Levy primer on pain medications 2slides by Mark Martino

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A Primer on Pain Medications Howard P. Levy, M.D., Ph.D. Assistant Professor, Johns Hopkins University July 21-22, 2011 Ehlers Danlos National Foundation 2011 National Learning Conference Baltimore, MD

Pain

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Miracle Chocolate Pill

•  •  •  •

Brings you back from almost dead Take as needed Works fast No side effects

“You can’t always get want you want” -Mick Jagger, 1969

EDNF 2011 Conference

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“But if you try sometimes, you might find, you get what you need” -Mick Jagger, 1969

Pain Med Principles •  Easier to prevent than get rid of pain §  Scheduled, preventive medication more effective than as-needed •  Goal is to limit, not eliminate pain •  Cocktail of multiple medications §  Incremental benefits §  Synergies §  Maximize safer meds §  Minimize riskier meds

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Tylenol® (acetaminophen) •  Relatively weak by itself •  Can provide incremental pain reduction •  Augments other meds •  Regular standing dose, not just as

needed •  Very well tolerated, few side effects

Tylenol® (acetaminophen) •  OTC: 3 strengths §  Regular = 325 mg (3 tabs = 975 mg) §  Extra = 500 mg (2 tabs = 1000 mg) §  Arthritis = 650 mg (2 tabs = 1300 mg) •  Max safe dose 4000 mg/day §  975 mg or 1000 mg 4 times/day §  1300 mg 3 times/day

EDNF 2011 Conference

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Tylenol® (acetaminophen) I thought 2000 mg was the max? •  White lies: up to 4000 mg/day is safe •  Found in many OTC meds •  Accidental overdose is too common •  READ ALL LABELS §  acetaminophen §  APAP §  paracetamol §  “non-aspirin”

NSAIDs •  Non-Steroidal Anti-Inflammatory Drugs •  Reduce pain (incremental effect) •  Reduce inflammation •  Regular standing dose, not just as

needed

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Side effects •  Gastritis:

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NSAIDs

§  Take w/food and/or antacids

•  Bruising: Usually just cosmetic §  Rarely significant bleeding •  Blocks cardiac benefit of aspirin §  Wait 2 hours •  Heart attack, kidney disease §  Rare, mainly w/high dose & prolonged use

NSAIDs Generic name ibuprofen (OTC)

Brand name Advil®, Motrin®

ibuprofen (Rx) naproxen (OTC)

200-800 mg 4 times/day 600-800 mg 4 times/day

Aleve®

naproxen (Rx)

Typical Adult Dosing

220-440 mg 3 times/day 500 mg 3 times/day

meloxicam (Rx)

Mobic®

7.5 mg twice daily OR 15 mg once daily

nabumetone (Rx)

Relafen®

500 mg 3 times/day OR 750 mg twice daily

diclofenac (Rx)

Flector® Patch

1 patch twice daily

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Cox-2 Inhibitor •  CycloOXygenase 2 inhibitor §  More targeted than NSAIDs •  Reduce pain (incremental effect) •  Reduce inflammation •  Regular standing dose, not just as

needed

•  No stronger or weaker than NSAIDs •  Different side effect profile

Cox-2 Inhibitor

Side effects •  Gastritis: Less common than NSAIDs •  Bruising: Less common than NSAIDs •  Blocks cardiac benefit of aspirin §  Wait 2 hours

•  Heart attack §  More common than NSAIDs, but still rare §  Mainly w/high dose & prolonged use

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Cox-2 Inhibitor Generic name celecoxib(Rx)

Brand name Celebrex®

Typical Adult Dosing 100-200 mg 1-2 times/day

Topical Lidocaine (Lidoderm®) •  Anesthetic: local pain control •  Few side effects §  Local rash/skin irritation •  Up to 12 hours/day •  Up to 3 patches at a time •  Can cut patches

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Skeletal Muscle Relaxers •  Reduce spasm §  Less pain §  Possible ↑ laxity •  Sedation is most common side effect §  metaxolone may be least sedating •  Standing or as-needed dosing §  Especially bedtime

Skeletal Muscle Relaxers Generic name

Brand name

Typical Adult Dosing

metaxolone (Rx)

Skelaxin®

400-800 mg 1-3 times/day

cyclobenzaprine (Rx)

Flexeril®

5-10 mg 1-3 times/day

orphenadrine (Rx)

Norflex®

100 mg twice daily

baclofen (Rx)

Lioresal®

5-10 mg 1-3 times/day

carisoprodol (Rx)

Soma®

350 mg 3-4 times/day

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Neuropathic Pain •  Antiseizure medications •  Tricyclic (& tetracyclic) antidepressants •  SNRI antidepressants

