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Opioids: Part2

Amelie Hollier, DNP, FNP-BC, FAANPAdvanced Practice Education Associates

PatientAssessmentandMonitoring

PatientAssessmentandMonitoring

1. What screeningshould takeplace?2. Patient-Provider Agreement3. UrineDrugScreen4. AdverseEffects:Nuisance5. AdverseEffects:Serious

CommonAdverseEffects:Nuisance

• Sedation:goesawayovertime• Constipation:doesnotgoawayovertime!

Constipation• Opioidsslowdownmotilityinthegut• Constipationisacommonsideeffect• OIC:Opioidinducedconstipation

OIC

www.practicalpainmanagement.com

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ApproachtoManagementofOpioidInducedConstipation

• Consider abowel regimen when opioid isinitiated

• Lifestyle changes: fluids, fiber,prunes,physical activity

• Consider osmotic laxative(polyethyeneglycol) (Miralax)

• Cheap, well tolerated, safelong-term and itworks!

Prescriber’s Letter:June2015;Vol:22

Opioid InducedConstipation: PlanB

• Consider astimulant laxative(bisacodyl)• Noproof thatthis produceslaxativedependence

Prescriber’s Letter:June2015;Vol:22

OpioidInducedConstipation:PlanC

• Consider anopioidantagonist:Mechanismof Action:Inhibitopioidbindinginthegut

• Donotinhibitanalgesia

OpioidInducedConstipation:PlanC

• Consider anopioidantagonist:Naloxegol (Movantik), methylnaltrexone(Relistor)

Prescriber’s Letter:June2015;Vol:22

WhyareOpioidAntagonistsPlanC?

• Expensive!• Naloxegol ($10/day)• Methylnaltrexone($72/day)byinjection• STOPlaxatives!

Prescriber’s Letter:June2015;Vol:22

OpioidInducedConstipationWHATDOESNOTWORK!

• Stoolsoftenersdon’tproducemotility• “Allmushandnopush”!J

Prescriber’s Letter:June2015;Vol:22

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OtherCommonAdverseEffects

• Itching• Edemaandsweating• Dizziness• Confusion

“Other”TypesofReactionsarePrettyCommon

Pseudoallergic Reactions• Don’tbefooledbythename!!!!!• Range frommildtofatal• Uncertain howthesereactions occur• Probablymast celldegranulation byanon-IgE mediatedmechanism

• Don’tworsenwith repeated exposure

Example1:OpiatesPseudoallergic Reactions

• Opiateanalgesics:Morphineandcodeinecausedirectmastcellactivation

Common CulpritsPseudoallergic Reactions• Radiocontrast medium• Opiates• NSAIDs• Muscle relaxants (atracurium, vecuronium,succinylcholine, curare)

• Chemo agents• Vancomycin: “Redman” syndrome

HowtomanageAdverseEffects

• Treatwithanother drug: drugcascade• Rotateopioids• Dialdown thedoseofopioid

www.medicalnewstoday.com

AdverseEffects:Serious• Respiratorydepression• Death

Umanitoba.com

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RiskFactors forRespiratoryDepression

1.Initialdose istoohigh!üStartlow andgoslow!

2.Mustknowwhetheryourpatientisopioidnaïveoropioidtolerant

üDonot prescribe aLAorERopioid toapatient who isopioid naïve….you’llprobably kill them!

RiskFactorsforRespiratoryDepression

• Opioid plusbenzodiazepine• Opioid plusEtOH• Opioid plusbenzo plus EtOH (mostlethalcombo)

• Opioid plusdiphenhydramine• Opioid plus“Z-drugs”

PatientScenario• Patientnotfeelingwellduring coughand coldseason. Goestobedearlyandtakes prescribedmedsplus Benadryl:

• LAopioid• SAopioid• Trazodone• Benadryl

OtherRiskFactors forRespiratoryDepression

• Sleepapnea patient• COPD/Asthma patient• Smoking: producessomedegreeofrespiratory impairment

• Heartfailure patient• Obesity• Others?

AvoidanceofRespiratoryDepression

• PatientEducation• FamilyEducation• Informedproviders• Nalaxone (Narcan)Autoinjector

It’sallabout patientsafety!

ChronicPainThenext5slidesarenotinyourhandout

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QuizWhat substance isresponsible forarunner’s “high” (ifyou believethatitexists)?

