Analgesia: What are the Options

Analgesia: What are the Options?

Helen N. Turner, DNP, RN-BC, PCNS-BC, FAAN

Disclosure Honoraria: Cadence Pharmaceuticals

Speakers Bureau: Cadence Pharmaceuticals

Learning Objectives Describe appropriate classes of medications to be used in multimodal analgesia Describe five options of multimodal pain management Explain three goals of therapy when pain is viewed as a disease process

What does multimodal analgesia mean to you?

Multimodal

Relating to, having, or utilizing more than one mode or modality

Analgesia  Inability to feel pain  A deadening or absence of the sense of pain without loss of consciousness  Relief of pain  Painlessness

Analgesic Options Pharmacological—multimodal Nonpharmacological Integrative therapies Interventional Multimodal Treatment Plan

Multimodal Analgesia Rational combinations of analgesics with differing mechanisms and sites of action Incorporates pharmacological and nonpharmacological

Adjuvant Something that aids or assists; auxiliary

Substance that enhances the activity of another

Additive Substance added in small amounts to something else to improve, strengthen, or otherwise alter

Synergistic  Acting together

Potentiate

 One drug increases the effect of a second drug

Pharmacokinetics Biological process –Absorption –Distribution –Metabolism –Elimination

What the body does

Pharmacodynamics Effect of drug at site of action What the drug does

Variation in Medication Response Alteration in concentration reaching receptor Variation in concentration of endogenous receptor ligand Alterations in number of function of receptors Changes in components of response distal to receptor

Where Medications Work CENTRAL •Opioids •TCA/SSRI/SNRI •α 2 agonists •Acetaminophen

DESCENDING PERIPHERAL

•Local anesthetics •Na+ channel blockers •Anti-inflammatory agents

•Anticonvulsants •Opioids •TCA/SSRI/SNRI •α 2 agonists

Multimodal Analgesia

Intent is to –Optimize effectiveness –Reduce side effects –Minimize complications

Multimodal Analgesia May include: –NSAIDs –Acetaminophen –Opioids –Alpha 2, delta ligands –Antidepressants –Local anesthetics –NMDA receptor agonists –Alpha 2 adrenergic receptor agonists

Multimodal Analgesia

Polypharmacy

Pharmacological Non Steroidal Anti-Inflammatory agents –Nonselective (COX-1)—prevent formation of prostaglandin mediators that trigger inflammation –Selective (COX-2)—reduce inflammation at tissue site but not systemically like (COX-1)

Pharmacological Acetaminophen –Inhibits prostaglandin synthetase (central) –Some anti-inflammatory activity (peripheral)

Pharmacological Opioids –Mu agonists • Exogenous opioids selective for mu receptors • Mimic endogenous endorphins and enkephalins

–Partial agonists • Exogenous with mixed mu and kappa activity

– Antagonists • Bind with opioid receptors to displace the opioid

Pharmacological Anticonvulsants –Carbamazepine* –Lamotrigine* –Oxycarbazepine* –Topiramate** –Valproic acid** –Gabapentin*** –Pregabalin***

**

*Na Channel Blockers **Na channel blockers/increase GABA ***Ca channel binders reduce neurotransmitter release

Pharmacological Antidepressants –TCAs –SSRIs –SNRIs –Atypicals

Pharmacological Local Anesthetics –Bupivacaine –Levobupivacaine –Ropivacaine –Lidocaine –Prilocaine –Procaine

Pharmacological

NMDA Receptor Agonists –NMDA receptors play a role in transmission of pain signal and opioid tolerance

Pharmacological

Alpha 2 Adrenergic Receptor Agonists –Clonidine –Dexmedetomidine –Tizanidine

Pharmacological Goal is optimal pain control which is safe, effective, and responsibly prescribed

Nonpharmacological Physical & Occupational Therapies –Early mobility –Transcutaneous electric nerve stimulation (TENS) –Heat/cold –Ultrasound

Nonpharmacological Physical & Occupational Therapies –Reprogramming –Improved function –Reconditioning –Rehabilitation –Adaptive

Nonpharmacological Cognitive Behavioral Therapies –Behavioral training (operant conditioning) • Relaxation – Rhythmic breathing – Progressive muscle relaxation

• Biofeedback

–Cognitive training (psycho-education) –Respondent therapies • Hypnosis • Visualization/Guided Imagery/Virtual Reality • Distraction—active or passive

Integrative Therapies Complementary medicine: together with conventional therapies Alternative medicine: in place of conventional therapies Integrative combines –Conventional –Complementary –Alternative

Integrative Therapies Mind-body therapies –Humor, Imagery, Meditation, Prayer, Yoga Biological –Herbs, Vitamins, Nutritional Supplements Manipulative/Body based –Acupuncture, Chiropractic, Massage Energy –Healing Touch, Therapeutic Touch, Reiki, Magnets

Nonpharmacological & Integrative Therapies

 Goal is to utilize and optimize the power of the mind-body connection

http://agaroli.files.wordpress.com/2010/01/human-energy-field2.jpg

Interventional Regional anesthesia/analgesia Peripheral nerve blocks/infusions Percutaneous infusions Trigger point injections

Interventional Joint injections Spinal cord stimulation Neuroablative techniques Surgery

Interventional

Goal is targeted pain control

Cognitive Behavioral Therapies Pharmacological Therapies

PAIN

Integrative Therapies Interventional Therapies

Physical & Occupational Therapies

Goals of Multimodal Analgesia Target pain in the CNS and PNS Restore or optimize function Prevent development of chronic pain Improve overall outcomes

“The management of pain is a cornerstone of the compassionate practice of medicine. The knowledge exists to ameliorate pain in most of our patients. We now require the will to do so�

Schecter, Berde, & Yaster (2003)

Discussion

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