Summer 2003 Volume 5, Number 2

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1 PAIN Summer 2003 Volume 5, Number 2 IN THIS ISSUE: 1. ADJUVANT PHARMACOLOGIC TREATMENTS FOR PAIN 2. PROVIGIL - AND OPIOID-INDUCED NARCOSIS 3. PRN MATCHING GAME 4. NEW PRODUCT INFORMATION: GELCLAIR FOR MUCOSITIS 5. EMLA CREAM VS. ELA-MAX Adjuvant Pharmacologic Treatments for Pain Jean Holland, MSN, RN, AOCN Adjuvant or co-analgesic drugs are medications with other primary indications that are effective against certain types of pain. Adjuvant drugs are valuable to enhance analgesia, treat concurrent symptoms and provide analgesia for certain types of pain. By enhancing analgesia, adjuvant drugs may help to reduce opioid dose requirements and their accompanying side effects. It is important to recognize that adverse drug reactions are possible and that there are individual and ethnic differences in drug metabolism. Patients with advanced cancer may receive several drugs for symptom relief and as a result, are at high risk of drug interactions. Drugs for Neuropathic Pain Tricyclic antidepressants have been commonly used in the treatment of neuropathic pain syndromes. These drugs inhibit the reuptake of serotonin and norepinephrine, which then increases the levels of these neurotransmitters that reduce pain modulation. Spontaneous pain and hyperalgesia respond to tricyclic antidepressants. Neuropathic pain characterized by continuous dysesthesia is believed to benefit from antidepressant management. The most common side effects of tricyclic antidepressants: Constipation Dry mouth Blurred vision Cognitive changes Tachycardia Urinary retention A slow upward titration is a good way to avoid side effects. Dose titration should be pushed to therapeutic blood levels or maximum tolerated side effects. Other antidepressant drugs which have shown some benefit are venlafaxine, which has fewer side effects than tricyclics and was shown in a small trial to benefit patients with painful sensory neuropathy related to cancer. Bupropion diminished pain by about 30% in patients with neuropathy from multiple causes within six weeks of treatment. 6. COST VS. COMPLIANCE Anticonvulsants have been used for many years, particularly for pain described as electrical, lancinating or shooting. These medications block ionic channels, suppressing abnormal firing of the excitable nerve cell membranes. The commonly used anticonvulsants for pain include carbamazepine, valproate, phenytoin, gabapentin, clonazepam, and oxcarbazepine. Carbamazepine has limited use in the cancer population because of possible bone marrow suppression. Phenytoin can be administered using a loading dose, which may be useful in patients with severe pain. Gabapentin is a useful drug in the cancer population for the management of neuropathic pain, with its more favorable side effect profile. Clonazepam is commonly used for treating lancinating or paroxysmal neuropathic pain. Continued on Page 7 PRN Newsletter Vol. 5(2) 1

2 Provigil - and Opioid-induced Narcosis Seth Cohen, MD as the end of the day approaches. Choosing between pain relief and drowsiness is a not a good choice. The side effects of opioids are well known to include nausea, sedation, and constipation. Often, clinicians are limited in the amount of an opioid that can be given to a patient secondary to intolerable side effects. To prevent and treat the complications of opioids, patients are placed on laxatives and may need to be rotated on various opioids to avoid and attenuate the side effects. A patient s quality of life can be impacted if sedation begins to interfere with activities of daily living. Patients often lower the opioid dose without direction in order to regain cognitive thought while sacrificing adequate pain control. There are many therapeutic options for patients with opioid-induced narcosis. Healthcare workers need to rule out other sources of sedation, including concurrent infection, thyroid disease, depression, CNS disorders, and severe constipation. Other non-opioid agents can also contribute to progressive sedation; therefore, a complete review of all medications is essential. Furthermore, opioid-sparing agents like NSAIDs and adjunctive therapies in the form of radiation therapy and nerve blocks should always be considered. Pharmacological approaches provide another option. These include the psychostimulants methylphenidate and dextroamphetamine, and newer agents like Provigil (modafinil). Provigil (modafinil) is a wake-improving substance that has been FDA approved for excessive daytime sleep (EDS) associated with narcolepsy. Although the mechanism of action is unknown, the pharmacological actions may be similar to CNS stimulants. However, unlike these agents, the side effect profile is different from sympathomimetic amines. Provigil does not affect nighttime sleep, blood pressure, or heart rate. Provigil is well tolerated, with the most common side effects being mild, including headaches, nervousness, anxiety, insomnia, nausea, and diarrhea. Patients report smoother onset of action with Provigil and less crash Provigil is an oral medication given in starting doses of mg and titrated up to 400 mg to achieve the desired effect. The primary route of metabolism is the liver. There is interaction with drugs that are metabolized through the cytochrome p-450/cyp2c19 enzyme. Drugs that affect this pathway include diazepam, phenytoin, and propranolol. Moreover, caution is advised with elderly patients and those with hepatic impairment secondary to the slower metabolism and, therefore, lower doses are advised. While other potential pharmacological agents are on the horizon, Provigil is being used in the off-label setting for opioid-induced narcosis. In the future, more comprehensive studies need to further our understanding and use of this potentially beneficial agent. Source: Required Screening for Pain: Every outpatient visit Admission to inpatient setting Vital signs 5 th vital sign PRN Newsletter Vol. 5(2) 2