Answer• Endorphins: “natural opiates”• Feeling ofbeingrelaxed,atpeace,produces amood change,euphoria

• Common afteranendurance event

HowdoOpioidsWork?• Morphine• Codeine• Hydrocodone• Others

3 Opioid(Endorphine)Receptors• Mu (μ1andμ2)• Kappa (modest anesthesia effect; little ornorespiratorydepression ordependence)

• Delta (don’t knowwhat itdoes)

3 Opioid(Endorphine)Receptors

• Mu(μ1andμ2)Mu1islocated outside spinal cord;responsible forpain interpretationMu2islocated throughout CNS

• Kappa (K1,K2,K3) modest anesthesia effect;little orno respiratorydepression ordependence)

• Delta (1,2)might help regulatemuactivity)

ActivationofReceptorSitesResponse Mu1 Mu2 kappaAnalgesia ✔ ✔ ✔

modestRespiratoryDepression

✔

Euphoria ✔

Dysphoria ✔

Constipation ✔

Dependence ✔

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NoNewDrugsOlddrugs innewdelivery systems• Morphine• Methadone• Hydrocodone• Oxymorphone• Oxycodone• Buprenorphine• Fentanyl• Hydromorphone• Tapentadol

USpharmacist.com

NoNewDrugs• Olddrugsinnewdeliverysystems• Allscheduleddrugs• Highpotentialforabuse• Diversiondoesoccur

ER/LA OpioidsWhoareCandidates?

• Non-opioid analgesics orimmediatereleaseopioids areineffective,nottolerated

• Nota PRNanalgesic• Notformildpain• Notfor acutepain

NonCancer-RelatedPain• Periodicallyreassesstheneedforcontinuedopioids• ***Documenttheneedforcontinueduseofopioids

DrugDrugInteractions(DDIs)

• 5ormoredrugsincreasethe riskofDDI• Pharmacodynamic (PD)Interactions• Pharmacokinetic (PK) Interactions: Effectabsorption, metabolism, distribution,excretion

• Theseinteractions could increase ordecreaseeffect ofdrug

CNSDepressantsPlusOpioids• Sedatives: EtOH• Hypnotics: Pot• TCAs: phenothiazines (thorazine, prolixin,compazine)

• RespiratoryDepression• Hypotension• Sedation• Coma

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Alcohol plusOpioid• Magnifies the effectofthe opioid• “Dose Dump”: EtOHimpairs the deliverysystemofthelong acting opioid

• Example:Palodone plus EtOH:markedincrease releaseofopioid….now pulled offthemarket

Alcohol plusOpioid• All newopioid delivery systemsmustbestudied foreffect with alcohol (“dosedump”)

• Teachpatient: NOEtOHwith opioids!!!

SkeletalMuscleRelaxantsPlusOpioids

• Increaseriskofrespiratorydepression• Enhance neuromuscular blocking action

blog.ng.jovago.com

MAOPlusOpioids• Mayprecipitateserotoninsyndrome• Agitation,coma,death• Manybizarresymptomsassociatedwithserotoninsyndrome• Examples:selegiline transdermal(Emsam),isocarboxazid (Marplan),phenelzine (Nardil),tranylcypromine(Parnate)

(Mostlyused forDepression,but someareusedforbulimia)

Anticholinergics PlusOpioids

• Effectmagnifiedbyopioids• Urinaryretention• Constipation

AnticholinergicMedicationsAnti-cholinergicSideEffectsMemory impairment,confusion,hallucinations, drymouth,blurredvision, urinary retention,constipation,tachycardia, acuteangle glaucoma

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“AnOdetoanAnticholinergic Med”

Oh thisdrug,itmakesmepink,Sometimes, Ican’t thinkorevenblink.

Ican’tsee,Ican’tpee,Ican’tspit,Ican’t(**it) (“defecate”).

Quiz:Whatdo thesedrugsallhave incommon?

• Macrolides,quinolones, telithromycin,sulfonamides

• Amitriptyline,citalopram, paroxetine,sertraline,venlafaxine, fluoxetine

• Albuterol,levalbuterol,salmeterol• Phenylephrine,pseudoephedrine• Cocaine

QTintervalProlongationwithOpioids

• Methadone: 3-5%ofprescriptions foranalgesics; causes30-50% ofthe ODs

• Buprenorphine

How toHandle:• SerialEKGs• Consider alternatives inpatients who areonother medsthat prolong QTintervals

CYP450Enzymes• 3A4Enzymes: responsible for50%ofmeds thataremetabolized

• 2D6involvedinmetabolismofmany painmeds

Codeine=>morphineHydrocodone=>hydromorphoneOxycodone=>oxymorphoneMorphine=>hydromorphone (tracemetabolite)

CYP450Enzymes• 3A4Enzymes: responsible for50%ofmeds thataremetabolized

• Manydrugs are3A4inhibitors: statins,CCBs, benzos,warfarin, Betablockers,antifungals

• ItturnsOFF activedrugs! Iftheseareinhibited,thenamount of drugisGREATLY MAGNIFIED!!!

