Transcript How To Prescribe Pain Medications Without Killing People

How To Prescribe Pain
Medications Without Killing
People
Catherine Casey MD
Case #1
A 28yo F with MSK pain s/p MVA one
week ago is taking ibuprofen 800mg QID
and 4-6 oxycodone per day. She does
not feel tired, constipated, confused or
depressed on this regimen. She does
find that the medicine helps improve her
function, but that it wears off after 3
hours.
Convert her to OxyContin.
Case #2
A 45 yo M with chronic LBP with
sciatica has been taking 2 Vicodin
QID for the last eight months. They
help his back pain, but the sciatica is
still impeding his function.
Suggest a methadone regimen for
him.
Case #3
A 54 yo physician on Zanaflex has a
UTI. What are you going to
prescribe her?
Case #4
A 23 yo F on the inpatient service is
on a fentanyl drip at 100mcg/h. You
want to convert her to a patch. How
do you propose doing this?
Case #5
A 57yo F with NASH cirrhosis
sustains a compression fracture.
What can you give her, and what
should you avoid?
Pain Management Principles
By the mouth
By the clock
By the ladder
By the ladder…
Pain Management Principles
Add non-drug therapies
Differentiate nociceptive from
neuropathic pain
Strive for complimentarity
Opiate Principles
Titrate by percents rather than
milligrams
Convert short-acting to long-acting
Use equianalgesic doses, but
anticipate incomplete cross-tolerance
If you remember nothing else…
SEDATION PRECEDES RESPIRATORY
DEPRESSION
Start low and go slow in elderly, liver, and
kidney patients. Dose-adjust and use
longer intervals.
Reassess frequently
Don’t forget the bowel regimen
ACETAMINOPHEN – nociceptive
pain
The “starter drug” of choice, even in
folks with kidney or liver disease
Limit to 2g/d in liver disease, 4g/d in
healthy folks
Highest risk for hepatotoxicity –
alcoholics
NSAIDS – nociceptive pain (but not
neuropathic)
Ibuprofen has a NNT=2
Monitor kidney function. If Cr bumps,
check for AIN.
Use carefully or not at all in kidney or
liver disease.
NSAIDS – nociceptive pain (but not
neuropathic)
Use big, scheduled doses for a limited
amount of time
Consider adding a PPI or misoprostol,
esp in elderly – & NO indomethacin.
No aspirin in kids, teenagers,
pregnant or breastfeeding moms
TRAMADOL – nociceptive or
neuropathic pain, fibromyalgia
SEROTONIN SYNDROME
HAPPENS
Start 50mg Q6h
Can be addictive!
Avoid in liver disease, seizure hx
Max 50mg BID in kidney disease due
to prolonged elimination
OPIATES – nociceptive >
neuropathic pain
Codeine, Demerol, and Darvocet suck
Kidney pts: No Demerol or Darvocet.
Consult before using morphine.
Liver pts: No oxycodone, tramadol,
codeine. Fentanyl OK.
Fentanyl patches contraindicated in
pts < 110 lbs.
METHADONE – nociceptive &
neuropathic pain
Consult a specialist when converting
btw methadone & fentanyl.
Starting methadone in an opiatetolerant pt: 5 mg BID x 7 d, then 5 mg
TID. Opiate-naïve or elderly patient:
2.5mg QHS, then 2.5 mg BID after 7
d.
Titrate weekly. NOT A PRN MED!
MUSCLE RELAXANTS – muscle
spasm
CIPRO + TIZANIDINE = POTENTIALLY
FATAL DRUG INTERACTION
Baclofen – good for lancinating,
paroxysmal neuropathic pain.
Tizanidine (Zanaflex) - neuropathic pain &
fibromyalgia.
Avoid carisoprodol (Soma). Metabolizes to
a sedative. Very addictive.
BENZODIAZEPINES – muscle
spasm
BENZOS + OPIATES = INCREASED
RISK OF RESPIRATORY
DEPRESSION.
Avoid in liver disease. If you must,
use Ativan.
Taper slowly.
TRICYCLICS – neuropathic pain
Trazodone 10-25mg is great for sleep
in the elderly. Avoid amitriptyline in
old folks.
Check EKGs when titrating up either
tricyclics or methadone in someone
on both, attn: QT interval.
May take a few weeks to fully kick in.
ANTIEPILEPTICS – neuropathic
pain, postherpetic neuralgia
Sudden d/c of gabapentin (Neurontin)
can cause seizures.
Check electrolytes on topiramate
(Topamax).
No carbemazepine (Tegretol) in liver
disease.
TOPICALS – muscular or
neuropathic pain
Lidoderm patch or capsaicin for
periphereal neuropathic pain,
menthol-containing ointments for
MSK pain, compounded
ointments/gels containing NSAIDs,
TCAs, and AEDs also available.
ADJUVANTS
steroids, heat/ice, TENS,
acupuncture, massage, addressing
accompanying
depression/anxiety/insomnia
And finally…