PAIN DRUGS HANDBOOK TABLE
OF CONTENTS
About the
Author
About
the Handbook
Acknowledgments
Forward
to 2rd Edition
Forward
to 1st Edition
DRUGS (Alphabetical Order)
TOPICAL AGENTS
Amitriptyline
Baclofen
Clonidine
Cyclobenzaprine
2-deoxy-d-glucose
Dexamethasone
Dextromethorphan
Diclofenac
Doxepin
DMSO
Gabapentin
Ketamine
Ketoprofen
NEUROLYTIC AGENT
Phenol
APPENDICES
Appendix 1: World Health Organization
Three-step Ladder
Appendix 2: Drug Tables
Appendix 3: Infusion Tables
Appendix 4: Relative Potencies of
Opioids Effects
Appendix 5: Relative Potencies of Steroids
Appendix 6: Intravenous PCA
Standard Orders
Appendix 7: Patient Controlled Analgesia Flow Sheet
Appendix 8: Relative Potencies of Opioids
Appendix 9: Epidural Analgesia Monitoring Orders
Appendix 10: Pain Rating Scales
Appendix 11: Multiplication Factors for Converting the
Daily Dose of a Prior Opioid to the Daily Dose of Oxycontin
Appendix 12: CPR Algorithms
Appendix 13: Pediatric CPR Algorithms
Appendix 14: Trade Name Table
BIBLIOGRAPHY
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Sota
Omoigui's
Pain Drug Handbook
2nd Edition:
Nalbuphine
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SECTION
ONE:
Class,
Uses, Dosing,
Elimination
SECTION TWO:
Preparation, Pharmacology, Pharmacokinetics
SECTION THREE:
Interactions, Toxicity
Guidelines/Precautions
Principal Adverse Reactions
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Class
(NARCOTIC AGONIST-ANTAGONIST)
Uses
treatment of acute and chronic pain
Dosing
Pain: IV/IM/SC 5-10 mg (0.1-0.3 mg/kg) every 3-6 hours
Patient Controlled Analgesia IV: bolus 1-5 mg (0.02-0.1 mg/kg)
infusion 1-8 mg/hr (0.02-0.15 mg/kg/hr)
Lockout Interval 5-15 minutes
Administer analgesic regularly (not prn). Due to impaired elimination, accumulation and excess sedation may occur in patients with hepatic dysfunction. Analgesia may be enhanced by addition of adjuvant drugs e.g. NSAIDs, antidepressant agents (see front matter for drug combinations) and use of non-drug therapies e.g. TENS.
Elimination
hepatic
Preparation
Nalbuphine HCL (Nubain)
Injection: 10 mg/ml, 20 mg/ml
Pharmacology
A synthetic opioid agonist-antagonist and a potent analgesic, nalbuphine is related chemically to oxymorphone and naloxone. Nalbuphine is equal in potency as an analgesic to morphine and one-fourth as potent as nalorphine as an antagonist. It exhibits ceiling effect at high doses (greater than 30 mg) for respiratory depression and analgesia. It is effective in reversing the ventilatory depression of agonist opioids e.g. fentanyl, while maintaining reasonable analgesia. In patients who are not opiate-dependent , the analgesic effects of nalbuphine and morphine are additive, but in patients tolerant to opiates, nalbuphine may produce a dose related reduction in the analgesic effects of morphine. Nalbuphine is not recommended for patients with cancer pain and patients who have received opioids on a long term basis. Naloxone reverses the respiratory depressant, analgesic and sedative effects of nalbuphine.
Pharmacokinetics
ONSET OF ACTION: IV 2-3 minutes IM/SC <15 minutes
PEAK EFFECT: IV 5-15 minutes
DURATION OF ACTION: IV/IM/SC 3-6 hours
Interactions
potentiates CNS and circulatory depressant effects of other narcotic analgesics, volatile anesthetics, phenothiazines, sedative-hypnotics, alcohol, tricyclic antidepressants; analgesia enhanced and prolonged by narcotic and non-narcotic analgesics (e.g. aspirin, acetaminophen), alpha-2 agonists (e.g. clonidine).
Toxicity
Toxic Range:
Not routinely monitored
Manifestations:
Somnolence
Coma
Respiratory Arrest
Apnea
Cardiac Arrhythmias
Combined respiratory and metabolic acidosis
Precipitation of withdrawal symptoms from opioids:
abdominal cramps, vomiting, skin crawling, piloerection,
nasal stuffiness, lacrimation, yawning, sweating, tremor, myalgia
Circulatory Collapse
Cardiac Arrest
Death
Antidote:
Naloxone 0.4-2 mg IV/IM/SC. Repeat dose every 2 to 3 minutes to a maximum of 10-20 mg.
