ntubebate said:
So next week I am doing a presentation to the nursing & pharmacy staff on pain management and I need to know some "most commons". By this I mean most commonly used medications and dosages seen in practice as well as their typical indication with difference noted for inpatient -vs- outpatient settings. I'm also hoping to use this list to help revamp our pain formulary and as a handout for our new interns.
Examples:
Inpatient:
Vicodin 5/500 1 tab q4-6 PRN given for post surgical analgesia.
MSO4 2mg IVP q2 PRN given for post surgical analgesia.
Outpatient:
Lortab 7.5 1 tab q6 PRN for pain.
MS Contin 30mg 1 tab q12 for pain.
Thanks!
ntubebate
dude, i agree w/ algos, hard to make one size fit all. A few philosophical thoughts which will influence your medication choice: (I am sure others on the list can add on more random thoughts)
1. ACCURATE dx of the pain generator: push yourself to a diagnosis or a mechanism: herniated disc vs. facet vs. muscle vs. headache vs. shingles, incisional pain, visceral pain; CRPS, myalgias; neuropathy...
2. Natural hx: acute post-op, subacute, chronic; acute on chronic
3. 24 hours behavior: am, midday, afternoon; night pain; pain incident to certain movements?
4. type of pain: nocioceptive, neuropathic, mixed; malignant vs. non-malignant pain; auto-immune; *utilize medications synergistically
5. age of patient: geriatric/compromised cognition
6. side effect profile of meds/adverse effects: see tylenol article below; nsaids; opiates; drug-drug interaction (tramadol and SSRIs); always include a bowel program w/ opiates.
7. Always consider optimizing non-pharmacologic options: Scott Nadler, DO did a great article on non-pharmacologic rx options. My favorite these days for back and neck pain are the continuous low heat wraps. Little iron discs which oxidize when exposed to air, heat up to 104 degrees for 8hrs, increase local vasodilation for 16 additional hours after patch is removed. As good as nsaids head to head for acute low back strain, great for long car trips or plane rides. Other: ice; counter-irritants;
8. Method of delivery: many folks won't tolerate opiates bc of constipation, therefore need a fentanyl patch for example; topical analgesics; actiq suckers, etc.
9. Always practice the 4 A's of pain medicine. Required for outpatient chart documentation in CA when rx opiates, but good medicine:
A: analgesia -- get a numerical rating scale 1-10 of pain; assess your intervention
A: activity; must show functional improvement. It is not enough to get stoned and watch TV. Less pain should mean improved ADLs
A: adverse effects of meds
A: aberrant behavior/abuse.
Peace out for now....
JAMA. 2006 Jul 5;296(1):87-93. Related Articles, Links
Aminotransferase elevations in healthy adults receiving 4 grams of acetaminophen daily: a randomized controlled trial.
Watkins PB, Kaplowitz N, Slattery JT, Colonese CR, Colucci SV, Stewart PW, Harris SC.
Department of Medicine, University of North Carolina, Chapel Hill, USA.
[email protected]
CONTEXT: During a clinical trial of a novel hydrocodone/acetaminophen combination, a high incidence of serum alanine aminotransferase (ALT) elevations was observed. OBJECTIVE: To characterize the incidence and magnitude of ALT elevations in healthy participants receiving 4 g of acetaminophen daily, either alone or in combination with selected opioids, as compared with participants treated with placebo. DESIGN, SETTING, AND PARTICIPANTS: A randomized, single-blind, placebo-controlled, 5-treatment, parallel-group, inpatient, diet-controlled (meals provided), longitudinal study of 145 healthy adults in 2 US inpatient clinical pharmacology units. INTERVENTION: Each participant received either placebo (n = 39), 1 of 3 acetaminophen/opioid combinations (n = 80), or acetaminophen alone (n = 26). Each active treatment included 4 g of acetaminophen daily, the maximum recommended daily dosage. The intended treatment duration was 14 days.Main Outcomes Serum liver chemistries and trough acetaminophen concentrations measured daily through 8 days, and at 1- or 2-day intervals thereafter. RESULTS: None of the 39 participants assigned to placebo had a maximum ALT of more than 3 times the upper limit of normal. In contrast, the incidence of maximum ALT of more than 3 times the upper limits of normal was 31% to 44% in the 4 treatment groups receiving acetaminophen, including those participants treated with acetaminophen alone. Compared with placebo, treatment with acetaminophen was associated with a markedly higher median maximum ALT (ratio of medians, 2.78; 95% confidence interval, 1.47-4.09; P<.001). Trough acetaminophen concentrations did not exceed therapeutic limits in any participant and, after active treatment was discontinued, often decreased to undetectable levels before ALT elevations resolved. CONCLUSIONS: Initiation of recurrent daily intake of 4 g of acetaminophen in healthy adults is associated with ALT elevations and concomitant treatment with opioids does not seem to increase this effect. History of acetaminophen ingestion should be considered in the differential diagnosis of serum aminotransferase elevations, even in the absence of measurable serum acetaminophen concentrations.
