Anti-Inflammatories, Analgesics, and Muscle Relaxants

Pain

• Nerves send signal that travels from the site of injury to the spinal cord and brain (may cause inflammation from substances sent to injury site to start healing process)

• Mainly treated by pain relievers (analgesics)

Muscle Spasms

• Muscle can become damaged and contracts uncontrollably causing the pain and discomfort

• Mainly treated by muscle relaxants

Drug Classes

• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Provide relief by blocking a signal produced by the body that causes inflammation and pain. Some can also be used to lower fever

• Muscle relaxants: Block receptors on muscles to prevent them from contracting uncontrollably, or spasming

• Analgesics: Block signals to the spinal cord to tell the brain that there’s pain at an injury site, therefore providing relief. Acetaminophen can also be used to lower fever. Some opioid analgesics, like methadone and buprenorphine, can be used to treat opioid addiction

Practice Tip

All opioid analgesics are considered high-alert medications (care must be taken to ensure the correct product is dispensed

Dosage Forms

• Oral Solids: Oral tablets and capsules are usually for patients who can swallow them

• Oral Liquids: Suspensions and solutions are for patients

• Buccal/Sublingual: Some meds are administered in the cheek (buccal) or under the tongue (sublingual) because they can’t be absorbed properly in the stomach

• Injectables: Injectables are used for patients who need quick action for pain relief

• Inhalation: Nasal sprays are used to treat migraine pain

• Topicals: Topicals (patch and gel) are used to treat pain directly at an injury site (knee, back, etc.) For convenience so patients don’t have to take oral meds on a regular basis

Central Nervous System (CNS) Effects

• Muscle relaxants and opioid analgesics can depress the nervous system (may cause dizziness and drowsiness)

• Effect can be so severe and cause dangerously slowed breathing (respiratory depression)

Gastrointestinal (GI) Effect

Opioid analgesics can cause nausea and vomiting, as well as constipation:

• Due to the effects of the medication in the GI tract

• Taking opioids with food may help with nausea and vomiting

• Stimulant laxatives (bisacodyl, etc) can help with constipation

Hematological Effects

NSAIDs increase the risk of bleeding and bruising (especially if they’re taken often and in high doses)

Abuse Potential

• All opioids analgesics are controlled substances, due to addiction potential. Can also lead to accidental overdoses if used improperly, or with other meds that can cause respiratory depression (muscle relaxants, etc)

• Patients must be opioid-tolerant before starting more potent opioids, like fentanyl. Opioids have Risk Evaluation and Mitigation (REMS) requirements that need to be met before they’re dispensed to the patient

• Ensure patients taking opioids also receive naloxone, an opioid-reversal agent, to treat an overdose

Allergic Reactions

Some patients may experience a rash while taking opioid analgesics, but this isn’t a true allergic reaction:

• Due to a histamine release from taking opioid, and is seen more with methadone

• Patients can usually continue to safely take opioids if they experience a rash

Opioid Analgesics-Alcohol

• CNS depressants (opioid analgesics and muscle relaxants) interact with other CNS depressants, like alcohol, and increase the risk of dizziness and drowsiness

• In some cases, dangerously slowed breathing (respiratory depression) may occur, and can be fatal

Muscle Relaxants-Benzodiazepines

• CNS depressants (muscle relaxants and opioid analgesics) interact with benzodiazepines (diazepam, etc), and increase the risk of dizziness and drowsiness

• In some cases, dangerously slowed breathing may occur, and can be fatal

NSAIDs-Warfarin

NSAIDs increase bleeding risk and can further increase the risk of bleeding when used with warfarin and other “blood thinners”

Children

Some opioids (tramadol, etc) should be avoided in children under 12 since they can cause respiratory depression in this age group

Older Adults

Older patients may experience worsened CNS side effects (dizziness, drowsiness, etc) when taking NSAIDs, muscle relaxants, and opioid analgesics. These meds are on the Beers criteria of high-risk meds that can potentially cause falls and harm to older adults

Food

• Opioid analgesics and NSAIDs may cause nausea and vomiting, and taking them with food may help with these side effects

• Apply a “Take with food” auxiliary label to these Rxs

Driving

• Opioid analgesics cause dizziness and drowsiness, so operating heavy machinery (vehicles, etc) should be avoided when taking opioids

• Apply a “Do not operate heavy machinery” auxiliary label to these Rxs

Acetaminophen

• Most healthy patients can take a maximum of 4,000 milligrams (4 grams) of acetaminophen daily

