1 / 26

Prepared by J. Mabbutt & C. Maynard NaMO September 2008

9: Pharmacotherapies – Pain Management. Prepared by J. Mabbutt & C. Maynard NaMO September 2008. 9: Pharmacotherapies & Pain Management: Objectives. 1. During the session, pharmacotherapies, their uses & nursing practice issues will be overviewed

tameron
Download Presentation

Prepared by J. Mabbutt & C. Maynard NaMO September 2008

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 9: Pharmacotherapies – Pain Management Prepared byJ. Mabbutt & C. MaynardNaMO September 2008

  2. 9: Pharmacotherapies & Pain Management: Objectives 1. During the session, pharmacotherapies, their uses & nursing practice issues will be overviewed 2. Pain management related to the opiate pharmacotherapies will also be highlighted providing key issues for practice 3. At the end the session, nurses & midwives will have a basic understanding of the pharmacotherapies used in the drug & alcohol field & pain management issues related to these

  3. 9: Pharmacotherapies for dependence and related pain management There is a range of pharmacological therapies that are effective in the treatment of alcohol, opioid & nicotine dependence in Australia All nurses, midwives, medical officers & allied health professionals need to know about these treatments, the rationale & benefits of use Pain management for opioid pharmacotherapies is often misunderstood and patients may not receive effective pain relief

  4. 9: Opioid pharmacotherapiesMethadone (1) • One of the most researched treatment modalities for dependence, & an overall assessment of its effectiveness can be made with more confidence than for other treatments • It is more effective at higher daily doses (at least 60mgs) as a maintenance therapy • A synthetic opioid with a long half-life – longer acting than heroin • It is active orally as syrup, can be administered once a day under medical or nursing supervision at a clinic, or dispensed from a specified community pharmacy or hospital

  5. 9: Opioid pharmacotherapiesMethadone (2) • There are criteria for admission into methadone maintenance programs • A specialist doctor or GP prescribes methadone, with the client being registered with the local relevant authority such as the health department • Methadone should be used as part of a program that includes treatment for a comorbid psychiatric disorder, & where counselling for personal problems is available • Caution needs to be observed regarding patients receiving high doses if there is concurrent alcohol or benzodiazepine dependence as there is a risk of respiratory depression

  6. 9: Opioid pharmacotherapiesMethadone – Side effects (1) Short term • Related to the central nervous system depressant properties of opioids: • Constipation • Nausea/vomiting • Drop in body temperature • Bradycardia, palpitations • Hypotension

  7. 9: Opioid pharmacotherapiesMethadone – Side effects (2) Long term • Weight gain • Tooth decay due to decreased oral secretions Contraindications • Kidney disease • Liver disease For further information, see Appendix 7: Drug interactions with Methadone

  8. 9: Opioid pharmacotherapiesBuprenorphine (1) • Buprenorphine is a partial opioid agonist – an opioid analgesic • It has a high affinity (binds) to the opioid receptor sites not allowing other opiates to act but at the same time it gives a partial opioid effect • Buprenorphine is as effective as methadone for people with moderate levels of dependence, & possibly for those with higher levels (Hulse et al. 2002, p. 91) • However, retention on buprenorphine appears to be less than that achieved with methadone • Patient selection is important

  9. 9: Opioid pharmacotherapiesBuprenorphine (2) Buprenorphine is available in two forms: • buprenorphine (Subutex) & • buprenorphine-naloxone (Suboxone) • Both forms are usually administered sublingually (usually takes 5 minutes to dissolve) • The tablet (s) can be used whole or in crushed form, as this does not affect sublingual absorption directly • The drug reaches its peak effect after about 3 hours

  10. 9: Opioid pharmacotherapiesBuprenorphine (3) • It is easier to taper buprenorphine than methadone, & as a partial agonist is safer in overdose • It results in less respiratory depression than full agonists, such as methadone • A wider safety margin & strong receptor binding leading to a long half-life make alternate day dosing a convenient option for many patients

  11. 9: Opioid pharmacotherapiesBuprenorphine – Side effects Some side effects have been reported, however, these are relatively mild and include: • Headache • Sedation • Nausea • Constipation • Anxiety • Dizziness and itching

  12. 9: Opioid maintenance treatment in acute hospital setting • Effective nursing care includes appropriate management of a person receiving opioid maintenance treatment during their hospital stay • Because they are taking methadone or buprenorphine, the continued provision of their opioid maintenance treatment is important • This will help maintain their comfort & safety, assist in planning pain management, & prevent the harms associated with poorly managed opioid withdrawal, thus reducing the risk of relapse &/or unplanned early discharge

  13. 9: Opioid maintenance treatment in acute hospital setting – General principles • Consult with the drug & alcohol specialist or drug & alcohol nurse practitioner about the care of all patients admitted to hospital who are receiving opioid maintenance treatment • Ensure that their methadone or buprenorphine dose is known & confirmed with prescriber and dosing point, and that the dose is quoted in both mg and mls for methadone • Find out from the prescriber &/or the dispensing pharmacy the timing of the last dose of medication and any takeaway doses

  14. 9: Altered tolerance and effective pain management • The patients most likely to have altered tolerance are: • Those who have been on regular prescribed opioid medication for long periods – they may be said to have iatrogenic dependence (medically caused) • Those currently receiving opioid maintenance treatment program or who are currently dependent on opioids • Those who regularly take liver enzyme-inducing drugs (e.g. alcohol, dilantin, interferon and rifampicin etc)

