Medication Review Notes

Pain Management Medications

• Medications Discussed:
  • Morphine
  • Tramadol
  • Acetaminophen
  • Ibuprofen
  • Celecoxib
  • Aspirin
  • Duloxetine
  • Pregabalin
  • Amitriptyline

Categorizing Pain Medications

• Pain medications can be categorized based on:
  • Pharmacological class
  • Therapeutic class (what they treat)

Pain Medication List (Alphabetical Order)

• Acetaminophen
• Amitriptyline
• Aspirin
• Celecoxib
• Ibuprofen
• Morphine
• Pregabalin
• Tramadol

Types of Pain Managed

1. Musculoskeletal Pain
2. Nerve Pain:
   • Originates from nerve-related issues.
   • Examples: fibromyalgia, peripheral neuropathy, diabetic neuropathy, chronic pain syndromes.

Nerve-Based Pain Medications

• Pregabalin:
  • Specific for nerve-related pain.
• Amitriptyline:
  • Class of antidepressants for managing nerve pain.
  • Duloxetine is also an option, although it is not on the stated medicine list.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

• Ibuprofen
• Celecoxib:
  • Specific type of NSAID
• Aspirin

Differences Among NSAIDs

• Key Difference:
  • Between aspirin/ibuprofen and celecoxib.

Cyclooxygenase (COX) Inhibition

• Celecoxib: selective COX-2 inhibitor.
• Aspirin & Ibuprofen: inhibit both COX-1 and COX-2.
• $COX$ is the abbreviated from of cyclooxygenase.

Celecoxib and GI Bleeding

• Developed to prevent GI adverse effects.
• Less GI side effects (GI ulcers/bleeding) compared to ibuprofen.
• Observed clinical difference is minimal i.e. not as significant as theory suggested.

Ibuprofen and Kidney Damage

• NSAIDs can cause kidney damage.
• Patients with acute renal failure should avoid ibuprofen.
• Over-the-counter medication use can be risky, as patients may mistakenly believe NSAIDs are safe for kidneys, unlike acetaminophen for the liver.

Acetaminophen

• Uses:
  • Pain relief
  • Headaches
  • Fever
• Adverse effect: Liver toxicity, especially in overdose or chronic high doses.
• Risk increases with combination products leading to unintentional overuse.
• Patients may exceed maximum daily dose through combined use of multiple products containing acetaminophen.

Medications for Neuropathic Pain

• Amitriptyline: affects neurotransmitters (serotonin, norepinephrine) to interfere with pain pathways.
  • Antidepressant class.
• Side effects:
  • Constipation (significant when combined with opioids).

Opioids (Morphine)

• Mechanism: Activating the mu opioid receptor, interfering with pain sensations

Morphine as the Gold Standard

• Morphine is the "gold standard" of opioids for pain management.
• Other opioids (hydrocodone, oxycodone, fentanyl) compared to morphine for potency.
• Doses are compared to a morphine standard to ensure correct dosage.

Morphine Equivalent Dose (MME)

• MME:
  • Morphine equivalent dose.
  • Used to compare doses when switching between opioids to prevent overdose.
• Converting opioid doses:
  • Crucial to avoid overdosing patients when switching between opioids (e.g., oxycodone to fentanyl).

Opioid Crisis

• Providers once freely prescribed opioids, but now there is a more balanced approach due to the opioid crisis.

Common Side Effects of Opioids

• Constipation
• Nausea
• Vomiting
• Respiratory depression
• Drowsiness/sedation
• Itchy skin (pruritus)

Life-Threatening Side Effects of Opioids

• Respiratory depression:
  • Occurs when opioids interrupt signals telling the body to breathe.
  • Requires close monitoring of dosage, interval, and potential buildup.

Opioid Overdose Antidote: Naloxone (Narcan)

• Mechanism: Complete opioid receptor antagonist.
  • Blocks opioid receptors and knocks opioids off receptors.
  • Reverses opioid effects, including pain control.
• Administration:
  • Should be prescribed to patients on long-term opioids.
  • Family/friends should be trained on how to use it.
• Patient response:
  • Patients wake up quickly but can be combative and in pain.
• Readministration:
  • May be necessary due to shorter half-life compared to some opioids (e.g., extended-release).
  • Hospital monitoring is preferred.

