high as with
  the other D)
• AEs same as with morphine

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Ketorolac (Toradol)

• Good for musculoskeletal pain
• DO NOT use greater than 5 days
• DO NOT use in patients with RI, active bleeding,
  or an ASA/ NSAID allergy
• CAUTIOUSLY use in patients with hepatic dsfxn,
  thrombocytopenia, anticoagulants, and peptic
  ulcer disease

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DO NOT USE DEMEROL !!!!

• But why????????????????

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Why NOT use Meperidine (Demerol)?

• Active metabolite.normeperidine
• Metabolized in the liver
• Eliminated by the kidneys
• ½ analgesic potency of meperidine
• 2x the toxicity of meperidine
• Accumulates in patients with RI and elderly
• Toxicity manifests as SEIZURES, IRRITABILITY,
  TREMORS, MYOCLONUS, etc

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Why NOT use Meperidine (Demerol)?

• VERY EUPHORIC (especially if given with
  phenergan)
• Confusion of euphoria and analgesia
• Promotes Drug Seeking Behavior
• NO advantage over morphine or fentanyl

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What about Oddi?

• Current literature does NOT support the use of
  Demerol over Morphine
• No basis for myth that meperidine is preferred
  over morphine for pancreatitis
• Equianalgesic doses, meperidine raised common
  bile duct pressure more than morphine
• Morphine controls pain for a longer duration of
  time
• Repeated doses of meperidine lead to
  normeperidine accumulation

Arch Int Med November 1998158(21)2399.
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Morphine vs. Meperidine

• Meperidine or morphine in acute pancreatitis? Am
  Fam Physician Jul200164(2)219-20.
• Meperidine vs morphine in pancreatitis and
  cholecystitis. Arch Int Med Nov
  1998158(21)2399.
• Narcotic analgesic effects on the sphincter of
  Oddi. Am J Gastroent Apr200196(4)1266-72.

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PCA Order Basics
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Which agent to use?

• Morphine 1 mg/ml
• Fentanyl 10 mcg/ml
• Hydromorphone 0.2 mg/ml
• Meperidine

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PCA dose

• Morphine
• 0.02 mg/kg lbw
• 70 kg 1.4 mg
• Fentanyl
• 0.2 mcg/kg lbw
• 70 kg 14 mcg
• Dosing is for opioid naïve patients
• Decrease dose in elderly, debilitated, and obese

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Loading dose

• Used to achieve adequate level of analgesia when
  initiating PCA
• 2 times the calculated PCA dose
• PCA dose of 1.4 mg LD of 2.8 mg
• Repeat every 10 minutes as needed to a maximum of
  3 doses

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Lockout interval

• Minimum amount of time between PCA doses
• DO NOT shorten recommended intervals
• Morphine
• 8 minutes
• Fentanyl
• 6 minutes

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Continuous (basal) Infusion

• Opioid tolerant or high utilization patients
• Do not have to give CI for all patients
• 1/3 to 2/3 of hourly use determined over extended
  period
• 12 hours

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One Hour Maximum Dose

• Max amount of drug that PCA pump will deliver in
  1 hour
• Continuous infusion
• PCA doses
• Morphine 0.075 mg/kg lbw
• 70 kg 5.25 mg (round to whole number)
• Fentanyl 0.75 mcg/kg lbw
• 70 kg 52.5 mcg
• May have to remove limit for severe pain

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Methods to Adjust PCA

• Increase PCA dose by 25
• Consider adding a continuous infusion
• Divide average hourly use by 2 to estimate new
  PCA dose
• Dont provide PRN doses of opioids around the PCA

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Transition to Orals

• Give 2/3 of previous 24 hour morphine
  requirements as OxyContin
• Maintain PCA dose for prn use
• Oxycodone for breakthrough
• D/C continuous infusions

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Oral Therapies

• For Moderate to Severe Pain

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Morphine (CII)

• Brand name products
• Immediate Release
• Roxanol
• MSIR
• Controlled Release
• MS Contin
• Oramorph
• Others

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MS Contin

• DO NOT USE for ACUTE pain management!
• Should be used selectively for CHRONIC pain
  management.
• May need short acting agent for relief of break
  through pain.
• No maximum dose for morphine

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Oxycodone (CII)

• Brand name products
• Combination products with APAP
• Roxicet
• Percocet
• Tylox
• Controlled release
• Oxycontin

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Oxycodone

• No maximum dose for oxycodone alone
• Doses are limited with combination products due
  to the APAP

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Oxycontin

• DO NOT USE for ACUTE pain management!
• Should be selectively used for CHRONIC pain
  management!
• May need short acting agent for relief of
  breakthrough pain.

