1. Analgesics/Antipyretics Musculoskeletal System and Disorders Welcome to Week 6 Chapters: 16 and 24 1

2. ANALGESICS Drug Classes 2

3. Analgesics and Pain What does “pain” look like? Evaluate pain based on:  Where pain is felt  Duration  Intensity (1-10 scale)  Precipitating factors Pain may be Acute or Chronic:  Acute-short duration, responds to analgesics  Chronic-over time, less responsive to analgesics, tolerance 3

4. Types of Analgesics Three Classes Opioid Nonopioids Adjuvant 4

5. Opioid (Narcotic) and Opiate Analgesics Strong and capable of reducing pain from any origin Derivatives of opium or synthetic chemicals that produce effect similar to opium. Examples: ____________________________ Vary in potency, onset and action Tolerance and potential for dependence are important concerns Many are schedule II…what does that mean? 5

6. Narcotic Analgesics Side Effects Respiratory depression Constipation Itching (may subside in 4-5 days) Nausea (may subside in 4-5 days) Confusion Euphoria Idiosyncratic (restlessness and agitation) Sedation 6

7. Drug Interactions with Narcotics Alcohol –leads to CNS and Respiratory depression Other medications that have CNS depression What can we give to treat narcotic overdose? __________________________ 7

8. Nonopioid Analgesics For mild to moderate pain Differ from narcotic analgesics 1. Not related to morphine 2. Work on peripheral nervous system rather than CNS (outside brain and spinal cord) 3. Do not produce physical dependency and tolerance 4. Do not alter consciousness or mental function 8

9. Characteristics of Nonopioid Analgesics Relieve low-intensity pain of inflammation and dull aches and vague pain Reduce Fever Uses are -anti-inflammatory -analgesic -antipyretic Not every drug in this class has all three 9

10. More Characteristics on Nonopioid Analgesics Usually first step in pain control Can be OTC or Rx Less expensive that Narcotics May be combined with narcotics to become Rx items:  Hydrocodone and APAP = _____________,  Hydrocodone and ibuprofen = __________,  Oxycodone and APAP = _______________ May be combined with non-narcotics to become Rx or OTC items:  ASA and caffeine_________  APAP and caffeine and butalbital 10

11. Salicylate Analgesics, ie. ASA (aspirin) Oldest of nonopioid analgesics; not for children Four distinct therapeutic actions of ASA:  1. Analgesic – inhibits prostaglandin release from damaged tissues  2. Anti-inflammatory—reducing prostaglandin synthesis  3. Anti-pyretic—reduces fever by causing vasodilation and sweatin, resets temperature control in brain  4. Anti-coagulant—prevents platelets from aggregating (clump) to decrease clot formation Beware GI effects, bleeding out 11

12. Acetaminophen (APAP) Has analgesic and antipyretic actions; No anti- inflammatory action Reasons to use APAP over ASA:  Can be used in all ages including children  Good choice for people allergic to ASA or ASA-like compounds  Rarely causes GI upset and bleeding  Can take with anticoagulation medications Main disadvantage –liver damage with long term or high doseages or concurrent heavy alcohol use No more than 4 grams in 24 hours for adults with normal liver function! 12

13. Nonsteroidal Anti-inflammatory (NSAID’s) Examples: ibuprofen (Advil®, Motrin®), naproxen (Aleve®) Treat mild to moderate pain Normally used for inflammatory conditions, dysmenorrhea, dental pain Inhibits cyclooxygenase (COX) which results in decreased formation of prostaglandin precursors Side Effects - GI Do not take with ASA, APAP or other NSAID’s. Time limits 10 days for pain, 3 days for fever or as directed by MD 13

14. World Health Organization (WHO) Pain Ladder Mild Pain-APAP, ASA, other NSAIDS around the clock Moderate Pain- add mild opioid (codeine or hydrocodone) Severe Pain-DC Mild Opioid, give strong opioid (Demerol or morphine). The nonopioid should be continued. 14