TheOppositeCanHappen!• Ifamedication isaProdrug,a2D6inhibitorcandecreasethe effectsofthe drug

• Codeine isaProdrug• Thisisthe opposite ofwhat happened in theprevious slide where3A4caused anincreaseindruglevels

• Inhibitionwithaprodrug canDECREASEdruglevels!

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CYP450Enzymes• Ifyouinhibitanactivedrug,youMAGNIFYtheeffectsofthedrug!• IfyouinhibitaProDrug,youDECREASEtheeffectofthedrug!

Codeine =>morphine

Codeine isaprodrug…..decreased effect ofmed

CYP450InfluenceMedication CYP450

Tramadol 3A4,2D6Codeine 2D6

Hydrocodone 3A4Oxycodone 2D6,3A4

Acetaminophen 2D6Fentanyl 3A4Methadone 3A4,2D6,2B6,2C9,

2C19

WhichmedicationhasthegreatestpotentialtocauseaDDI?

CYP450Enzymes4opioids doNOT go thrutheCYP450System (MOTH)• Morphine• Oxymorphone• Tapentadol (Nucynta, Nucynta ER)• Hydromorphone

P-glycoprotein(PGP)• DrugTransporteracrosscell membranes• Limits absorption, distribution ofmanydrugs(important in preventing toxicity)

• Responsible forconcentrations ofdrugsincells andinthe serum

• Drugsthat inhibit the PGP systemcan causeschanges inconcentrations ofdrugsthat usethis system

P-glycoprotein(PGP)Examples ofPGPdrugs:• Morphine• CCBs• Cyclosporine• Digoxin• Macrolide antibiotics• Protease inhibitors• Quinidine• DabigatranAustralianPrescriber.com

PGPInhibitor• Wouldincreasetheconcentrationofmorphine• Examples:quinidine

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QTProlongation• LongQTSyndrome(LQTS)• Increasedriskofventriculartachycardia

QuinolonesandmacrolidescanprolongQTintervals.

TakeHomePointBewareofdrug-druginteractionswithopioids!!!

NoNewDrugs

• Morphine• Methadone• Hydrocodone• Oxymorphone• Oxycodone

• Buprenorphine• Fentanyl• Hydromorphone• Tapentadol

Belbuca (transdermalbuprenophine)

• C-III• Mayhavelowerabuse potential thanotheropioids

• Fewerwithdrawal symptoms when stopped• Partial agonist (seemstohit aceiling to limitrespiratorydepression; analgesic ceiling too!)

• Consider insomeone in whom respiratorydepression maybegreat

Buprenorphine(BuTrans)

• QTinterval prolongation athighdoses, 3A4warnings with inhibitors andinducers

• Rotatesite anddon’t reapplywithin 3weekstothe samesite

Buprenorphine(BuTrans)

• Dispose ofused/unused patches byfoldingtheadhesive side together andflushing downtoilet*** (FDABlueprint)

• Check with statelaws about handling this!

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Dolophine (Methadone)• Multipledrug interactions• Verylonghalf-life• QTintervalprolongation (torsade depointe)

• Respiratory depression occurslaterandpersists longerthananalgesiceffect

Duragesic (Fentanyl)• Usualprecautions with patches• CONTRAINDICATEDin patients whoarenotopioid tolerant

• Avoidaccidental contact when holding orcaringforchildren

• 3A4precautions

Hydromorphone (Exalgo)• Donot useinpatients with sulfite allergy-contains sodium metabisulfite

• Usein opioid tolerant patients ONLY• Turns into athick gelifliquid isadded (topreventsnorting orinjection)

Hydrocodone (Zohydro ER)

• Extendedreleasehydrocodone• 3A4inhibitor/inducerprecautions

Hydrocodone (Hysingla ER)

• Lowest dose inopioid naïve patients• Increasedoseevery3-5daysforadequateanalgesia

• DONOTUSEinpatients whocannotcompletely swallow

• 3A4warnings• Stronglaxatives(Lactulose) mayresult inrapidGItransit andreduced analgesic effect

Morphinesulfate(Kadian)