Antiseizure Medications •  Suppress undesired nerve signaling •  Can prevent/reduce migraines •  Side effects §  Sedation §  Dizziness §  GI upset •  Gradual dose increase minimizes side

effects •  Regular standing dose

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Antiseizure Medications Generic name

Brand name

Typical Adult Dosing

gabapentin (Rx)

Neurontin®

300-1200 mg 3 times/day

pregabalin (Rx)

Lyrica®

25-100 mg 2-3 times/day

topiramate (Rx)

Topamax®

25-100 mg 1-2 times/day

lamotrigine (Rx)

Lamictal®

25-100 mg 1-2 times/day

Tricyclic Antidepressants •  Reduce nerve pain •  Can prevent/reduce migraines •  Helps treat stress, anxiety, depression •  Regular standing dose or as-needed •  Sedation is common §  Can help treat insomnia §  Take at bedtime •  Other side effects: §  constipation, dry mouth

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Tricyclic Antidepressants Generic name

Brand name

Typical Adult Dosing

trazodone (Rx)

Desyrel®

25-150 mg at bedtime

nortriptyline (Rx)

Pamelor®

25-100 mg at bedtime

amitriptyline (Rx)

Elavil®

10-75 mg at bedtime

• Listed in order of increasing likelihood of side effects • These doses are less than used for primary treatment of depression

SNRI Antidepressants •  Serotonin-Neurepinephrine Reuptake

Inhibitors •  Cousins of SSRIs

§  (e.g. fluoxetine/Prozac®)

•  Also treat stress, anxiety, depression §  Full antidepressant dosing •  May also help prevent migraines •  Regular standing dose

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SNRI Antidepressants Side Effects (most common) •  Increased appetite •  Sexual dysfunction •  May increase suicide risk, esp in teens Venlafaxine (Effexor®): •  Requires higher doses for pain benefit •  May ↑ blood pressure (good for NMH?) •  Only one currently available as generic

SNRI Antidepressants Generic name

Brand name

Typical Adult Dosing

venlafaxine (Rx)

Effexor XR®

150-225 mg daily

desvenlafaxine (Rx)

Pristiq®

50 mg daily

duloxetine (Rx)

Cymbalta®

30-90 mg daily

milnacipran (Rx)

Savella®

25-100 mg twice daily

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Opioids (narcotics) •  Most potent painkillers available •  Treat both myofascial & neuropathic •  Many risks & side effects •  Best to minimize use §  1st maximize cocktail of all other meds §  Add occasional opioids as-needed •  If daily doses required, switch to long-

acting form

§  Use short-acting version of same drug for

breakthrough pain

Opioids (narcotics) Side Effects •  Severe sedation •  Clouded thinking •  Disrupted sleep •  Urinary retention •  Dry mouth •  Dizziness “Mostly Dead” •  Itching, sweating •  Constipation, nausea (worsens IBS)

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Opioids (narcotics) •  Tramadol works the same way, with

fewer side effects & problems •  Available in combination with acetaminophen (Ultracet®) •  Caution when combining with TCA or SNRI antidepressants Generic name

Brand name

Typical Adult Dosing

tramadol(Rx)

Ultram®

50-100 mg 1-3 times/day

tramadol(Rx)

Ultram ER®

100-300 mg daily

Opioids (narcotics) •  If tramadol fails, switch to true opioid •  Short acting form as needed §  available in combination with acetaminophen •  Use long acting forms if taking daily §  Add short acting version of same drug as needed for breakthrough pain

EDNF 2011 Conference

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Opioids (narcotics) Generic

Short/Long

Typical Adult Dosing

oxycodone

short

5-15 mg 3-4 times daily

oxycodone

long-Oxycontin®

10-60 mg twice daily

morphine

short

10-30 mg 4-5 times daily

morphine

long-MS contin®

15-100+ mg twice daily

morphine

long-Avinza®, Kadian®

10-100+ mg once daily

fentanyl

short-Actiq®

0.2-0.6+ mg 4-5 times daily

fentanyl patch

long-Duragesic®

12-100 mcg/hr every 3 days

Opioids (narcotics) Other problems •  Stigma/suspicion of abuse •  Target of crime •  Written Rx only •  Narcotic bowel syndrome §  Pain stimulation exceeds pain reduction §  Especially abdominal, possibly other areas §  Hard to distinguish from IBS/other GI prob’s

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Opioids (narcotics) Addiction? •  Tolerance: need ↑ dose for same effect •  Dependency: withdrawal sx’s if stopped •  Addiction: §  take for reasons other than pain

(“I just feel better”) §  modify actions to get more drug

Summary •  Cocktail of multiple meds •  Incremental effects •  Maximize safer, less potent drugs •  Regular schedule to keep pain controlled •  Use opioids as last resort & try to limit

use to no more than a few years