Tramadol

• Mechanism: Weak agonist at mu receptor (weak opioid) and increases serotonin.
• Use: Mixed-type pain (nerve and musculoskeletal).
• Risks:
  • Serotonin syndrome (with other serotonergic drugs or St. John's wort).
  • Potential for abuse due to weak opioid component.

Opioid Addiction Treatment: Buprenorphine

• Mechanism:
  • Partial opioid agonist that works at the opioid receptor
  • Less response than full agonists, reduces cravings.
• Combination: Given with naltrexone to prevent injection abuse.
• Administration: Oral medication with naltrexone inactive unless injected.
• Benefits:
  • Longer days' supply (up to 30 days) compared to daily methadone clinic visits.
  • Supports patient stability and routine.
• Compared to Methadone:
  • Buprenorphine patients has been more successful than methadone patients.

Methadone Overview

• Original Use: Safer alternative to IV drug use (heroin) to reduce risks of hepatitis and AIDS.
• Goal: Transition from IV drug use to a safer and more controlled substance use, not necessarily complete opioid cessation.

Medications for Substance Abuse

Disulfiram

• Use: Alcohol cessation.
• Mechanism: Produces a disulfiram-like reaction (flushing, GI upset) upon alcohol ingestion.
• Challenge: Requires self-control to consistently take the medication.
• Duration: Could be lifelong for some patients.

Alcohol Withdrawal

• Life-threatening, unlike opioid withdrawal.
• Delirium tremens: Severe seizures associated with alcohol withdrawal.
• Management: Hospital admission, monitoring with CIWA scale, preemptive benzodiazepines (e.g., diazepam).
• If not successful, use benzodiazepines to stop seizures once they start.

Smoking Cessation

• Medications:
  • Bupropion
  • Varenicline
  • Reduce nicotine cravings.

Bupropion Contraindications

• Risk of seizures:
  • Epilepsy
  • History of anorexia or bulimia (current or past)
  • Alcoholism
  • Lowers seizure threshold.

Nicotine Replacement Therapy

• Often more effective than bupropion or varenicline.

Neurological Disorders

Parkinson's Disease Medications

• Medications:
  • Levodopa, carbidopa
  • Pramipexole
  • Entacapone
  • Benztropine
  • Selegiline

Parkinson's Disease Overview

• Dopamine disorder: Not enough dopamine in the nigrostriatal pathway (coordination of movements).
• Medication Actions:
  • Increase dopamine
  • Increase sensitivity of dopamine receptors
  • Benztropine is the oddball, because it targets acetylcholine and helps solely with symptoms without addressing dopamine issue.

Parkinson's Disease Side Effects

• Due to increased dopamine in pathways responsible for mood and perception, side effects mimic schizophrenia.
  • Hallucinations
  • Delusions
  • Agitation
• Medication combination: patient often needs to use more than one medication.

Levodopa/Carbidopa

• Early-onset Parkinson's:
  • Try to reserve use until Parkinson's interferes with their quality of life.

Parkinson's Disease Symptoms

• Shuffling gait
• Hunched over posture
• Pill rolling of fingers
• Tremors
• Quieting or change in voice
• Flat affect, decreased emotional expression

Parkinson's Disease Management

• Progressive disease managed but not treated or prevented.

Alzheimer's Disease Medications

• Medications:
  • Memantine: used as an adjunct
  • Donepezil: the mechanism needs to be known for this medication.
    • Increases acetylcholine by inhibiting acetylcholinesterase. i.e. prevents the breakdown of acetylcholine.

Alzheimer's Disease Management

• Progressive disease that is managed, not treated.

Muscle Relaxants

• Baclofen: do not stop abruptly as it will cause a seizure. Taper off slowly.
• Dantrolene: treatment for neuroleptic malignant syndrome (NMS) caused by schizophrenia medications.

Migraine Treatment

• Cause: Vasodilation in the brain.
• Treatments: Pain medications (ibuprofen), amitriptyline for prevention.

Acute Migraine Treatment: Triptans (Sumatriptan)

• Mechanism: Causes vasoconstriction. Is taken when the it is known that patient has a migraine or when the auras starts.
• Adverse Effect: Chest pain (due to vasoconstriction in the heart) which can cause heart attack.
• Contraindications: Recent heart attack.

Prophylactic Migraine Treatment

• Medications: Amitriptyline, duloxetine, beta blockers.
• Used to prevent migraines.
• Ineffective once migraine has started; abortive therapy is then needed.