• Notforuseasafirst opioid• Avoidalcohol: rapid release(“dosedump”)• PGP inhibitors increaseabsorption about 2-fold

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Morphinesulfate(MSContin)

• Notfor useas afirstopioid• PGPinhibitorsincrease absorptionabout 2-fold

Tapentadol (Nucynta ER)• EtOHmayresult inrapid releaseandabsorption of apotentially fataldose

• Contraindicated inpatients takingMAOs• Riskofserotonin syndrome,angioedema

Oxymorphone (Opana ER)• EtOHmayresult inrapid releaseandabsorption of apotentially fataldose

• Patient mustbeable toswallow medicinewithout difficulty; mustswallow immediatelyafterplacing inmouth

Oxymorphone (Oxycontin)• 3A4inhibitor/inducerprecautions• Patientmustbeabletoswallowmedicinewithout difficulty;mustswallow immediatelyafter placinginmouth

• Break intoclumpsifcrushed

AbuseDeterrentOpioids

AbuseDeterrentOpioids• It’s agreatidea!• Seems simpletodo: physicalpropertieswellunderstood,theyarestable, notmacromolecules

• But…..meds have beenonand off themarket

• Targiniq ERhas beendiscontinued

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OxymorphoneplusNaloxone(Targiniq ER)

• Approved July,2014,discontinued in 2015• Second opioid with deterrentto preventoral/intranasal (snorting) orinjecting

• Supposed toworkby:Naloxone onlyactivated ifthepill iscrushedorsnorted. Ifpill remains intact, naloxone lies dormant

OxymorphoneplusNaloxone(Targiniq ER)

WHY discontinued in2015?Lackofefficacycompared toplacebo(10%vs 24%)

MorphinesulfateER-Naltrexone(Embeda)(on andoffmarket-back on)

• Morphine:Naltrexone (100:4)• Naltrexoneisanantagonist atthemuopioidreceptor

• Abuse deterrenttechnology: Naltrexoneexpected toreduce oraland intranasal(snorting) abusewhen crushed

• Still canabuse but….

KeepingPatientsSafeCounseling Patients andCaregiversabout safeusefromFDABlueprint1. Usethe Patient Counseling Document as

partofthe discussion when prescribingopioid analgesicsWeonly rememberabout 20-25% ofwhat

we hear2.Include product specific info about the ER/LAopioid

KeepingPatientsSafeCounseling Patients andCaregiversabout safeusefromFDABlueprint3.Should include exactlyhow totakeit.

Ifamedication isBID,it should begivenevery12hoursNottwice dailywhich could beat6AMand10PM

4.What todoifyoumiss adose (this isn’tabirth control pill!!!)

KeepingPatientsSafeCounseling Patients andCaregiversabout safeusefromFDABlueprint5.Contact provider ifpainisnot controlled.

Common practice bypatients isto takeanadditional dose ifthedose theytook didn’tachieve thedesired effect.

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KeepingPatientsSafeCounseling Patients andCaregiversabout safeusefromFDABlueprint6.Pharmacist isanadditional resourceforthe

patient.Keywordis“additional”. Notthesoleresource!

KeepingPatientsSafeCounseling Patients andCaregiversabout safeusefromFDABlueprint7.UnderNOcircumstances should apill be

crushed,chewed, split.Apatchshould neverbecutortornpriortouse.Patients split pills ALLthetime!Takethe old patch off!

SpeakingofPatches…Counseling Patients andCaregiversabout safeusefromFDABlueprint• Donot exposepatches to externalheat(hottub), highfever,exertion: canincreaseabsorption of theopioidè overdose

• Patches with foil backings areNOTsafeinanMRI!

SpeakingofPatches…Thecaseofthe5yearold:• Stepped onafentanyl patch left onthekitchen floor

• ReachedERbut too lateto beresuscitated• Accidental ingestion ofopioids bychildren < 5yearsincreased 225% from2004 to2011

KeepingPatientsSafeCounseling Patients andCaregiversabout safeusefromFDABlueprint8.Absolutely avoidCNSdepressants like

EtOH!!!!Askapatient ifhedrinksEtOH.Ifhesaysno,askhim why.

KeepingPatientsSafeCounseling Patients andCaregiversabout safeusefromFDABlueprint9.Donot abruptly discontinue ER/LAopioid

analgesics. Discuss tapering.

10.Tell patient/caregiver that thesemedications cancausesevereside effects:respiratorydepression, death.