15. Adjuvant Analgesic Used to enhance analgesic efficiency and prolong effects of opioid medications Typically not prescribed alone for pain Goal=Decrease amount of pain medication with increase in pain control Help to reduce side effects of analgesics (ex: nausea) Examples of adjuvants:  Tricyclic Antidepressants (amitriptyline) *treat dull aches  Corticosteroids (prednisone) *treat edema  Anti-Convulsants (lorazepam, phenytoin) *treat sharp, shooting, or burning pain  Antihistamine (hydroxyzine) *treat anxiety/nausea 15

16. Review Name the three types of Analgesics 16

17. Answer 17 Opioid Nonopioids Adjuvant

18. Musculoskeletal System – Chapter 24 (2) Different systems working closely together Muscular System made up of Muscles Connective Tissue … ligaments, tendons Skeletal System made up of Bones -- osteoporosis Joints – arthritis, bursitis 18

19. Osteoporosis and Rx Therapy Osteoporosis = Bone resorption (Bone loss) Most patients are Not Aware it is occuring! -as we age, resorption begins to exceed formation -common causes: *decreasing Estrogen (women) *low/insufficient Calcium intake *decreased Physical-activity (exercise) Biphosphonates -(Fosamax, Actonel, Boniva) Evista – for both prevention and treatment! Calcitonin-salmon –treatment only! (Miacalcin) Forteo – stimulates new bone growth 19

20. Osteoporosis – Patient Education Increase load-bearing exercise –walking, stairs Calcium supplement + Vitamin-D – don’t forget the natural sources! – dairy products, etc. Biphosphonates: important guidelines … always take on empty-stomach 30-60 minutes before breakfast with a full glass of water to make sure the tab doesn’t stick in the throat (may cause esophageal erosion!), and patient should remain upright 30-60 minutes after swallowing (to prevent reflux, erosion). Miacalcin(nasal calcitonin-salmon) – alternate nostril every other day (apply in 1 nostril per day) 20

21. Joint Diseases and Rx Therapy Osteoarthritis – most common, generative noninflammatory, caused by ‘wear-and-tear’ Rheumatoid arthritis – autoimmune, various forms, all ages, progressive, pain/swelling/limits movement Bursitis – inflammed ‘fluid-sacks’ in the joints Common Antiarthritis Medications: Salicylates – ASA, salsalate NSAIDs – ibuprofen, naproxen, Celebrex DMARDs – methotrexate **dangerous drug!! Gluco-corticosteroids – prednisone, dexamethasone 21

22. General Characteristics of Arthritis meds Salicylates – fast-acting, inexpensive, GI s/e(enteric-coated) NSAIDs – potency, duration, $, less GI side-effects, blocks both COX1 and COX2 enzymes (GI danger in long-term use) COX2 Inhibitors – much greater potency and duration, much less GI side-effects(only block COX2), indicated for both Osteo and Rheumatoid arthritis (only one available is Celebrex) Glucocorticosteroids – powerful in reducing inflammation, preferably only used for a limited time (specific courses of therapy) DMARDs(immunosuppressants) – reduces the body’s own immune-response (autoimmune) to provide relief These only produce short-term remission, disease will worsen! 22

23. Gout Hyperuricemia (excess uric acid accumulation) Uric acid accumulates, then crystalizes (ouch!) Symptoms: *acute pain *swelling *redness *tenderness (usually the big-toe, ankle, knee, elbow) Medications: Acute attack – colchicine Prophylaxis – allopurinol, probenecid 23

24. Muscle Relaxants Treat Muscle spasms and muscle spasticity Most spasm caused by local injury, seizure-disorders Muscle-relaxants *decrease local pain/tenderness, *increase range-of-motion, *cause sedation Soma (carisoprodol) Flexeril (cyclobenzaprine) Skelaxin (metaxalone) Robaxin (methocarbamol) CNS agents: diazepam, Lioresal (baclofen) 24