3 PRN Matching Game Regina Rocchi, RN, OCN Trade Name 1. Flexeril Hydrocodone Generic 2. Dilaudid Fentanyl 3. Ecotrin Ibuprofen 4. Darvon Ketorolac Tromethamine 5. Trilisate Gabapentin 6. Ultram Oxycodone 7. MSIR Dexamethasone 8. Vioxx Celecoxib 9. Motrin Cyclobenzaprine Hydrochloride 10. Celebrex Naproxen Sodium 11. Tylenol Hydromorphone 12. Duragesic Propoxyphene 13. OxyContin Pamidronate 14. Aredia Aspirin 15. Lortab Morphine 16. Aleve Sodium Salicylate 17. Demerol Rofecoxib 18. Decadron Tramadol 19. Toradol Meperidine 20. Neurontin Acetaminophen (answers on Page 4) Pain Assessment Includes: Onset Location Duration Character/quality Alleviating factors Aggravating or precipitating factors Rating PRN Newsletter Vol. 5(2) 3

4 New Product Information: Gelclair for Mucositis Marilyn Riley, RN, BSN, OCN Gelclair is a bioadherent oral gel used to coat the wound and soothe the pain of mucositis. By forming a protective barrier over the oral mucosa, it shields exposed nerve endings and reduces pain. The coating protects the mucosa and allows the individual to eat and drink more easily. The improved oral intake, in turn, improves nutrition. Oral mucositis or stomatitis is a common complication for patients receiving high-dose chemotherapy, or for head and neck cancer patients receiving radiation therapy. Treatment includes good oral care, hydration, systemic analgesics and topical preparations. Lidocaine/Xylocaine-based magic mouthwashes can be helpful but are short-acting. These products produce numbing and increase the risk for trauma, like biting the inside of the cheek. The gag reflex may be impaired if these products are swallowed. If the mouthwash contains diphenhydramine (Benadryl ), it may dry the mucosa. Gelclair has three key ingredients that form a film coating, enhance hydration, and inhibit inflammation. It is a non-numbing agent that is easy to use. Single dose (15-mL) packets are diluted in one tablespoon of water. Stir and use at once. More water can be added if it is too viscous. Rinse the mouth with the solution for one minute, thoroughly coating the tongue, roof of the mouth, throat, inside of cheeks and oral tissue. Gargle and spit out. Avoid eating or drinking for one hour after use. Use three times a day or more to control pain. In mild to moderate mucositis, Gelclair can provide as much as 5-7 hours of relief. In severe mucositis, it may be necessary to use it more frequently because the duration is reduced to a 45-minutes to two-hour range. New Medication New Darvocet preparation approved Darvocet A500. The 100-mg propoxyphene mg acetaminophen preparation has less acetaminophen than Darvocet N (650 mg). Product launch in October. Propoxyphene: Poor Choice Pamela Kedziera, MSN, RN, AOCN Propoxyphene is a schedule IV controlled substance. It is indicated for mild to moderate pain but has only 1/3 to 1/2 the potency of codeine. Efficacy with this agent has been shown to be no better than NSAIDS and equal to acetaminophen, or aspirin. Propoxyhene s biggest drawback is its metabolite, norpropxyphene, the half-life of which is hours, much longer than the 4-6 hour analgesic effect. It is the metabolite that is responsible for the toxicities which include, CNS depression, cardiotoxicity, seizures and pulmonary edema. This drug is a poor choice for those with renal impairment because the drug and its metabolite are metabolized by the kidneys. The American Geriatric Society (2002) suggests that other analgesic strategies are more appropriate. Dosing is limited by the amount of combined ASA or acetaminophen. Preventive mouth care and early treatment of mucositis is an important component of patient care. Gelclair offers a new option for preventing pain, increasing the ability to eat and drink, and enhancing patient comfort. Reference: Gelclair prescribing information Cell Pathways 2002 Answer Key from Page 3 (ordered top to bottom) 15; 12; 9; 19; 20; 13; 18; 10; 1; 16; 2; 14; 4; 3; 7; 5; 8; 6; 17; 11 For more info: or PRN Newsletter Vol. 5(2) 4

