A Primer on Pain Medications Howard P. Levy, M.D., Ph.D. Assistant Professor, Johns Hopkins...
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![Page 1: 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.](https://reader035.fdocuments.us/reader035/viewer/2022062321/56649dc65503460f94abaf39/html5/thumbnails/1.jpg)
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
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Pain
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Miracle Chocolate Pill
• Brings you back from almost dead
• Take as needed• Works fast• No side effects
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“You can’t always get want you want”
-Mick Jagger, 1969
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“But if you try sometimes, you might find,
you get what you need” -Mick Jagger, 1969
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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
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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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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”
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NSAIDs• Non-Steroidal Anti-Inflammatory Drugs• Reduce pain (incremental effect)• Reduce inflammation• Regular standing dose, not just as
needed
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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
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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
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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
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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
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Cox-2 InhibitorGeneric name Brand name Typical Adult Dosing
celecoxib(Rx) Celebrex® 100-200 mg 1-2 times/day
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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
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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
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Neuropathic Pain• Antiseizure medications• Tricyclic (& tetracyclic) antidepressants• SNRI antidepressants
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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 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
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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 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
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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 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
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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
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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
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Opioids (narcotics)Side Effects • Severe sedation• Clouded thinking• Disrupted sleep• Urinary retention• Dry mouth• Dizziness• Itching, sweating• Constipation, nausea (worsens IBS)
“Mostly Dead”
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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
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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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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
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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
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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