  15. 9: Altered Tolerance and effective pain management – Acute Pain Management • Clear communication regarding changes in their medication will help to lessen any anxiety and provide reassurance • It is critical that analgesia is not withheld from the person unless medically indicated • Providing pain relief will not make the person more drug dependent

  16. 9: Opioid pharmacotherapiesMethadone – Pain Relief • If a person is being prescribed methadone as a maintenance pharmacotherapy for opioid dependence, even at high doses, they will require additional opioids over & above their daily methadone dose for effective pain relief due to tolerance • Accident & emergency & other nursing & medical staff need to know that a person is taking methadone so that effective pain relief can be offered • Refer to NSW Health Policy Directive PD 2006_ 049. Opioid-dependent Persons Admitted to Hospitals in NSW – Management

  17. 9: Opioid pharmacotherapiesBuprenorphine – Pain relief • Standard doses of opioid analgesia are not likely to be effective in any patient who has used buprenorphine within the 3-4 days prior to requiring such analgesics • Advice should be sought from a Medical Officer skilled in drug & alcohol or D&A nurse practitioner in these instances • Accident & emergency & other nursing & medical staff need to know if a person is taking buprenorphine so that effective pain relief can be provided by using non-opioid analgesics, local anaesthetic approaches or higher dose opioid prescriptions in these situations

  18. 9: Opioid pharmacotherapiesNaltrexone (1) • As an antagonist, naltrexone blocks both the euphoric & analgesic effects of opioids • It is long acting, with effects lasting between 24 & 72 hours • Use of naltrexone while still opioid-dependent will bring on severe withdrawal symptoms and there are particular management issues for nurses when this drug has been self-administered by opioid users

  19. 9: Opioid pharmacotherapiesNaltrexone (2) • If depression occurs as a side effect of Naltrexone, an alternative pharmacotherapy is often considered • Research into its effectiveness shows that there is a high drop-out rate from treatment • Relapse could run the risk of overdose due to reduced opioid tolerance (Gowing et al. 2001; Young et al. 2002)

  20. 9: Opioid pharmacotherapiesNaltrexone – Pain relief • Opioid analgesia is not likely to be effective in any patient who has used naltrexone within the previous 7 days • In these instances, advice should be sought from a Medical Officer skilled in drug & alcohol or a D&A nurse practitioner • Accident & emergency & other nursing & medical staff need to know if a person is taking naltrexone so that effective pain relief can be provided by using non-opioid analgesics in these situations

  21. 9: Opioid pharmacotherapiesNaltrexone – Withdrawal – Rapid opioid detoxification (ROD) (1) • This form of detoxification is known by a number of names, including “ultra-rapid detoxification”, “accelerated detoxification”, “sedated detoxification” & “detoxification under anaesthetic” • Rapid opioid detoxification is the process of accelerating acute withdrawal by administration of an opioid antagonist, while providing symptomatic relief to enable patients to tolerate the procedure • The detoxification is followed with daily naltrexone treatment either tablets or implants

  22. 9: Opioid pharmacotherapiesNaltrexone – Withdrawal – Rapid opioid detoxification (ROD) (2) • For treatment guidelines for the management of opioid withdrawal inadvertently precipitated by naltrexone, see the relevant section in Chapter 9.1, Opioids • Some significant risks have been associated with sedation during ROD, including death as a result of aspiration or respiratory depression • For further information on methadone & buprenorphine treatment, refer to: NSW Opioid Treatment Program: Clinical Guidelines for methadone and buprenorphine treatment. Doc No. GL2006_019. www.health.nsw.gov.au/policies/gl/2006/GL2006_019.html

  23. 9: Pharmacotherapies for dependence & maternal & neonatal care • Methadone is the drug of choice for opioid dependent pregnant women • Buprenorphine is not approved but a patient can continue on it if pregnant • Withdrawal for the baby is likely to occur with both of these maintenance drugs as it would with heroin dependence • For information regarding pharmacotherapies for dependence and maternal/neonatal care, refer to the National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn. (March 2006)http://www.health.nsw.gov.au/pubs/2006/ncg_druguse.html

  24. 9: Alcohol pharmacotherapies –Acamprosate (Campral) • Acamprosate is a pharmacotherapy used to prevent alcohol relapse post-withdrawal • It assists in the reduction of cravings for alcohol, where the person is seeking to abstain or reduce their consumption • Compliance can be an issue as dosage is usually two tablets x three times/day (333mg in each tablet) • Acamprosate does not interact with alcohol, and does not have hypnotic, anxiolitic or antidepressant effects

  25. 9: Alcohol pharmacotherapies –Naltrexone • Naltrexone suppresses the priming effect of alcohol (blunts the euphoric effects of alcohol and reduces the positive reinforcement of alcohol use) & can assist in achieving goals of reduction in consumption &/or abstinence • Monitoring the liver profile is recommended during the course of naltrexone treatment, which is usually three to six months • A dose of 50mg daily has shown positive outcomes with relapse rates, craving & number of non-drinking days

  26. 9: Alcohol pharmacotherapies –Disulfiram (Antabuse) • The goal in prescribing disulfiram is to provide a powerful disincentive to drink – it inhibits the ALDH in the liver, and if the person drinks alcohol, causes an accumulation of acetaldehyde – making them feel sick • Within 15 minutes of drinking the person may experience the following: flushing; feeling heat & sweating; nausea; vomiting; palpitations & rapid pulse; headache; difficulty breathing blood pressure increase then decrease

More Related