Alternatives to Opioids · ©2011 MFMER | slide-7 Lidocaine • Mechanism – blocks transmission...

Alternatives to Opioids

Susan R. Griffee M.D.

June 1st, 2018

©2011 MFMER | slide-2

Susan R. Griffee M.D.• Dual Board Certified- Pain and Physical

Medicine and Rehabilitation• Medical School- University of Arkansas• Residency- Mayo Clinic Rochester MN• ACGME Pain Medicine Fellowship- LSU• Advanced Spine Fellowship-Texas Spine and

Joint• 2016 Clearway/GCPI Provider of the Year

Disclosure

Relevant Financial Relationship(s)None


Learning Objectives

• Understand the neurological rational of non-opioid medication

• Explain a multidisciplinary approach to pain

• Explore selected “alternative” therapies for acute and chronic pain


Pain Pathway


Creams and Patches


Lidocaine

• Mechanism – blocks transmission of pain sensations at the skin level

• Available Strength - 5% for patch

• 2%, 4% and 5% in cream and gel form

• Uses – Neuropathic pain, musculoskeletal pain, soft tissue pain

• Cautions – Dosage important in pediatric patients

• Alternatives to cream – EMLA cream (mix of Lidocaine and Prilocaine) –causes both analgesia and anesthesia – can be used prior to starting IV.

• Alternative to patch – No true alternative – Flector patch may be a choice with different mechanism


Acetaminophen (Tylenol)

• Mechanism - decreases prostaglandins

• Available Strength - 325, 500, 625mg

• Liquid and suppository available

• Uses - arthritis, headaches, musculoskeletal pain, soft tissue pain

• Cautions - Liver Damage, Alcoholism

• Alternatives- cardiovascular or stomach problems with NSAID

• Tylenol plus NSAID similar to Tylenol plus Opioid


Non-Steroidal Anti-inflammatory (NSAIDS)


NSAIDS


NSAIDS• Bleeding due to platelet inhibition (COX 1 Blocking effect)

• Clotting resulting in cardiovascular risk and stroke(selective COX 2 Blocking effect)

• Inhibit bone healing – patients with recent ortho surgery

• Gastrointestinal irritation (inhibition of PG Synthesis)

• Increase in allergies and asthma


NSAIDS• Renal toxicity

• Liver toxicity

• Pregnancy – can cause birth defects when used in 1st trimester and fetal cardiac defects (early closure of PDA) when used in 3rd

trimester


Diclofenac• Mechanism: inhibition of COX – non selective

• Strength: 1%, 3% for cream, 1.3% as Flector Patch. Also in tablet form 25, 50 & 100mg

• Duration of action: 12 hours – BID dosing

• Uses: Musculoskeletal pain, acute injury (sports injury, MVA patients)

• Cautions: GI irritation, cardiovascular risk, bleeding due to platelet inhibition, renal toxicity, hepatotoxicity, bone healing


Ketorolac (Toradol)• Mechanism: inhibit synthesis of Prostaglandins

• Strength: 10 and 20mg oral doses, 15, 30 and 60mg for IM and IV use. Effect ceiling with 15mg IV/30mg IM Dose

• Duration of action: Starts within 30 min, peaks in 1-2 hours, lasts 6 hours

• Uses: Musculoskeletal pain, acute injury (post surgical pain)

• Cautions: GI irritation, cardiovascular risk, bleeding due to platelet inhibition, renal toxicity, hepatotoxicity, bone healing. Do not use in patients with liver or kidney diseases.


Celebrex• Mechanism: COX 2 Selective blocker

• Strength: 100mg, 200mg caps – Max of 400mg per day

• Duration: Peak levels 3 hours after administration, half life of 11 hours

• Cautions: Cardiovascular risk. Do not use in patients with heart disease.