• This limit can be quickly reached, and exceeded, if patients are receiving acetaminophen from prescription and over-the-counter sources, and may cause liver toxicity

• Apply a “Do not take acetaminophen containing products” auxiliary label to these Rxs

Identifying Meds

• Opioids: Some will end with “-codone” such as hydrocodone and oxycodone

• Zanaflex and Flexeril are muscle relaxants that help patients “flex” muscles again

• Duragesic is an opioid for analgesic

Aspirin

• Brand Name: Ecotrin (has other brand names)

• Drug Class: Non-steroidal Anti-Inflammatory Drugs (NSAIDs)

• Indications: Fever, Inflammation, Pain

• Special Considerations: Avoid in patients with an NSAID or salicylate allergy. Interacts with other meds that may cause bleeding (DOACs, warfarin, etc) and probenecid. Patients should take oral form with food

• OTC option available

Celecoxib

• Brand Name: Celebrex (has other brand names)

• Drug Class: Non-steroidal Anti-Inflammatory Drugs (NSAIDs)

• Indications: Inflammation, Pain

• Special Considerations: Avoid in patients with an NSAID, salicylate, or sulfonamide allergy. Interacts with other meds that may cause bleeding (DOACs, warfarin, etc) and probenecid

• Patients with CV issues (heart disease, etc) should use with caution

Diclofenac Sodium

• Brand Name: Voltaren (has other brand names)

• Drug Class: Non-steroidal Anti-Inflammatory Drugs (NSAIDs)

• Indications: Inflammation, Pain

• Special Considerations: Avoid in patients with an NSAID or salicylate allergy

• Interacts with meds that may cause bleeding (DOACs, warfarin, etc) and probenecid. Patients should take oral with food. Patients with CV issues (heart disease, etc) should use with caution

• OTC topical gel exists

Diclofenac Potassium

• Brand Name: Cataflam (has other brand names)

• Drug Class: Non-steroidal Anti-Inflammatory Drugs (NSAIDs)

• Indications: Inflammation, Pain

• Special Considerations: Avoid in patients with an NSAID or salicylate allergy. Interacts with other meds that may cause bleeding (DOACs, warfarin, etc) and probenecid. Patients should take with food. Patients with CV issues (heart disease, etc) should use with caution

Etodolac

• Brand Name: Lodine

• Drug Class: Non-steroidal Anti-Inflammatory Drugs (NSAIDs)

• Indications: Inflammation, Pain

• Special Considerations: Interacts with other meds that may cause bleeding (DOACs, warfarin, etc) and probenecid. Patients should take with food. Patients with CV (heart disease, etc) should use with caution

Ibuprofen

• Brand Name: Motrin (has other brand names)

• Drug Class: Non-steroidal Anti-Inflammatory Drugs (NSAIDs)

• Indications: Fever, Inflammation, Pain

• Special Considerations: 200 mg dosage form is OTC. Interacts with other meds that may cause bleeding (DOACs, warfarin, etc) are probenecid. Patients should take oral form with food. Patients with CV issues (heart disease, etc) should use with caution

Indomethacin

• Brand Name: Indocin

• Drug Class: Non-steroidal Anti-Inflammatory Drugs (NSAIDs)

• Indications: Inflammation, Pain

• Special Considerations: Interacts with other meds that may cause bleeding (DOACs, warfarin, etc) and probenecid. Patients should take with food. Patients with CV issues (heart disease, etc) should use with caution

Ketorolac

• Brand Name: Toradol (has other brand names)

• Drug Class: Non-steroidal Anti-Inflammatory Drugs (NSAIDs)

• Indications: Inflammation, Pain

• Special Considerations: Injectable and oral dosage can only be used for a max of 5 days. Interacts with other meds that may cause bleeding (DOACs, warfarin, etc) and probenecid. Patients should take oral form with food. Patients with CV issues (heart disease, etc) should use with caution

Meloxicam

• Brand Name: Mobic

• Drug Class: Non-steroidal Anti-Inflammatory Drugs (NSAIDs)

• Indications: Inflammation, Pain

• Special Considerations: Interacts with other meds that may cause bleeding (DOACs, warfarin, etc) and probenecid. Patients should take with food. Patients with CV issues (heart disease, etc) should use with caution

Nabumetone

• Brand Name: Relafen

• Drug Class: Non-steroidal Anti-Inflammatory Drugs (NSAIDs)