5 EMLA Cream vs. ELA-Max Suzanne Anastasia, RN, BSN EMLA is a prescriptive anesthetic mixture of 2.5% lidocaine and 2.5% prilocaine. Two safe and effective topical anesthetics are available to prevent and reduce the pain of minor procedures. The emulsion cream is applied to the skin and covered with an occlusive dressing for at least 60 minutes. EMLA is now once again available to patients following a brief recall for repackaging. FCCC patients have been using ELA-Max, an over-the-counter 4% lidocaine cream, as a substitute. Below is a comparison of the two: How supplied: Directions for use: Duration: EMLA Prescriptive 5-gram tube 30-gram tube anesthetic discs Apply thick layer to skin, cover cream with occlusive dressing without spreading cream 1-4 hours; most effective at 2-3 hours Will last one hour after dressing is removed ELA-Max Over-thecounter (OTC) 5-gram tube 30-gram tube Apply thick layer to skin, no occlusive dressing needed, best to rub in 30 minutes to effect EMLA Cream and ELA-Max are both about equal in cost ($40-70). However, ELA-Max is available over the counter and will not be covered under a prescription plan. In a study comparing the two drugs at Oregon Health and Science University, ELA-Max applied for 30 minutes was found to be as effective as EMLA applied for 60 minutes. EMLA is most effective minutes after application. Currently, there is no data regarding longer application times for ELA-Max. In addition, the study found that rubbing in ELA-Max was not only a challenge, but also messy ; therefore, they used an occlusive dressing over the cream. According to Helen Turner, MSN, RN, CNS of Oregon Health and Science University, a variety of clinicians do not feel ELA-Max works as well as EMLA. Chart It! Order Date Exp. Date Sec/RN Init. RN Init. Remember to document: Response to ATC analgesics Response to PRN analgesics Full assessment of pain Calculation Corner Ann Pellegrino, OCN, MSN, CRNP Med Frequency and Route Admin. Date Time Initial Route Effect Sally Sharp has right-shoulder pain that started three weeks ago. It is constant and sharp. She rates the pain a 3/10. She tells you that she has been taking Zydone (7.5 mg hydrocodone / 400 mg acetaminophen) one tablet every four hours. Today, before she left for her appointment, she took two tablets because she knew that sitting would make her very uncomfortable. Sally then tells you that she lies in bed all day with her right arm propped up on pillows so her pain medicine works. When she tries to participate in normal activity her pain becomes 8-9/ What dose of OxyContin would you order for Sally? 2. What dose of oxycodone would you order for breakthrough pain? Answer 3/2 = 35/x 105 = 3x x=35 35mg of oxycodone in 24 hours mg of OxyContin every 12 hours 2. 5mg of oxycodone every four hours PRN Sources were the EMLA cream package insert and an abstract from Helen Turner at Oregon Health and Science University PRN Newsletter Vol. 5(2) 5

6 vs. Compliance Elaine McCann-Jones, RN, OCN To assure compliance, know the cost of medications prescribed. Inquire about patients prescription plans: Are they self-pay? Is only a small percentage paid by the plan? Do they have co-pays? Co-pay with brand name? Any limit on the number of tablets? * Prices based on AWP (average wholesale price) expect double/triple the price! OxyFast 20 mg/1 cc 1 cc = $4.83 (comes in 30-cc bottle) Short-acting Drug Use for breakthrough, acute, or limited time Oxycodone 1-5 mg tab + 35 Percocet 1-5 mg oxycodone 325 mg Tylenol = $1.28 or 1-10 mg oxycodone 325 mg Tylenol $1.81 Long-acting Drug Use for chronic or long-term pain OxyContin 1-10 mg q12h = $ mg = $ mg = $ mg = $ mg = $16.55 *Daily *Monthl y $4.83 $ Roxanol (MSIR) 10 mg/1 cc 1 cc = 70 (comes in 30-cc bottle) $1.40 $ /day Morphine Tabs (generic) 15 mg = mg = 33 5-mg $5.12 $ (4/day) 10-mg $3.62 $ (10-mg tabs may be broken in half) *Daily Monthly 10 mg $2.96 $88.80 MS Contin 15 mg = $1 30 mg = $ mg = $ mg = $ mg = $ cc q4-6 $ Dilaudid (generic) 2 mg = 8 4 mg = 11 8 mg = $ mg q4-6 $ Daily Monthly 15 mg = $2 $60 Fentanyl Patch (Duragesic) 25 µg = $15.14 q72h 50 µg = $26.70 q72h 75 µg = $40.70 q72h 100 µg = $54 q72h 4 mg = 44 $13.20 *Based on four doses daily Q3day Monthly 25 µg $ $15.14 PRN Newsletter Vol. 5(2) 6