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KeepingPatientsSafeCounseling Patients andCaregiversabout safeusefromFDABlueprint

11.Teach patients/caregivers thesigns/symptoms ofopioid overdose,respiratorydepression, intestinal obstruction, allergicreaction, riskoffalls, riskofworking withheavymachinery, andespecially driving!

KeepingPatientsSafeCounseling Patients andCaregiversabout safeusefromFDABlueprint

12.Sharing medsisagainstthe law.Teach howtoprotect fromtheft.

13.Teach how todispose ofwhen nolongerneeded.

All infoisspecifically outlined inFDABlueprint!

KeepingPatientsSafeDo’s• Read themedguidefromPharmacist• TakemedEXACTLY as prescribed• Storemedaway from children/petsinasafe place

KeepingPatientsSafeDon’t• Don’tgivemedtoothers• Don’ttakemeds unless prescribedbyaprovider

• Don’tdrink EtOH

Whatelsecanbedone?KeepingPatientsSafe

NeedaHOMEPLAN!• Mostopioidemergenciesoccurinthehome

• Mostarewitnessed by closefriends,family

WhoisatHighRiskforOpioid Emergency?

• Patientswhotake50mg/dayormoreoforalmorphineequivalents• Thosewhotakelong-actingopioids• Switchingopioids• CNSdepressants(EtOH,benzos,etc.)• COPD,sleepapnea,etc.

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Whatelsecanbedone?KeepingPatientsSafe

NeedaHOMEPLAN!• Mostopioidemergenciesoccurinthehome

• Mostarewitnessed by closefriends,family

• FDAhas approved 2products thatreverseopioidoverdosethat canbeadministered athome

Whatelsecanbedone?KeepingPatientsSafe

• Nalaxone nasal spray:Narcan ($125)• Nalaxone auto-injector (Evzio upto$3750)

• Naloxone Kit(about $50):pharmacistputs kittogether

NaloxoneNalaxone nasal spray:Narcan ($125)• Does not need to beinhaled to work• Lie patient on hisback• Tilt patient’s head back gently and the tip ofthe nozzle inserted into the patient’s nostriluntil the fingers holding the nozzle areoneither side ofthe person’s nose

• Remove from nostril• Call 911

NaloxoneNalaxone auto-injector (Evzio upto$3750)• “talks” userthrough theinjection• Placeinjectoragainst theouterthigh(can injectthrough pants)

• Press theinjectorfirmlyand holdfor5seconds (injectormakes ahiss and clicksound duringinjection)

• Call911

NaloxoneKitRx2naloxone doses: forIM• Naloxone 0.4mg/ml plus 2syringes• Useshoulder, thigh orupper buttocks• Inject at90degree angleRx2naloxone doses: forIntranasal• 2mg/2mL prefilled syringesand 2atomizers(mucosal atomizer device (MAD300)

• Give short vigorous push delivering halfnaloxone into each nostril

PrescribersLetter;DetailDocument#320122

Whatelsecanbedone?KeepingPatientsSafe

• Call911EVEN IFNALOXONEadministered andpatientwakes up!

• Naloxone lasts about 30-90minutes,symptoms canreturnwhenithas beenmetabolized

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AfterNaloxoneAdministration

• Position patient on his side: they vomit!• Mayrepeat dose every2-3minutes ifremains unresponsive orno spontaneousbreathing

• Patient mayexperience opioid withdrawalsymptoms: fever,agitation, combativeness,sneezing, yawning, runny nose (none areusually life-threatening )

• Harmless ifgiven to someone who does nottakeopioids

Whatelsecanbedone?KeepingPatientsSafe

NeedaHOMEPLAN!• Universal precautionary approach• Prescribenalaxone withEVERY opioidprescription(not justhighrisk patients)

ChronicLowBackPain

StepwiseApproachtomanagementofChronicLowBackPain

• NSAIDoracetaminophen forlow backpain.Don’t useopioids firstline forbackpain

• Tricyclic oranticonvulsant (gabapentin) forneuropathic pain

• Physical Therapy:doesn’t necessarilydecreasepain but might improvefunction

Prescriber’s letter:December2014;Vol:30

StepwiseApproachtomanagementofChronicLowBackPain

• A30%improvementinpainisaWIN!Almostneverabletoeliminatepain• Manageco-morbids:especiallydepression!