Meloxicam• Mechanism: COX 2 Preferential blocker

• Strength: 7.5mg, 15mg Tabs

• Duration: 20 hour half life – once a day dosing

• Cautions: General NSAID cautions apply. Fewer GI symptoms compared to other NSAIDS. Does have higher cardiac risk than Naproxen, Ibuprofen, Celecoxib and Diclofenac


Naproxen

• Mechanism: Non selective COX Blocker

• Strength: 250 – 500mg Tabs

• Duration: 12 hour half life – BID dosing

• Cautions: General NSAID cautions apply. NSAID with least Cardiac Risk. Increases bleeding time, can cause neonatal jaundice if used in pregnancy


Muscle Relaxers


Cyclobenzaprine (Flexeril)

• Mechanism: Acts primarily in the brainstem, depresses reflexes in spinal dorsal horn

• Strength: available in 5 and 10mg Tablets

• Duration: onset in 1 hour, duration 12-24 hours

• Cautions: structural similarity to TCAs - Anticholinergic side effects – dry mouth, urinary retention, constipation, risk of hallucinations and confusion in older adults, arrythmias in patients with cardiac disease, risk of seizures due to serotonin syndrome in patients on Tramadol


Cyclobenzaprine (Flexeril)

• Mechanism: Acts primarily in the brainstem, depresses reflexes in spinal dorsal horn

• Strength: available in 5 and 10mg Tablets

• Duration: onset in 1 hour, duration 12-24 hours

• Cautions: structural similarity to TCAs - Anticholinergic side effects – dry mouth, urinary retention, constipation, risk of hallucinations and confusion in older adults, arrythmias in patients with cardiac disease, risk of seizures due to serotonin syndrome in patients on Tramadol


Tizantidine (Zanaflex)

• Mechanism: depresses presynaptic neurons at spinal and supraspinal levels, α-2 agonist

• Strength: available in 2 and 4mg tablets

• Duration: Variable duration of action, can take up to 2 weeks to act

• Cautions: Drowsiness, dry mouth, hypotension. Dose must be reduced in patients with Kidney diseases, can cause excess sedation with alcohol, OC Pill use can decrease clearance and increase sedating effects


Baclofen (Lioresal)• Mechanism: inhibits synaptic transmission along spinal cord.

• Mainly used in stiffness due to Multiple Sclerosis, Spinal cord injury


• Duration: Variable duration of action, can take up to 3-4 days to act

• Cautions: Drowsiness, hypotension, slurred speech, constipation, urinary retention, short term memory loss when used with antidepressants


Methocarbamol (Robaxin)

• Mechanism: centrally acting sedative


• Duration: acts in 30 min, duration 4 - 6 hours

• Cautions: Drowsiness, dizziness and blurred vision. Do not use with alcohol.


Anti-Convulsants


Gabapentin (Neurontin)• Mechanism: blocks calcium channels on peripheral nerve endings

• Used in a wide variety of conditions- neuropathic pain, Multiple Sclerosis, phantom limb pain, lumbar spinal stenosis

• Strength: available in 100 and 300mg tablets. Use 100mg dosing in patients with kidney disease.

• Gabapentin 600 TID + Nortryptiline 50QHS worked better for diabetic pain and shingles pain than either medication alone. Gabapentin might improve the analgesic efficacy of opioids.

• Duration: Can take up to 2 months to act

• Cautions: Dizziness, sedation, pedal edema, weight gain. Dementia association?


Topiramate (Topamax)

• Mechanism: Multiple mechanisms including calcium channel blockade and GABA receptor stimulation

• Used in a wide variety of conditions- Migraine prophylaxis, diabetic neuropathy, post herpetic neuralgia, CRPS

• Strength: Start at 50mg QHS, may increase to 200BID

• Duration: May take up to 2 weeks to effect

• Cautions: May cause sedation, kidney stones, glaucoma


Anti-Depressants


Duloxitine (Cymbalta)

• Mechanism: increases Serotonin and Norepinephrine levels in brain and spinal cord

• Used in a wide variety of conditions- diabetic neuropathy, arthritis, musculoskeletal pain, fibromyalgia

• Strength: Start at 30mg daily, may increase to 60 daily

• Duration: May take up to 2 weeks to effect

• Cautions: Nausea may be a side effect.