• Indications: Inflammation, Pain

• Special Considerations: Interacts with other meds that may cause bleeding (DOACs, warfarin, etc) and probenecid. Patients should take with food. Patients with CV issues (heart disease, etc) should use with caution

Naproxen

• Brand Name: Naprosyn (has other brand names)

• Drug Class: Non-steroidal Anti-Inflammatory Drugs (NSAIDs)

• Indications: Fever, Inflammation, Pain

• Special Considerations: 220 mg dosage form is OTC. Interacts with other meds that may cause bleeding (DOACs, warfarin, etc) and probenecid. Patients should take with food. Patients with CV issues (heart disease, etc) should use with caution

Baclofen

• Brand Name: Lioresal (has other brand names)

• Drug Class: Muscle Relaxants

• Indications: Muscle Spasms

• Special Considerations: Interacts with other meds that may cause drowsiness (BDZs, opioids, etc). May cause CNS depression adverse effects (dizziness, drowsiness, etc)

Carisoprodol

• Brand Name: Soma (has other brand names)

• Drug Class: Muscle Relaxants

• Indications: Muscle spasms

• Special Considerations: Abuse potential (C-IV). Interacts with other meds that may cause drowsiness (BDZ, opioids, etc). May cause CNS depression adverse effects (dizziness, drowsiness, etc)

Cyclobenzaprine

• Brand Name: Flexeril (has other brand names)

• Drug Class: Muscle Relaxants

• Indications: Muscle spasms

• Special Considerations: Interacts with other meds that may cause drowsiness (BDZs, opioids, etc). May cause CNS depression adverse effects (dizziness, drowsiness, etc)

Metaxalone

• Brand Name: Skelaxin

• Drug Class: Muscle Relaxants

• Indications: Muscle spasms

• Special Considerations: Interacts with other meds that may cause drowsiness (BDZs, opioids, etc). May cause CNS depression adverse effects (dizziness, drowsiness, etc)

Methocarbamol

• Brand Name: Robaxin

• Drug Class: Muscle Relaxants

• Indications: Muscle spasms

• Special Considerations: Interacts with other meds that may cause drowsiness (BDZs, opioids, etc). May cause CNS depression adverse effects (dizziness, drowsiness, etc)

Tizanidine

• Brand Name: Zanaflex

• Drug Class: Muscle Relaxants

• Indications: Muscle spasms

• Special Considerations: Interacts with other meds that may cause drowsiness (BDZs, opioids, etc). May cause CNS depression adverse effects (dizziness, drowsiness, etc)

Buprenorphine

• Brand Name: Subutex (has other brand names)

• Drug Class: Opioid Analgesics

• Indications: Opioid dependence, Pain

• Special Considerations: Abuse potential (C-III). Interacts with other meds that cause respiratory depression (BDZs, muscle relaxants, etc). High-alert med. May Cause constipation, dizziness, and drowsiness. REMS med if treating opioid dependence.

Butorphanol

• Brand Name: Stadol

• Drug Class: Opioid Analgesics

• Indications: Pain

• Special Considerations: Abuse potential (C-IV). Interacts with other meds that cause respiratory depression (BDZs, muscle relaxants, etc). High-alert med. May Cause constipation, dizziness, and drowsiness. REMS med.

Codeine

• Brand Name: Codeine

• Drug Class: Opioid Analgesics

• Indications: Pain

• Special Considerations: Abuse potential (C-II as a single product). Interacts with other meds cause respiratory depression (BDZs, muscle relaxants, etc). Children under 12 should not use. High-alert med. May cause constipation, dizziness, and drowsiness. REMS med.

Fentanyl

• Brand Name: Duragesic (has other brand names)

• Drug Class: Opioid Analgesics

• Indications: Pain

• Special Considerations: Abuse potential (C-II). Interacts with other meds that cause respiratory depression (BDZs, muscle relaxants, etc). High-alert med. May cause constipation, dizziness, and drowsiness. Patients must be opioid-tolerant before starting. REMS drug (TIRF if using an immediate-release buccal product)

Hydrocodone

• Brand Name: Zohydro ER (has other brand names)

• Drug Class: Opioid Analgesics

• Indications: Pain

• Special Considerations: Abuse potential (C-II). Interacts with other meds that cause respiratory depression (BDZs, muscle relaxants, etc). High-alert med. May cause constipation, dizziness, and drowsiness. REMS med.

