Multimodal anesthesia

Upper Chesapeake Medical Center Spine Conference

Friday July 7th, 2017

An unpleasant sensation occurring in varying degrees of severity as a consequence of injury, disease, or emotional disorder

pain

• Definition: an internal and personal phenomenon consisting of an unpleasant sensory and emotional experience. This experience is associated with actual or potential tissue damage or described in terms of such damage

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Visual analogue scale

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Endogenous morphineSecreted in response to pain, strenous exercise, orgasm or excitement

Opium poppy fruit latex from cut• Opium poppy fruit exuding latex from a cut

• BotanicalOpium

• Source plant(s) Papaver somniferum

• Part(s) of plant latex

• Geographic origin Indochina

• Active ingredients Morphine, Codeine

• Main producers Afghanistan (primary), Pakistan, Northern India, Thailand, Laos, Myanmar, Mexico, Colombia, Hungary

• Main consumers worldwide (#1: U.S.)

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opioids

1. Cortex: analgesia, euphoria, sedation, addiction

2. Hypothalamus/Pituatary: decrease testosterone

3. Brainstem: N/V, Mioisis, respiratory depression

4. SC: analgesia

5. GI: gastroparesis, decreased peristalsis

6. UG: increased tone ureter, detrussor, urinary sphincter

7. CVS: decreased peripheral resistance, decreased HR

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Friedrich Wilhelm Adam Sertürner 1804

• 1783-1841

• isolated morphine from opium in 1804 and sold it in 1817

• first person to isolate the active ingredient associated with a medicinal plant or herb

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MORPHEUS

• God of dreams

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Morpheus: greek godOf dreams

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Gold standardNatural substanceActs on CNSGastric emptying/peristalsisHeroin is a precursorMorphine/heroin most addictivePsychological and physical dependenceToleranceanalgesia, sedation, euphoria, physical dependence, and respiratory depressionPeak Levels: IV/SQ 20 min PO 30 minMetabolized in liverControlled substance Harrison Narcotic Tax Act of 1914

heroin• Diacetylmorphine discovered 1874 from morphine commercially

available in 1898 Bayer

• 1.5-2 times more potent than morphine

• Lipid soluble therefore crosses BBB faster more addictive

• Overtook morphine for choice drug of abuse once available

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oxycodone

• OxyContin is Purdue Pharma slow release oxycodone

• Opioid synthesized in Germany 1916 thought to replace Heroin/Morphine

• High risk of withdrawal

• Peak plasma level one hour, 10 min onset

• Excreted in urine/sweat watch for CRI

• 50% weaker than Morphine

• Abuse potential for snorting unlike Morphine and Heroin (must be injected)

• Less stigma involved than Heroine/morphine

• Street price $1 per mg

• Percocet: Endo pharmaceuticals

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MORPHINE WITHDRAWAL

I: 6-14 hours Drug craving, anxiety, irritability, perspiration, and mild to moderate dysphoriaII: 14-18 hours Yawning, heavy perspiration, mild depression lacrimation, crying, running nose, dysphoriaIII: 16-24 hours Rhinorrhea, dilated pupils, piloerection (gooseflesh), muscle twitches, hot flashes, cold flashes, aching bones and muscles, loss of appetite and the beginning of intestinal cramping.IV: 24-36 hours severe cramping and involuntary leg movements “kick the habit”, loose stool, insomnia, elevation of blood pressure, moderate elevation in body temperature, increase in frequency of breathing and tidal volume, tachycardia (elevated pulse), restlessness, nauseaV: 36-72 hours fetal position, vomiting, free and frequent liquid diarrhea

TOTAL 7-10 daysPSYCHOLOGICAL: severe depression, anxiety, insomnia, mood swings, amnesia (forgetfulness), low self-esteem, confusion, paranoia

A paradoxical response whereby the patient receiving opioids for the treatment of pain can become more sensitive to certain painful stimuli

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Cold pressor test: methadonePeople are sensitive

Opiate adverse effects postoperatively

ConstipationHyperalgesiaConfusionRespiratory depressionUrinary dysfunctionToleranceNauseaLight headedness

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Inflammation:

PainRednessSwellingheat

Side effectsspine

Non-unionPlatelet function

Neuromodulatingagents

Gabapentin: 1200 mg 1 hour preop?renal issues

Pregabalin: 150 mg 1 hour preop

Decreased opiate use, continue for one Week postop

600 mg optimal dose for gabapentin?

Neuroaxial blockade• Epidural/intrathecal

opioids

• Respiratory depression

• Direct steroidal application to inflamed root

4g /day

Fatty liver in obesity

200/500mg

options

• Celebrex 200mg

• Gabapentin/pregabalin

• Extended release oxycodone

• Acetaminophen

• Lidocaine

• Ketamine?

• Clonidine?

• Tramadol

• steroids

THANKS!

• Some pain can be experienced as a pleasant experience i.e. Dominatrix

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Hypodermic needle 1857

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Merck of Darmstadt, Germany 1827 commercial Morphine sold out of a single chemist’s shop

Alcohol tolerance

Controlled substances act 1970

• Schedules for “potential of abuse”

• I:high potential no accepted medical use: Heroin, Marijuana?, psychotropic mushrooms

• II: high potential for abuse but accepted for medical use: cocaine, ritalin, oxycodone, morphine, methadone, fentanyl, dilaudid, nucynta; no refills

• III: less potential: hydrocodone with another drug;5 refills

• IV: low potential: xanax, valium, ambien

• V: lower: lyrica, cough suppressant, lomotil

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3 Methyl Morphine or CodeineLess potent than morphine and less dependency issues and withdrawal symptoms1832 in France by Pierre RobiquetMost widely used opiate in the worldIn some countries it is available without prescription in combination preparations from

licensed pharmacists in doses up to 15 mg/tablet in Australia, New Zealand, Poland, Romania (Codamin), and Costa Rica, 12.8 mg/tablet in the UK, 10 mg/tablet in Russia and Israel and 8 mg/tablet in Canada and Estonia

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