UPDATE IN PAIN MEDICINE

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UPDATE IN PAIN MEDICINE

• RICHARD A. DuBOSE, M.D.
• DIRECTOR, IDAHO PAIN CENTER
• BOISE, IDAHO

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OXYCONTIN

• DEATHS w/ POLY ABUSE
• ER INCIDENCE 30 RX, 5 OPIATES
• ABUSE POTENTIAL LOW IF USED CORRECTLY
• COMPANY PROVIDES EDUCATION
• SPECIAL MARKINGS TO TELL WHERE MEDS COME FROM
• SMART PILL IN WORKS

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METHADONE

• VERY CHEAP (90 X 10MGS 17.49)
• ALPHA HALF LIFE 8 HOURS
• BETA HALF LIFE 30 HOURS
• NMDA RECEPTOR ANTAGONIST
• EQUIVALENT DOSING IV vs PO
• NO FIRST PASS EFFECT
• EQUIPOTENT WITH MORPHINE

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DURAGESIC

• 12-18 HOURS TO KICK IN
• 25, 50, 75, 100 UGS/HOUR
• ACTIQ NOW AVAIABLE FOR B/T
• MAY HAVE SOME ADDITIONAL EFFECTS IN NEUROPATHIC
  PAIN
• NOT EASILY DEVERTED
• GOOD FOR PATIENTS WITH GI PROBLEMS

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LOW-DOSE ANTAGONISTS

• NALTREXONE
• BUPRENORPHINE
• SLOWS TOLERANCE
• MAY HAVE EFFECTS AT VERY-LOW DOSES TO BLOCK PAIN
  RECEPTORS

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NMDA ANTAGONISTS

• NEURO-EXCITATORY CHEMICAL
• METHADONE
• KETAMINE
• TRAMADOL TO A MILD EXTENT

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ANTICONVULSANTS

• NEURONTIN
• TRILEPTAL
• TOPAMAX
• GABTRIL
• ZONEGRAN

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ULTRACET

• TRAMADOL 37.5 MG
• ULTRAM TO BE PHASED OUT
• TYLENOL 325
• MAY BE USEFUL
• MILD NMDA EFFECT
• REBOUNDING?

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ZANAFLEX

• TIZANADINE
• UNIQUE CENTRALLY ACTING MUSCLE RELAXANT
• SEDATING
• ALPHA AGONIST
• PAIN RELIEVING ABILITY
• CHECK LIVER FXN AT HIGH DOSES

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IDET PROCEDURE

• DISCOGENIC LOW BACK PAIN
• NOT GOOD FOR RADICULOPATHY
• MUST HAVE FAILED 3-6 MOS OF TX
• USUALLY GOOD FOR 1-2 LEVELS
• WHERE FUSION IS NOT INDICATED
• LONG RECOVERY
• PROVIDERS/INSURANCE ISSUES

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IDET
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INTRATHECAL PUMPS

• ORALS CAUSE TOO
• MANY SIDE AFFECTS
• WHERE NEUROPATHIC PAIN IS MAJOR COMPONENT
• EXCELLENT FOR SPASTICITY
• BEST FOR MALIGNANT PAIN

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CORD SPINAL STIMULATORS

• RSD
• CAUSALAGIA
• CLAUDICATION/VASCULAR DZ
• RADICULOPATHY
• FAILED BACK SYNDROME

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SCS
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SCS
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VERTEBROPLASTY

• FOR COMPRESSION FXS
• 1,000,000 PER YEAR
• 85 -90 EFFECTIVE
• METHYLMETHACRYLATE
• PAIN RELIEF IN 5-10 MINUTES
• RISK OF LEAKAGE OF CEMENT

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VERTEBROPLASTY
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BOTOX AND MYOBLOC

• TORTICOLLIS
• RECURRENT MUSCLE SPASMS
• HEADACHES
• HIGHER INCIDENCE OF ANTIBODIES WITH MYOBLOC
• QUITE EXPENSIVE

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DUPLICATE LAW

• CLASS IIIS MORE ABUSED
• LONG-ACTING LESS LIKELY TO BE ABUSED OR DIVERTED
• ATTEMPT TO AVOID REINFORCEMENT DUE TO ASSOCIATED
  DOPAMINE WITH QUICK RELEASE DRUGS
• IDAHO HAS CHANGED LAW

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OPEN DISCUSSION

• THANKS FOR COMING!