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Drug Use in Acute Pain Management - Final 010708
Drug Use in Acute Pain Management - Final 010708
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5th Vital Sign: Doctors’ training module: Pharmacology
Analgesics
Non Opioids
Paracetamol
NSAIDS
COX 2 inhibitors
Opioids
Weak
Strong
Naloxone
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5th Vital Sign: Doctors’ training module: Pharmacology
Non-opioid analgesics
Acetaminophen (Paracetamol)
Non-steroidal anti inflammatory
drugs (NSAIDS)
COX 2 inhibitors
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5th Vital Sign: Doctors’ training module: Pharmacology
Acetaminophen - Paracetamol
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5th Vital Sign: Doctors’ training module: Pharmacology
Acetaminophen – Paracetamol (cont.)
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5th Vital Sign: Doctors’ training module: Pharmacology
NSAIDS
Effects
Anti-inflammatory
Analgesic
Anti-pyretic
Anti-platelet
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5th Vital Sign: Doctors’ training module: Pharmacology
Mode of Action
Act by inhibiting prostaglandin
biosynthesis
Involved in conversion of
arachidonic acid to prostaglandin
Irreversibly blocks the enzyme
cyclo-oxygenase (COX)
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5th Vital Sign: Doctors’ training module: Pharmacology
Cyclooxygenase Pathways
Normal Normal
Inducible
constituent constituent
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5th Vital Sign: Doctors’ training module: Pharmacology
NSAIDS – limitations (2)
Gastritis and functional
thrombocytopenia are common
with therapeutic doses
Precautions – prolonged use can
lead to
Renal failure
Increased risk of myocardial infarct
and stroke
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5th Vital Sign: Doctors’ training module: Pharmacology
OPIOIDS
Drugs (natural or synthetic ) with
morphine-like properties and which
act through the opioid receptors.
Partial agonist
Nalbuphine
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5th Vital Sign: Doctors’ training module: Pharmacology
Pharmacokinetics
Definition
What happens to drugs in the body
Components
Plasma level in relation to dose given
The dosing interval
Route of administration
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5th Vital Sign: Doctors’ training module: Pharmacology
Aim for analgesia
- Plasma levels to fall in the “analgesic corridor”
=> comfortable
- Below level → pain
- Above level → side effects
- Difficult to predict
=> titration of analgesia
- Using: PCA,
Range of doses &
dosing intervals
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5th Vital Sign: Doctors’ training module: Pharmacology
PHARMACOKINETICS
IM or SC MORPHINE
“Analgesic corridor”
“Analgesic corridor”
“Analgesic corridor”
CONCLUSION:
The best way is to give smaller doses of
morphine more frequently
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5th Vital Sign: Doctors’ training module: Pharmacology
Pharmacokinetics
PCA / small frequent boluses
“Analgesic corridor”
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5th Vital Sign: Doctors’ training module: Pharmacology
Pharmacokinetics :
Bioavailability of oral route is 30% due to
first pass metabolism in the liver
Converted to morphine-6-glucuronide
(active metabolite) and morphine-3-
glucuronide in liver
Excreted through the kidney
Elimination half life is 3-4 hours
Peak analgesic effect
IM / SC : 30-60 minutes
IV : 5 minutes
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5th Vital Sign: Doctors’ training module: Pharmacology
Morphine: Adverse effects
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5th Vital Sign: Doctors’ training module: Pharmacology
Morphine
Pain Protocol
Adapted from the Acute
Pain Service, Royal
Adelaide Hospital ,
South Australia
FOR NURSES
WHO ARE
TRAINED
AND
ACCREDITED
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5th Vital Sign: Doctors’ training module: Pharmacology
Dihydrocodeine (DF118)
Natural opioid Side effects
Only oral form is available in Constipation
Malaysia: 30 mg tab
Worst constipating effect
Converted to morphine in the compared to other
liver opioids
Used for mild to moderate pain
Dose:
Tab 30mg-60mg 6hrly
(max 360mg/day)
Onset:
15 to 30 min (peak 1h)
Duration: 4-6hr
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5th Vital Sign: Doctors’ training module: Pharmacology
Pethidine
Dose: 1-2mg/kg Metabolised in liver to
(usually 50 – 100 mg 4 H) Norpethidine which has a
Route: iv /im /sc hallucinogenic and convulsant
effect
Peak analgesic effect : Elimination half life is 2.4-7
IM : 20-30 minutes hours
IV : 5 -10 minute
Norpethidine has a long half
Side Effects are the same as life (12 hours) and
for all opioids hallucinogenic effects outlast
Nausea/vomiting the analgesic effects of
Sedation pethidine
Respiratory depression
Constipation / Ileus
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5th Vital Sign: Doctors’ training module: Pharmacology
NALOXONE
Pure opioid antagonist
Used in diagnosis and treatment of opioid
overdose
Give IV (diluted) or IM
Half-life 45 – 60 minutes
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5th Vital Sign: Doctors’ training module: Pharmacology
OPIOIDS:TRADE NAMES AND DOSE EQUIVALENTS
EQUIVALENT
OPIOID TRADE NAME DURATION OF MORPHINE OPIOID
DOSE (MG)
ACTION (HRS) CLASS
IM/IV PO
MORPHINE MORPHINE 10 20 AGONIST
SULPHATE 3-4
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5th Vital Sign: Doctors’ training module: Pharmacology
LIST OF ANALGESIC DRUGS
DRUG FORMULATION AVAILABLE DOSAGE
NSAID
COX 2 inhibitors
COX 2 inhibitors
WEAK OPIOID
Tramadol Capsule 50mg, Injection 50mg/ml 50mg -100mg tds or qid (max 400mg/day)
Dihydrocodeine (DF118) Tablet 30 mg 30mg-60mg qid (max 360mg/day)
STRONG OPIOID
Nalbuphine (Nubain) Injection 10mg/ml Stat dose only: 10mg (equivalent to Morphine
10mg). Do not use in patients on regular
Morphine/ Pethidine/ Fentanyl.
Morphine Tablet SR 10mg,30mg SR and Aqueous to be used for cancer pain
Aqueous 10mg / 5ml IV and Subcut :
Injection 10 mg/ml, < 65yrs : 5mg -10mg 3-4hrly
> 65yrs : 2.5mg -5mg 3-4hrly
Reduce dose in renal and hepatic impairment
Fentanyl Injection 50 mcg/ml, IV only to be prescribed by APS team.
Patch 25 mcg, 50 mcg Patch to be used in cancer pain; NOT in Acute
Pain
Pethidine Injection 50mg/ml,100mg/2ml IV and Subcut :
< 65yrs : 50mg -100mg 3-4hrly
> 65yrs : 25mg -50mg 3-4hrly
Reduce dose in renal and hepatic impairment.
Use not encouraged because of Norpethidine
toxicity and high risk of addiction.
MANAGEMENT
OF SIDE EFFECTS
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5th Vital Sign: Doctors’ training module: Pharmacology
NAUSEA AND VOMITING
Nausea and vomiting is a common side effect
but should not be a reason for withholding
opioids in patients with severe pain
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5th Vital Sign: Doctors’ training module: Pharmacology
Sedation Score
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5th Vital Sign: Doctors’ training module: Pharmacology
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5th Vital Sign: Doctors’ training module: Pharmacology
Malaysian 5th Vital Sign Implementation: 2008-2010
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