Do not administer naloxone if withdrawal symptoms are present. Conversely, administer opioid agonists, benzodiazepines and treat withdrawal symptomatically.
Management:
Discontinue or reduce medication
Support ventilation and circulation (Patent Airway, Oxygen, IV Fluids, Vasopressors)
Administer antidote
Monitor blood gases, pH and electrolytes
Correct acidosis and electrolyte disturbance (lactic acidosis may require IV sodium bicarbonate 1-2 mEq/kg)
Symptomatic treatment
Airway protected - ipecac syrup induced emesis (30 mls or 0.5 mls/kg ipecac syrup followed by 200 mls or 4 mls/kg of water or clear fluid) or gastric lavage (with drug ingestion) followed by administration of activated charcoal (PO 50-100 grams or 1-2 gram/kg)
Guidelines
(1) Reduce dosage in elderly patients and with concomitant use of narcotics and sedative hypnotics.
(2) Prescribe or supply an antiemetic e.g. metoclopramide for use in the event of nausea and/or vomiting.
(3) Constipation may be more difficult to control than pain. Prevent and/or treat by daily administration of laxatives and stool softeners e.g. Colace (docusate sodium) 100-300 mg/day. Do not administer bulk forming agents that contain methylcellulose, psyllium or polycarbophil. Temporary arrest in the passage through the gastrointestinal tract may lead to fecal impaction or bowel obstruction.
(4) Tolerance may develop in all patients taking narcotic analgesics for more than a couple of weeks. It may be a function of dose, frequency and route of administration as IV and spinal infusions of narcotics are associated with rapid development of tolerance. The first sign is a decrease in duration of effective analgesia. To delay the development of tolerance, add adjuvant drugs e.g. NSAIDs, antidepressant agents, dextromethorphan or switch to alternative opioids (starting at one-half the equi-analgesic dose or supplement with non-drug therapies. e.g. TENS.
(5) Nalbuphine should be used with caution in patients who have been chronically receiving opiate agonists because nalbuphine does not suppress the abstinence syndrome in these patients and high doses may precipitate withdrawal symptoms. Titrated doses of benzodiazepines or opioid agonists may be used in the management of acute withdrawal.
(6) Drug combinations with adjuvant drugs enhance analgesia (see front section )
(7) Adjuvant drug therapies also include regional blockade, trigger point injections (with local anesthetics and steroids) and intravenous regional anesthesia.
(8) Adjuvant non-drug therapies include transcutaneous electrical nerve stimulation (TENS) and modalities such as ice or heat application, ultrasound and soft tissue mobilization.
(9) Patients should be warned that nalbuphine may impair their ability to perform hazardous tasks requiring mental alertness or physical coordination (e.g. driving a motor vehicle, operating heavy machinery).
(10) The drug formulation may contain sodium metabisulfite, which may cause allergic reactions or anaphylaxis in susceptible individuals
Adverse
CVS: hypertension, hypotension, tachycardia, bradycardia
PULM: respiratory depression, dyspnea, asthma
CNS: sedation, dizziness, vertigo, headache, euphoria, confusion, hallucinations
GI: nausea, vomiting, dry mouth
EYE: miosis
DERM: urticaria, itching, burning
OTHER: flushing, speech difficulty, urinary urgency
Reactions
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NOTICE:
Every effort has been made to ensure that the drug dosage schedules
herein are accurate and in accord with the standards accepted
at the time of publication. As new research and experience broaden
our knowledge, changes in treatment and drug therapy occur. The
medications described do not necessarily have specific approval
by the Food and Drug Administration for use in the situations
and the dosages for which they are recommended. This information
is advisory only. The package insert should be consulted for use
and dosage as approved by the FDA, for any changes in indications
and dosages and for added warnings and precautions. The ultimate
responsibility lies with the prescribing physician.
No part of this information may be reproduced or transmitted electronically
in any information storage or retrieval system, or within any
monitoring system without prior permission in writing from S.O.T.A.
Technologies (Electronic Publishers).
The Universal Drug Infusion Slide Ruler (patent pending) is now
available. It incorporates an infusion data guide and enables
infusion calculations for any drug at any dose and at any concentration.
It may be obtained by calling S.O.T.A Technologies (800 9-MEDIC-9)
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Copyright 2000. Sota Omoigui, M.D. All rights reserved.
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