7 Adjuvant Pharmacologic Treatments for Pain (Continued from cover) Common side effects of anticonvulsants: Sedation Ataxia Vertigo Blurred vision Slurred speech Nystagmus Hyperglycemia Gum hyperplasia (phenytoin) Blood dyscrasias (except gabapentin) Skin disorders Local Anesthetics Local anesthetics are sodium channel blockers and have been used for neuropathic pain. Mexiletine has been beneficial in the management of diabetic neuropathy and tocainide has been effective in the management of trigeminal neuralgia. Adverse effects include nausea, vomiting, CNS effects of dizziness, lightheadedness and tremor. These medications may potentially prolong a cardiac conduction defect; a baseline EKG is recommended. Topical lidocaine exerts its effect by reducing ectopic neural discharges in superficial nerves. Patients may benefit from patches, which match a specific area where there is excessive pain. Corticosteroids Corticosteroids are indicated for cancer pain of bone, visceral and neuropathic origin. Dosages range from low dose therapy to a larger starting dose (10 mg bid) with tapering to the minimal effective dose. High doses for short periods may benefit patients with severe pain. Adverse effects: Gastrointestinal disturbances Neuropsychiatric symptoms Immunosuppression Hyperglycemia Candidiasis Fluid retention Proximal myopathy Pseudorheumatism on withdrawal Bisphosphonates Bisphosphonates are recommended for management of bone pain, as well as the prevention of skeletal complications in patients with metastatic bone disease. Pamidronate in the dose range of mg IV over 2 hours every 3-4 weeks and zoledronic acid in the dose range of 4-8 mg IV over minutes every 3-4 weeks are available in the United States. Psychostimulants Psychostimulants may enhance the analgesic effect of opioids and may be used to diminish opioid induced sedation. This category of drugs includes dextroamphetamine, methylphenidate and modafinil. Potential side effects include nervousness, insomnia, dizziness, dry mouth, anorexia, diarrhea, hypertension, palpitations, tremors, seizures and hepatic dysfunction. N-methyl-D aspartate (NMDA) receptor antagonists may have a role in cancer pain management. Ketamine, methadone and dextromethorphan are drugs in this category. Ketamine may have severe psychotropic effects such as hallucinations. The oral route has less adverse effects. Miscellaneous Some of the other adjuvant medications for pain include: Baclofen for spasticity and neuropathic pain. Side effects include drowsiness, dizziness, ataxia, confusion, nausea and vomiting. Calcitonin for bone pain and neuropathic pain. Side effects relate to local reactions at the administration site and gastrointestinal symptoms. Clonidine for the management of neuropathic pain. Side effects may be dry mouth, dizziness, hypotension, sedation and constipation. There are other categories of adjuvant drugs that alleviate pain and relieve symptoms, which exacerbate pain. Neuroleptics such as haloperidol, prochlorperazine and promethazine may help with neuropathic pain as well as with other symptoms, such as nausea. Potential toxicities are sedation, orthostatic hypotension, confusion, extrapyramidal reactions and tardive dyskinesia. Benzodiazepines relieve anxiety that increases pain. Sedation, delirium, motor incoordination, hypotension, dizziness and respiratory depression are adverse effects. With this brief overview of adjuvant pain medications, it is obvious that nursing assessments and patient education must be ongoing to prevent adverse reactions that could compromise patient well-being and safety. References Mendell, J. & Sahenk, Z. (2003). Painful sensory neuropathy. The New England Journal of Medicine. 13, Web Site healthprofessional PRN Newsletter Vol. 5(2) 7

8 Editor Jerome Koss, RN, OCN Editorial Board Norma Fenerty, RN,C, BSN, OCN Jean Holland MSN, RN, OCN Pamela Kedziera, MSN, RN, AOCN Layout & Design Delonjo Barber Guest Editor Ann Pellegrino, OCN, MSN, CRNP The views expressed in do not necessarily reflect the views of the Fox Chase Cancer Center Vice President of Nursing & Patient Services Joanne Hambleton MSN, RN, CNA PRN Newsletter Vol. 5(2) 8

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