ACE Pain

define opioid tolerant and opioid naive

"Patients who are considered opioid-tolerant are those who have been taking, for a week or longer, at least 60 mg of morphine daily, or at least 30 mg of oral oxycodone daily, or at least 8 mg of hydromorphone daily, or an equianalgesic dose of another opioid." -this history must immediately priced the intended course of PCA therapy. If a wash-out period of a week or longer has occurred since the above dosages were taken, reconsider whether the patient truly meets this definition of tolerance. Definition of Naive: patients who do not meet the definition of opioid tolerant, who have not had narcotics doses at least as much those listed above for a week or more are considered to be naive.

Identify the RASS level of sedation for acute pain management

-1 or 1?????!!!

Things you should already know from IP7: Pain Management course notes (If you don't remember, please review) Know the brand/generic names of oral acetaminophen, ibuprofen, ketorolac, naproxen, hydromorphone, oxycodone SR and IR, morphine SR and IR, fentanyl patch, lidocaine patch, tramadol, methadone, and gabapentin.

Acetaminophen ibuprofen Oxycodone SR - Oxycontinoxycodone hydrochloride tablets (Roxicodone®, OxectaTM), liquid, solution; controlled release tablet (Oxycontin®); oxycodone hydrochloride and acetaminophen tablet (Percocet®, Endocet®, Roxicet®), solution (Roxicet®); capsule (Tylox®); (oxycodone/naltrexone) combination (Troxyca® ER); extended-release capsule (Xtampza® ER) Oxycodone IR - Roxicodone Morphine SR- MS Contin Morphine IR- Roxanol Fentanyl patch- Duragesic Lidocaine patch- lidoderm tramadol- Ultram tramadol tablet (Ultram®), extended release tablet (Ultram® ER, Ryzolt®), orally disintegrating tablet (Rybix® ODT), tramadol and acetaminophen (Ultracet®) methadone Dolophine; Methadone HCl Intensol; Methadose; Methadose Sugar-Free Gabapentin (Neurontin®, Gralise®)

Identify side effects and monitoring parameters of common medications used for acute pain management.

Acetaminophen- accumulation/Liver Tramadol Gabapentin fentanyl PAtch Lidocaine patch

Describe the mechanism of action for acetaminophen, NSAIDs, opioids, lidocaine, tramadol, and gabapentin.

Acetaminophen: Acetaminophen is a centrally acting analgesic and antipyretic with minimal anti-inflammatory properties. The mechanism of action of acetaminophen in reducing pain is unknown but may be due to an inhibition of central prostaglandin synthesis (specifically cyclooxygenase (COX)-2) and an elevation of the pain threshold. Acetaminophen reduces fever by inhibiting the formulation and release of prostaglandins in the CNS and by inhibition endogenous pyrogens at the hypothalamic thermoregulator center NSAIDS: inhibit pgs through COX-1 and 2 inhibition Opioids: opioids at mu opioid receptors. Activation of mu opioid receptors by an opioid agonist starts a cascade of intracellular steps, beginning with activation of Gi-proteins coupled to the opioid receptor Subsequent events include the following: • Inhibition of adenylate cyclase resulting in lower intracellular concentrations of cAMP; • Activation of outward potassium channels (net effect = hyper polarization); • Suppression of inward calcium currents; and • Inhibition of release of several different neurotransmitters.

Lidocaine MOA

Blocks both the initiation and conduction of nerve impulses by decreasing the neuronal membrane's permeability to sodium ions, which results in inhibition of depolarization with resultant blockade of conduction

Identify the bolus, lockout, and basal as it relates to PCA

Bolus (2 mg Morphine) (0.4 mg Hydromorphone) (20 mcg fentanyl) Lockout 10 minutes lockout Basal Not recommended for starting PCA

Transitioning to the medical floor

Breakthrough is 10-15% of scheduled dose, the dose of Oxycodone was too high * Promote multimodal - use least amount of opioids as possible * Liver function would be good to look at, patient is a drinker so doing q6h versus q4 for oxycodone/APAP is better. * Adding Ibuprofen for breakthrough is good for multimodal * Ketorolac IV, make sure to add stop date or duration

Identify first-line adjuvant therapy recommendations for the management of constipation, n/v, and itching

Constipation is less than 3 bowel movements per week Give: Senna or Senna plus Docusate N/V Give: Metoclopramide (Reglan) 10 mg IV q6 hours. May be advantages over others if poor GI motility is considered the cause of N/V Promethazine: 6.25 mg IV q6hrs PRN for nausea/vomiting Safety precautions: Dilute in 10 ml NS - assure IV patency before giving; give slowly; if patient complains of pain, stop!; use a large vein or preferably a central line if available; may repeat x1 if ineffective in 15 minutes Ondansetron (Zofran) 4 mg IV q12hrs PRN nausea/vomiting if no relief in 30-60 minutes following administration of metoclopramide Benedryl for itching

assessment of therapy

Examples Opioid naive going on fentanyl patch (safety, dose too high or route not correct Duplication (ketorolac and NSAID) Hydromorphone PCA and team order 500mg SR q12hrs (safety, dose too high) On morphine (missing med, need senna) Think about compliance (doses, less pill burden) Think cost

Compare Potency of Opioids

Fentanyl (most) hydromorphone oxycodone morphine hydrocodone (opioid)

CASE: Pain Management in a 44 y/o patient who is an IVDU and had a finger amputation