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Methadone (CII)

• NOT for ACUTE pain!
• Peak effects in 4 to 10 days, eliminated in 4 to
  10 days
• Doses do accumulate
• May need to decrease dose in 3 to 5 days to
  prevent toxicity
• Recognized for heroin addiction

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Fentanyl transdermal (CII)

• NOT for ACUTE pain!
• 24 hr for peak effect after initial application
  (will need to cover w/ short acting agent)
• Levels remain up to 18 hr after patch removal
• Absorption can be erratic
• May need short acting agent for breakthrough pain
• Rash may develop where patch is placed
• Inhaled steroids to application site???

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Fentanyl transdermal dose based on daily morphine
equivalence dose
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Fentanyl transdermal

• Each patch is worn 72hrs
• Do not adjust the dose more often than every 3
  days
• Doses greater than 100 mcg/hr.multiple patches
  will need to be used
• Application sites
• Chest, arms, abdomen
• Clean, minimal hair

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Oral Therapies

• For Mild to Moderate Pain

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Acetaminophen (Tylenol)

• Maximum daily dose 4g/d with less than 10d use
• Reduce the total daily dose for
• Elderly (2.4 to 3.2 g/d)
• Alcoholics (2.4 g/d)
• Debilitated patients (2.4 g/d)
• Renal failure patients (2.4 g/d)
• Contraindicated in hepatic disease

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NSAIDS

• Cautiously use in
• Renal insufficiency
• Hepatic dysfunction
• PUD
• Anticoagulants
• Thrombocytopenia
• Contraindicated
• Renal failure
• ASA/NSAID allergy

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NSAIDS

• Analgesia
• Ceiling effect
• Effects are evident in 1-2 hr
• Administration limited to 1-2 wks
• Rebound headaches
• Anti-inflammatory
• Effects are evident in days to weeks
• Peak in 2-3 wks
• If inadequate results, change to another NSAID

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COX IIs

• compared to generic NSAIDS
• (Celebrex)
• Recommended for use in patients
• Age 60
• Concurrent corticosteroid or anticoagulant tx
  (must check INRs regularly)
• Documented hx of GI bleed or PUD
• Post op with risk of significant bleed
• Heavy consumers of ETOH or cigarettes

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COX IIs

• Should not be used in patients
• Tolerant of NSAIDS
• Short term therapy (
• Treat HA or fever
• Renal failure or ASA/NSAID allergy
• Celebrex Sulfa allergy

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Other Issues.

• Cardiovascular risk
• Avoid use in patients with CAD history
• Dose and/or duration dependant???
• Traditional NSAIDs
• Diclofenac, indomethacin
• Low dose aspirin

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Hydrocodone (CIII)

• ONLY comes as COMBINATION products
• Lortab (APAP)
• Vicoprofen (ibuprofen)
• Loratab ASA (ASA)
• Doses are limited by the APAP, ibuprofen, and ASA
  components!

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Tramadol (Ultram)

• Also available combo with APAP (Ultracet)
• MOA
• NOT a CONTROLLED SUBSTANCE
• Potential for abuse
• AEs
• Hallucinations, seizures, etc

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Are there any oral agents

• available that shouldnt be used?

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YES!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
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And they are.

• Codeine (Tylenol 2,3 and 4)
• Weak analgesic
• AEs
• Nausea
• Vomiting
• Sedation

• Propoxyphene (Darvocet Wygesic)
• Minimal analgesic effects
• Induces tolerances
• Withdrawal seizures

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And they are..

• Toradol (po)
• Most ulceragenic potential of any NSAID

• Demerol (po)
• Same risks as with IV
• Same potential for abuse as IV
• Dilaudid (po)
• High potential for abuse

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Things to consider when using opioids

• Pruritis
• Benadryl 12.5-50 mg PO or IV (sedation)
• Narcan 0.5-1.0 mcg/kg/hr continuous infusion (max
  4 mcg/kg/hr)
• Nalmefene (Revex) 0.5 mcg/kg/dose q6-8 hr SC

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Other things to consider when using opioids

• Nausea/ Vomiting
• Phenergan
• Compazine
• Reglan
• Zofran

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Other things to consider when using opioids

• Constipation (adult doses)
• Docusate Sodium (Colace) 100-200mg BID
• Senna (Senekot) 2 tabs QD to 4 tabs BID
• Bisacodyl (Dulcolax) 5-15 mg
• Enemas

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Other things to consider when using opioids

• Sedation
• Transient, tolerance develops 1wk
• Change agents
• Respiratory depression
• Narcan
• 1-1.5 mcg/kg may repeat in 3 minutes
• Chronic pain patients and Narcan administration

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Conversion table for the Opioids
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Whew! Im glad hes done!
Me too!!