Amitriptyline (Elavil)

• Mechanism: wide range of mechanisms including serotonergic, noradrenergic, opioidergic, NMDA, Adenosine receptor, Na and Ca channel effects

• May be used in a wide range of pain conditions including PHN, PDN, spinal cord injury, fibromyalgia, post stroke pain, cancer related pain, HIV neuropathy

• 25-50mg PO QHS

• Cautions: anticholinergic effects – dry mouth, sedation, urinary retention, cardiac arrythmias


Serotonin Syndrome

• Can happen with SSRIs, SNRIs, MAOIs, TCAs, illicit drugs (methamphetamine, cocaine, Ecstacy, LSD), migraine drugs (triptans), pain medicine (Tramadol, Demerol, Oxycodone, Hydrocodone, Fentanyl)

• Symptoms: Agitation, confusion, muscle twitches and rigidity, diarrhea, dilated pupils, racing heart, high fever, seizures

• Libby Zion


Multi-Disciplinary Approach


Physical Therapy

• Education-Posture/body mechanics

example: sitting-Pathology-Sleep pattern


Physical Therapy

• Modalities- Iontophoresis- Ultrasound- Electrical Stimulation- Traction (decompression)


Physical Therapy

• Manual Therapy “Hands On”• Muscle Energy Techniques• Exercise regimen


Physical Therapy

• Include Diagnosis “Facet, Disc, Stenosis, SIJ”

• Pain Pattern; “Pain with Flexion”


Chiropractic Care

• Spinal Manipulation Therapy

• Soft Tissue Mobilization/Manipulation

• Graston and Cupping

• Class IV Laser Therapy

• Kinesiotaping

• Orthotics


Interventional Techniques


Injective Therapy

• Trigger Point Injections

• Radiofrequency

• Epidural

• Selective Nerve Root Blocks

• Radiofrequency Ablation


Spinal Cord Stimulation

• Advanced Technology that sends pulsed electrical signals to the spinal cord

A.B, 25 YOF Active Duty Navy injured in IRAQ

Suffered from low back and bilateral leg pain for greater than 2 years.

Failed conventional therapies.

She reported 70% pain relief and moved forward with a permanent implant.

She has returned to full duty.

Regenerative Medicine

•Prolotherapy•Platelet Rich Plasma (PRP)•Stem Cells

Prolotherapy• Injection of an irritant into a joint space, ligament, or

tendon• hyperosmolar dextrose, phenol-glycerine-glucose,

and morrhuate sodium• Studies show pain relief vs placebo

Platelet Rich Plasma

• Blood contains platelets- Contains growth factors to improve healing

• Draw blood, bedside centrifuge, inject platelets

Why we are debating Regenerative Techniques?

Will

Stem Cells

Change

Everything?

Stem Cells


Regulatory Issues of

Regenerative Medicine

• Non-FDA approved

• FDA “Minimal Manipulation” Standard for human cells, tissues, and cellular and tissuedbased


Alternative Therapies


Yoga Benefits

• Decreased Heart Rate/ Blood Pressure

(Jayasinghe 2004).

• Treatment Insomnia (Khalsa, 2004)

• Improved Sleep, Mood, Stress (Carlson, 2004)

• Improved VAS Pain Fibromyalgia (Da Silva,

2007: Carson 2010)


Yoga

• Yoga with Adrienne available on Youtube


Acupuncture


Cognitive and Behavioral Therapy

• Cognitive Coping Strategies

• Biofeedback

• Meditation/Relaxation Therapy

- iPhone App “Calm”


In Summary

#1 Discuss alternative medication therapy with risk/benefit analysis

#2 Develop a referral source for quality conservative treatment and modalities

#3 Offer “alternative” treatment options and resources


Questions?

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Alternatives to Opioids · ©2011 MFMER | slide-7 Lidocaine • Mechanism – blocks transmission...

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