First dose * Look for Scr and LFT labs before choosing drug of choice * Ketorolac is used for mild to moderate pain. NSAID good for swelling and pain - fast onset and long duration * Oxycodone/APAP - longer onset of action * Avoid opiates with substance abuse history upfront, if he had tested positive for opiates he might have tolerance so they might not work as well. * Opiates not best option for acute setting and instant pain relief. * Ketorolac was best answer (amazingly effective NSAIDS, don't get high, but feel so much better, it almost works better than IV Fentanyl) * Cant use more than 5 days or 20 doses for ketorolac. Due to upper GI bleeding risk (prostaglandin inhibition which blocks protective effects of gut-systemic) and prerenal AKI * Upper GI bleed (older age >65) * Steroid use * Septic shock - high risk for kidney damage * Pt who already have reduced kidney function - use reduced dose * Ketamine was not a good option because it can be abused * (0.2 mg/kg good low dose) - pain relief but not dissociative anesthesia effect * If can tolerate PO, do PO * No fentanyl patch because patient is opiate naïve because the patch will cause respiratory depression and even when you remove the patch, it still has effects, very dangerous * But could use fentanyl IV

gabapentin MOA

Gabapentin is structurally related to the neurotransmitter GABA; however, gabapentin and its metabolites do not bind to GABA(A) or GABA(B) receptors or influence the degradation or uptake of GABA. The mechanism by which gabapentin exerts its analgesic and anticonvulsant effects is unknown high affinity gabapentin binding sites have been located throughout the brain; these sites correspond to the presence of voltage-gated calcium channels specifically possessing the alpha-2-delta-1 subunit. This channel appears to be located presynaptically, and may modulate the release of excitatory neurotransmitters which participate in epileptogenesis and nociception.

gabapentin

Gabapentin levels in epileptic patients: May be useful due to interindividual variation in pharmacokinetics and dose-dependent bioavailability; the reference range of serum gabapentin levels is 2 to 20 mg/L; samples for measurements should be drawn before the morning dose since the short half-life may affect the interpretation of concentration [24]. Epilepsy: Reduction in seizure frequency is indicative of a therapeutic response to gabapentin Postherpetic neuralgia: Relief of pain associated with postherpetic neuralgia is indicative of a therapeutic response to gabapentin Emergence or worsening of depression, suicidality, and/or any unusual behavioral or mood changes (ie, anxiety, agitation, hostility, mania, and hypomania) [6][5]

Define and describe a PCA

PCA is an interactive method of pain management that permits patients to manage their pain by self-administering doses of analgesics, usually opioids

identify medications used for acute pain management

PO Ibuprofen plus PO hydromorphone IV ketorolac plus epidural fentanyl and bupivacaine IV ketorolac plus lidocaine infiltration of surgical site plus IV PCA morphine Intraoperative anesthetic plus IV ketorolac plus postoperative fentanyl and bupivacaine epidural

monitoring for tramadol

Pain reduction, improvement in ability to move Evaluate maintenance of pain control: Continuously Hypotension: With therapy initiation and dose adjustments in patients with compromised ability to maintain blood pressure Increased seizure frequency or severity: In patients with a history of seizure disorder Signs and symptoms of respiratory depression: Within the first 24 to 72 hours of therapy initiation and after dose increases, especially in the elderly, cachectic, debilitated, and those with chronic pulmonary disease or with concomitant use of other drugs that cause respiratory depression Signs of sedation and respiratory depression: During therapy initiation in patients susceptible to intracranial effects of carbon dioxide retention (eg, preexisting intracranial pressure, brain tumors, or head injuries) Suicidal ideation or worsening depression [5][7]

identify side effects and monitoring parameters of PCA use

RR SpO2- especially for those who have sleep apnea, obesity, decrease ventrally capacity, over the age of 65 (late indicator) ETCO2 for hypercapnia

identify the symptom of opioid overdose that precedes respiratory depression

Sedation precedes respiratory depression as less opioid is required to produce it. monitor for sedation

*Describe the PDMP system

The Colorado Prescription Drug Monitoring Program (PDMP) is a powerful tool for prescribers and dispensers to help reduce prescription drug misuse, abuse and diversion: helping them to make more informed decisions when considering prescribing or dispensing a controlled substance to a patient.

define multi-modal analgesia

This approach involves the use of more than one method or modality of controlling pain (e.g., drugs from two or more classes, drug plus nondrug treatment) to obtain additive beneficial effects, reduce side effects, or both.

identify the three treatment goals and strategies for acute pain

Treatment goals and strategies for acute pain can be summarized as: ■ Early intervention, with prompt adjustments in the regimen for inadequately controlled pain ■ Reduction of pain to acceptable levels ■ Facilitation of recovery from underlying disease or injury.

identify common types of acute pain

acute illness- appendicitis, renal colic, MI

procedural

diagnostic and or therapeutic medical procedure Bone marrow biopsy endoscopy catheter circumcision chest tube placement immunization suturing

define the nine general principles that guide the treatment of pain

identify and treat the source of the pain select the simplest approach to pain management select an appropriate drug establish a management plan select a route of administration titrate the dose optimize the administration watch for and manage side effects differentiate among tolerance dependence and addiction and appropriately modify therapy avoid use of placebo to treat pain

posttraumatic (major trauma)

includes generalized motor vehicle accident

*Identify reversal agents for opioid overdose.

naloxone

perioperative (includes postoperative)

pain in a surgical patient because of preexisting disease, the surgical procedure -head and neck surgery -chest and chest wall surgery -abdominal surgery -orthopedic and vascular surgery

obstetrical

pain related to labor and delivery childbirth by any means folks

burns

pains due to thermal or chemical burns fire chemical exposure

tramadol MOA

ramadol and its active metabolite (M1) binds to μ-opiate receptors in the CNS causing inhibition of ascending pain pathways, altering the perception of and response to pain; also inhibits the reuptake of norepinephrine and serotonin, which are neurotransmitters involved in the descending inhibitory pain pathway responsible for pain relief

posttraumatic minor trauma

sprain, laceration