a primer on pain medications howard p. levy, m.d., ph.d. assistant professor, johns hopkins...
TRANSCRIPT
A Primer on Pain Medications
Howard P. Levy, M.D., Ph.D.Assistant Professor,
Johns Hopkins UniversityJuly 21-22, 2011
Ehlers Danlos National Foundation2011 National Learning Conference
Baltimore, MD
Pain
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
“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
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
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
NSAIDsSide effects• Gastritis:
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
NSAIDsGeneric name Brand name Typical Adult Dosing
ibuprofen (OTC) Advil®, Motrin® 200-800 mg 4 times/day
ibuprofen (Rx) 600-800 mg 4 times/day
naproxen (OTC) Aleve® 220-440 mg 3 times/day
naproxen (Rx) 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
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 InhibitorSide 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
Cox-2 InhibitorGeneric name Brand name Typical Adult Dosing
celecoxib(Rx) Celebrex® 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
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 RelaxersGeneric 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
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
Antiseizure MedicationsGeneric 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
Tricyclic AntidepressantsGeneric 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
SNRI AntidepressantsSide 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 AntidepressantsGeneric 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
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• Itching, sweating• Constipation, nausea (worsens IBS)
“Mostly Dead”
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
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
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