Levy primer on pain medications 2slides

EDNF 2011 Conference

8/2/11

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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EDNF 2011 Conference

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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

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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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EDNF 2011 Conference

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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

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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)

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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

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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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EDNF 2011 Conference

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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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EDNF 2011 Conference

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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

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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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EDNF 2011 Conference

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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

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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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EDNF 2011 Conference

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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

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