Prescriber’s letter:December2014;Vol:30

StepwiseApproachtomanagementofChronicLowBackPain

• Whenallelsehas beentriedwithoutsuccess and painissevere,thenconsidera shortacting opioid

• Neverusean opioidforconditions likemigraines, fibromyalgia, TMJ,menstrualcramps

Prescriber’s letter:December2014;Vol:30

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PainandInflammationNon-opioidAnalgesics(NSAIDs,APAP,ASA)

Tramadol

Opioids

Alpha2blockers(Gabapentin,Pregabalin)

Steroids

TopicalAnalgesics

Anti-depressants(TCAs,SNRIs)

NociceptivePain• 25mgTramadol(50-100mgisusual)• 25mgPregabalin (Lyrica)• 25mgAmitriptylline

AgentChosenBasedonTypeofPain

Neuropathic Pain: Damageorpathology inthecentral orperipheral nervous system

• Example:DM,PHN,stroke,discogenic pain

Nociceptive Pain: Caused bydamagetotissues(actual orthreatened)

• Example:musculoskeletal conditions,inflammation, mechanical/compressiveconditions

ActivationofReceptorSitesResponse Mu1 Mu2 kappaAnalgesia ✔ ✔ ✔

modestRespiratoryDepression

✔

Euphoria ✔

Dysphoria ✔

Constipation ✔

Dependence ✔

PainandInflammationNon-opioidAnalgesics(NSAIDs,APAP,ASA)

Tramadol

Opioids

Alpha2blockers(Gabapentin,Pregabalin)

Steroids

TopicalAnalgesics

Anti-depressants(TCAs,SNRIs)

Opioids• Morphine• Codeine• Hydrocodone• Others

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NociceptivePain• 25mgTramadol• 25mgPregabalin (Lyrica)• 25mgAmitriptylline

Tramadol (Ultram)• Schedule IVofthecontrolled substance actinAugust 18,2014

Tramadol (Ultram)• Synthetic codeine analog (centrally actingsynthetic opioid analgesic)

• WeakMuopioid receptor agonist• Inhibits the uptakeofnorepinephrine andserotonin (Druginteractions!!!)

• Donot givetoopioid dependent patients (re-initiate physical dependence)

Tramadol (Ultram)• Absorbs well orally(similar tocodeine)• Duration is4-6hours• Incombo with acetaminophen• Extended releaseformavailable

Tramadol (Ultram)• Low abusepotential because oflow action ontheopioid receptors

• 100mg=10mgmorphine• Good useischronic neuropathic pain• Mostcommon sideeffect isnausea,vomiting, sweating, drymouth, dizziness,sedation

QuizWhycantramadolandotheropioidsproducenauseaandvomiting?

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AnswerIttriggerstheCTZ!!!

Pregabalin (Lyrica)Gabapentin (Neurontin)• ResembleGABA(gamma-aminobutyricacid)butdonotbindthere• Bindstothealpha2-deltasiteinCNS• Resultsindecreasedreleaseofglutamate,NE,substanceP

Gabapentin (Neurontin)• Uses:neuropathicpain(polyneuropathies,PHN,centralneuropathicpain)• Slowtitrationsomaytake2monthsforadequatetitration• Sedationiscommonsideeffect;elderlymoregreatlyeffected

Gabapentin (Neurontin)

CLEANDRUG!!!!!• Minimaldruginteractions• Doesnotinhibitorinducehepaticenzymes• OKwithSSRIs,SNRIs,TCAs

Pregabalin (Lyrica)Similaractiontogabapentin• CLEAN!• Uses:diabeticneuropathy,PHN,fibromyalgia• Sedation• Fastertolerabletitrationthangabapentin(andBIDvsTID)• ScheduleV(someeuphoria reported)

TCA“Amitriptylline”

• InhibitpresynapticreuptakeofserotoninandNE;blockcholinergic,adrenergic,histaminergic,andNachannels• Helpfulintreatmentofdiabeticneuropathy,polyneuropathy,centralneuropathicpain

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TCAsSimilar Efficacies

• Amitriptylline,imipramine(tertiaryamines)• Nortriptyline,desipramine(secondaryamines)• Secondaryaminesbettertolerated• OncedailyatHS• Anticholinergiceffects,DDIs

PainManagementPrinciples

• Evidence BasedManagement!• Multi-dimensional: providing treatmentsother thanopioids

• Needappropriate assessment: needassessment scales;need ameasurement toolforpain

• Pain changesovertime, soneedto continueassesspain (justasyouwould assessBP,HRwhen youtreatpatients)

PatientSafetyisPriority!!!

Thankyou!Forquestionsortocontactme:

Dr.AmelieHollieramelie@apea.com

Advanced Practice Education Associateswww.apea.comLafayette, LA