Hydromorphone

• Brand Name: Dilaudid

• Drug Class: Opioid Analgesics

• Indications: Pain

• Special Considerations: Abuse potential (C-II). Interacts with other meds that cause respiratory depression (BDZs, muscle relaxants, etc). High-alert med. May cause constipation, dizziness, and drowsiness. REMS med.

Methadone

• Brand Name: Methadose

• Drug Class: Opioid Analgesics

• Indications: Opioid dependence, Pain

• Special Considerations: Abuse potential (C-II). Interacts with other meds that cause respiratory depression (BDZs, muscle relaxants, etc), or prolong QT interval (amiodarone, etc). High-alert med. May cause constipation, dizziness, and drowsiness. REMS med.

Meperidine

• Brand Name: Demerol

• Drug Class: Opioid Analgesics

• Indications: Pain

• Special Considerations: Abuse potential (C-II). Interacts with other meds that cause respiratory depression (BDZs, muscle relaxants, etc). High-alert med. May cause constipation, dizziness, and drowsiness. REMS med.

Morphine

• Brand Name: MS Contin (Has other brand names)

• Drug Class: Opioid Analgesics

• Indications: Pain

• Special Considerations: Abuse potential (C-II). Interacts with other meds that cause respiratory depression (BDZs, muscle relaxants, etc). High-alert med. May cause constipation, dizziness, and drowsiness. REMS med.

Oxycodone

• Brand Name: Oxycontin (has other brand names)

• Drug Class: Opioid Analgesics

• Indications: Pain

• Special Considerations: Abuse potential (C-II). Interacts with other meds that cause respiratory depression (BDZs, muscle relaxants, etc). High-alert med. May cause constipation, dizziness, and drowsiness. REMS med.

Oxymorphone

• Brand Name: Opana

• Drug Class: Opioid Analgesics

• Indications: Pain

• Special Considerations: Abuse potential (C-II). Interacts with other meds that cause respiratory depression (BDZs, muscle relaxants, etc). High-alert med. May cause constipation, dizziness, and drowsiness. REMS med.

Tapentadol

• Brand Name: Nucynta

• Drug Class: Opioid Analgesics

• Indications: Pain

• Special Considerations: Abuse potential (C-II). Interacts with other meds that cause respiratory depression (BDZs, muscle relaxants, etc). High-alert med. May cause constipation, dizziness, and drowsiness. REMS med.

Tramadol

• Brand Name: Ultram (has other brand names)

• Drug Class: Opioid Analgesics

• Indications: Pain

• Special Considerations: Abuse potential (C-IV). Avoid in children under 12. Interacts with serotonergic meds (SSRIs, MAOIs, etc) and other meds that cause respiratory depression (alcohol, BDZs, muscle relaxants, etc). High-alert med. May cause constipation, dizziness, and drowsiness. REMS med

Acetaminophen

• Brand Name: Tylenol (has other brans names)

• Drug Class: Miscellaneous Analgesics

• Indications: Fever, Pain

• Special Considerations: Maximum daily dose is 4,000 mg. May cause chronic liver issues with consistent, high doses

Capsaicin

• Brand Name: Bengay (has other brand names)

• Drug Class: Miscellaneous Analgesics

• Indications: Pain

• Special Considerations: Wash hands after use

Lidocaine

• Brand Name: Lidoderm (has other brand names)

• Drug Class: Miscellaneous Analgesics

• Indications: Pain

• Special Considerations: Patch dosage form should only be worn a max of 12 hours/day

Codeine/acetaminophen

• Brand Name: Tylenol #3 (has other brand names)

• Drug Class: Combined Drug Class. Codeine - Opioid analgesics. Acetaminophen - Miscellaneous analgesics

• Indications: Pain

• Special Considerations: Abuse potential (C-III). REMS med. See special considerations for individual ingredients above.

Hydrocodone/acetaminophen

• Brand Name: Norco (has other brand names)

• Drug Class: Combined Drug Class. Hydrocodone - Opioid analgesic. Acetaminophen - Miscellaneous analgesics

• Indications: Pain

• Special Considerations: Abuse potential (C-II). REMS med. See special considerations for individual ingredients

Oxycodone/acetaminophen

• Brand Name: Percocet (has other brand names)

• Drug Class: Combined Drug Class. Oxycodone - Opioid analgesic. Acetaminophen - Miscellaneous analgesics

• Indications: Pain

• Special Considerations: Abuse potential (C-II). REMS med. See special considerations for individual ingredients