Medication Pain

Management
Daniel Alves MD, MPH
Board CertifiedPain
Management
Diplomate, Academy of Physical
Medicine and Rehabilitation

Why Learn about

Medications

CDC Facts
Each day, 46 people die from an
overdose of prescription painkillers*
in the US.
Health care providers wrote 259
million prescriptions for painkillers in
2012, enough for every American
adult to have a bottle of pills.
10 of highest prescribing states for
painkillers are in the South.
CDC website

Pain Treatment Continum

Treatments
Nonpharmacalogical
EXERCISE
Pharmacological
Interventional
Psychological/Behav
ioral
Acupuncture

Mechanistic Approach to
Treatment
Brain
Descending
Inhibition
NE/5HT
Opiate
receptors

TCAs
SSRIs
SNRIs
Opiates
Tramadol

Peripheral
sensitizati
on

Central
sensitization
GBP;OXC

Na+
CBZ
OXC
PHT
TCA
TPM
LTG
Mexilletine
Lidocaine

Spinal Cord
Others

CA+
+
NMD
A

Capsacian
NSAIDS
COX-2 inhibitors
Levodopa

Ketamine, TPM
Dextromethorphan
Methadone

Beydoun A,

Pharmacological Treatments

NSAIDSMobic, Naproxen, Ibuprofen

Opioids
Muscle Relaxants
Antidepressants
Anticonvulsants
Sedative
Topical
Neuroleptics

NSAIDS
Which is the best?
No conclusions can be drawn as to which is
the best!

Is it effective for chronic pain?

Benefit is unclear
Recent studies show increased risk for stroke
or heart attack

What about Tylenol?

As effective as NSAIDS: considered first line
treatment.

Antidepressants &
Anticonvulsants
Useful Analgesics
Patients with burning and shooting
pain may respond to either TCAs or
ACs.
Prior to prescribing understand side
effects and necessary baseline lab
tests

Which of the following is true regarding the

use of antidepressants to reduce chronic
pain?

(A) Only tertiary amine tricyclics are

effective.
(B) Serotonergic agents are not clearly
superior to noradrenergic ones.
(C) Serotonin potentiation is a
necessary characteristic of effective
agents.
(D) Only noradrenergic agents are
effective.

Which Antidepressant
TCAs
SNRIs
SSRIs have not been shown to be
effective for pain.
Will help for depression.

Opioid Guidelines
Cancer pain
WHO three step
ladder

Acute pain
management
Chronic nonmalignant pain
Some variance

Decision to Continue
Opioids
1. Good therapeutic efficacy
a. Selected medication produces
complete or substantial analgesia
b. No rapid dose escalation
c. Improvement in functional activity

2. No evidence of substance abuse

3. Minimal or tolerable side effects

Reduced Response to
Opioids

Neuropathic pain
Incident Pain
Cognitive impairment
Psychological distress
Psychiatric comorbidities

Neuronal Plasticity Producing

Hyperalgesia following noxious
stimulation or Neuropathic Pain
Persistent noxious stimulus produces
central sensitization and reduced
responsiveness to opioids
Prolonged exposure of opiate receptor to
exogenous opioids produces tolerance
and central sensitization
Drug Holiday may result in resolution of
hyperalgesic state-may requre prolonged
(weeks to months) abstinence.

NMDA Receptor and

Hyperalgesia
Windup
Repetitive noxious stimulation evokes
increasing response in dorsal horn neurons
Mediated by repetitive, prolonged release of
excitatory amino acids from primary afferent
terminals and opening of the NMDA receptor
A series of intracellular events leads to
markedly increased responsiveness of spinal
cord neurons to subsequent noxious and nonnoxious stimulationProtein Kinase C is an
important mediator

Opioids
Recent movement towards adequate
treatment of pain
Site guidelines, avoid under treatment
of pain

Philisophical shift with use towards

non malignant conditions

Types of opioids
Weak opioids
Codeine
Tramadol
Mu-agonist,
norepinhperine and
sertonin reuptake
inhibitor.

Strong opioids
Hydrocodone
Morphine
Oxycodone
Tapentadol
Buprenorphine
Fentanyl
Meperidine
Hydromorphone

Opioid Medications
Derived from the
poppy seed
Acts on the mu
receptors
The term Narcotic is
a considered a legal
term, not medical
Mimics endogenous
agnoists
Enkephalins,
endorphins

Opioids Pros/Cons
Pros
Good pain relief
Plays nice with other
medications
Less issues with renal
dysfunction
Can be less dangerous
for elderly patients

Cons
Constipation
Sedation
Nausea
Pruritus
Cognitive dysfunction

Opioid side effects

Constipation, sedation, nausea,
euphoria, dysphoria, cough
supression, miosis, respriratory
depression
GI- can obtain nausea, emesis and
constipation secondary to CTZ
stimulation in the medulla.

Opioid Prescribing
Guidelines
Prescribe by the clock, not prn
Use long acting drugs
Methadone, SR Morphine, Levorphanol,
Oxycontin, Transdermal Fentanyl, Opana
(oxymorphone)

Provide extra or more efficacioius

medication for episodic pain
(pancreatitis, sickle cell)

Patient Monitoring
Before prescribing obtain Inform consent
and Pain contract
Duration and degree of pain relief
Changes in Function, activity and mood
Any side effects?
Did they take the medication as
prescribed
Consider long acting or another
opioid????

The 4 As

Analgesia
Activities of daily living
Adverse side effects
Aberrant drug-taking behaviors
Escalation of medications
Taking medications for symptoms other
than pain
Anxiety or sleep

Addiction
Persistent pattern of dysfunctional
opioid use involving:
Adverse consequences associated with
opioid use
Loss of control over opioid use
Continued opioid use despite harm
Preoccupation with obtaining opioids
despite adequate pain control-craving.

Dependency not equal to Addiction

Pseudoaddiction
Similar behavior as addiction
May actually have true pathology but
behave as if they have an addiction
Undermedicated analgesic
Progression of disease

Patient may use street drugs, etOH,

doctor shopping but behavior
subsides once pain is managed
Important to complete full exam

 A 35-year-old man who has a 10-year history of HIV

infection and intravenous drug use has recent onset
of burning pain and dysesthesias in both feet. Nerve
conduction studies show a primary sensory symmetric
peripheral neuropathy. Administration of which of the
following medications is the most appropriate initial
step in management?
(A) Dexamethasone
(B) Etanercept
(C) Methadone
(D) Pregabalin
(E) Tramadol

Which of the following receptors mediates

the windup phenomenon?
(A) 5-HT1D
(B) Mu-opioid
(C) Nicotinic
(D) N-methyl-D-aspartic acid (NMDA)
(E) Vanilloid

 Addiction is characterized by all of the

following except?
Clock watching, hoarding of opioid
analgesics, requesting extra pills for fear
of running out and demanding behavior.
Impaired control over drug use and
compulsive use.
Continued drug use despite harm.
Use of opioid effects other than pain relief.