Narcotic Analgesics Jacqueline Morgan March 22, 2017
Pain Unpleasant sensory and emotional experience with actual or potential tissue damage Universal, complex, subjective experience Number one reason people take medication Generally is related to some type of tissue damage and serves as a warning signal
Pain Nociception- signal generated by afferent nervous system in response to tissue damage Pain perception of nociception. Potentially due to tissue damage, neuropathic pain or psychologic disturbance uffering- distress or unpleasant experience, to which pain, loss of function, other symptoms may all contribute
Pain cale
Pain cale #2
cope of the Problem Increasing problem 25 million people suffer acute pain related to surgery or injury Is a multibillion dollar industry Much ignorance exists about pain and analgesics Narcotic Epidemic
Cancer Pain Up to 50% of all cancer patients report moderate to severe pain 75%-90% of advanced stage patients report mod to severe pain
Cancer Pain Due directly to Tumor Infiltration into tissues/viscera Compression or infiltration of nerves Organ obstruction Due to treatment/procedures urgery Chemotherapy Radiation Interventions, biopsies Indirectly from malignancy Inflammation DVT Lymphedema Pain from comorbid conditions Diabetes, arthritis
Assessing Pain OCRATE ite Onset Character Radiation Associated ymptoms Timing Exacerbating or Relieving Factors everity
Pathophysiological Response Tissue damage activates free nerve endings (nociceptors) of peripheral nerves Pain signal is transmitted to the spinal cord, hypothalamus, and cerebral cortex Pain is transmitted to spinal cord by A-delta fibers and C fibers
Pain Pathways
Pathophysiological Response A-delta fibers transmit fast, sharp, well-localized pain signals C fibers conduct the pain signal slowly and produce poorly localized, dull, or burning type of pain Thalamus is the relay station for incoming stimuli, incl. pain
Inhibitory and Facilitatory Mechanisms Neurotransmitters chemicals that exert inhibitory or excitatory activity at post-synaptic nerve cell membranes. Examples include: acetylcholine, norepinehprine, epinephrine, dopamin, and serotonin. Neuromodulators endogenous opiates. Hormones in brain. Alpha endorphins, beta endorphins and enkephalins. Help to relieve pain.
Gate Control Theory
tepwise Pain Management Non medication Non Opioid Analgesic Adjuvant medication Oral immediate release opioid Long acting opioid Non oral Opioid Interventional Procedures
tepwise Pain Management
Non Medication Education/Information Mind body techniques Heat, Ice Accupuncture Massage
Non Opioid Analgesics Acetaminophen NAIDs COX2 Inhibitors
Adjuvant Medications Nerve agents Anticonvulsants- Gabapentin Antidepressants- Amitryptiline Corticosteroids Topical lidocaine
Opioid Receptors Opioid receptors binding sites not only for endogenous opiates but also for opioid analgesics to relieve pain. everal types of receptors: Mu, Kappa, Delta, Epsilon.
Opioid Receptors Location: CN incl. brainstem, limbic system, dorsal horn of spinal cord Mu primarily used for analgesic action
Narcotic Analgesics Relieve moderate to severe pain by inhibiting release of ubstance P in central and peripheral nerves; reducing the perception of pain sensation in brain, producting sedation and decreasing emotional upsets associated with pain
Mixed agonist/antagonist Potential role in opioid naïve patients Ceiling dose for analgesic effect Potential for inducing withdrawl in those taking chronic opioids Limited role in chronic pain
Narcotics- Route PO IV IM L Transdermal Q
Oral Agents afe cheap accessible Wide range of dosing available Easy to adjust Outpatient option Variable absorbtion Intact swallowing/digestion required Codeine, hydrocodone, oxycodone, morphine, hydromorphone
Oral Narcotics Patient responses and tolerances can vary widely to each agent One agent may truly work better for an individual patient Combination agents may limited total daily dose or frequency of dosing Avoid poly narcotic pharmacy Dose equivalency charts are a guide only
Opioid conversion
Post op Narcotics tart oral agents as soon as possible PCA with better patient satisfaction than intermittent IV analgesics Best suited to short acting oral narcotics Combination meds may reduce number of pills/medications if narcotic naive hort duration and decreasing need over time anticipated
Post op Narcotics 57yo, post laparotomy and tumor reductive surgery aka the big whack, day 4. Taking Oxycodone 5mg, 2 tabs every 3 hours. Along with tylenol 1000mg q 6hr and Ibuprofen 800mg TID. Discharged to home in Liberal on Thursday with script for Oxycodone 5mg i-ii PO q 3 hrly, #30 How many days before both patient and office staff are really angry with you??
Chronic Pain Narcotics Opioid only formulations preferred Agonist only agents Moderate pain- short acting as needed evere pain- long acting narcotics, non oral formulations Breakthrough medication
Chronic Narcotics Can take 4 half lives to reach steady state Avoid rapid dose escalation with long acting agents Continued pain typically treated with dose escalation rather than rapid drug changes
IM Acute severe pain No IV access One time or infrequent use anticipated
IV Rapid onset hortest acting Hospital/medical setting required Can be used for PCA or basal infusion
ublingual If N/V or unable to swallow Bad taste Good bioavailability
ub Q Palliative administration Constant infusion If oral route not available or unpredictable
Transdermal Fentanyl patch 72hr dosing Costly Difficult to manage high doses
Breakthrough Meds 10-15% of daily narcotic requirement available on as needed basis, q 2 hourly Oral or L most commonly used. Use amount of breakthrough medication required to guide adjustment in long acting agent.
Narcotic Rotation In chronic pain, if decreasing effectiveness to regimen develops Change agents, due to different receptor affinity and down regulation, may provide better analgesia without needing to increase doses.
Narcotic Tolerance Need to escalate dose to maintain effects Typically in oncology patients, increasing requirements is indication of progressive lesion or nociceptor stimulation
Narcotic Dependance When abrupt withdrawl or narcotic antagonist administration induces physical symptoms of abstinence syndrome.
Narcotic Addiction The psychological and behavioral syndrome with loss of control over drug use, compulsive use and continued use despite causing harm to self and others Fear of addiction should not limit narcotic use for cancer related pain.
Narcotic ide Effects GI Neurologic Respiratory
GI Constipation No tolerance develops tool softeners, stimulant laxative, osmotic agents Avoid bulking agents Prevention, prevention, prevention. Peripherally acting opioid antagonists Nausea Usually improves with time Antiemetics as needed
Neurologic edation, confusion Tolerance seen If pain controlled- try dose reduction If pain not controlled, sedation may be acceptable
Respiratory Respiratory depression Opioid antagonist for reversal in acute setting Will induce withdrawl symptoms hould not limit narcotic use in palliative setting Relief of air hungry Cough suppressant
Questions or Discussion