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Pain Management
What is pain?
A protective mechanism to warn of damage or
the presence of disease
Part of the normal healing process
ANALGESICS
I. Opioid (narcotic) analgesics
1. Agonists of opioid receptors morphine hydrochloride, promedol,
omnopon, fentanyl, codeine;
2. Agonists antagonists and partial agonists of opioid receptors
pentazocin, buprenorphine.
II. Non-opioid analgesics and non steroidal anti-
inflammatory drugs - NSAIDs
acetylsalicylic acid, paracetamol, analgin, indometacin, butadion,
ibuprofen, pyroxicam, diclofenac-sodium, ketorolac, ketoprofen.
III. Substances with mixed mechanism of action
(opioid and non-oioid components)
tramadole
The structures that take part in perception of pain:
thalamus, hypothalamus, reticular formation,
limbic system, occipital and frontal areas of
cortex
System which conducts and perceives pain -
nociceptive
Nociceptors - An Introduction to Pain.mp4
System which protects organism
from pain antinociceptive
Classification of Pain
By Onset and Duration
Acute pain
Sudden in onset
Usually subsides once treated
Chronic pain
Persistent or recurring
Often difficult to treat
Major Sources of Pain
Source Area Involved Characteristics Treatment
Analgesia
Respiratory
depression
Euphoria
Dysphoria
Decrease GI
motility
Physical
Dependence
Mania,
hallucination
Morphine CNS
Depressant effects Stimulate effects
Analgesia CTZ (nausea, vimiting)
Indifference to surroundings Edinger Wesphal nucleus
Mood and subjective effects (III nerve producing miosis)
Depression of respiration Vagal centre (bradycardia)
Cough centre Certain cortical areas and
Temperature regulating hippocampal
centre
Vasomotor centre
Morphine can be used as an
analgesic to relieve:
pain in myocardial infarction
pain associated with surgical conditions, pre- and
postoperatively (pre-anesthetic medication, balanced
anesthesia, surgical analgesia)
pain associated with trauma, burns
severe chronic pain, e.g., cancer
pain from kidney stones, renal colic, ureterolithiasis, etc
(pain may be valuable for diagnosis: should not be relived by
analgesic unless proper assessment of the patient has been done)
traumas of thorax accompanied by cough (morphine depresses
central links of coughing reflexes)
Applications in Dentistry
Precaution
pain that accompanies chronic inflammatory pain
children before the age of 2 years
Tolerance
Tolerance is a diminished responsiveness to the drugs action
that is seen with many compounds
Tolerance can be demonstrated by a decreased effect from a
constant dose of drug or by an increase in the minimum drug
dose required to produce a given level of effect
Physiological tolerance involves changes in the binding of a
drug to receptors or changes in receptor transductional
processes related to the drug of action
This type of tolerance occurs in opioids
Addiction
Physical dependence
Physiological dependence
Withdrawal reactions
Tolerance and Dependence
Withdrawl Reactions
Acute Action Withdrawl Sign
Analgesia Pain and irritability
Respiratory Depression Hyperventilation
Euphoria Dysphoria and depression
Relaxation and sleep Restlessness and insomnia
Tranquilization Fearfulness and hostility
Decreased blood pressure Increased blood pressure
Constipation Diarrhea
Pupillary constriction Pupillary dilation
Hypothermia Hyperthermia
Drying of secretions Lacrimation, runny nose
Reduced sex drive Spontaneous ejaculation
Flushed and warm skin Chilliness and gooseflesh
Fentanyl
synthetic opioid analgesic of short action
analgesic activity is 300 times higher
than of morphine
analgesic effect after intravenous
introduction after 1-3 min, lasts for
15-30 min
used with neuroleptic droperidol
(complex drug talamonal) for
neuroleptanalgesia
fentanyl transdermal system
should be used for long-
term (chronic) pain
requiring continuous
narcotic pain
Is designed to release the
drug into the skin at a
constant rate ranging
from 25 to 100
micrograms/h,
Codeine
opium alkaloid
analgesic action is not strong, but
anticough effect is considerable
administered as an anticough drug of
central action
combination with non opiod analgesics
(eg. Paracetamol) is supra-additive
Acute poisoning with opioid analgesics
Respiratory Depression
Euphoria
Relaxation and sleep
Tranquilization
Decreased blood pressure
Constipation
Pupillary constriction
Hypothermia
Drying of secretions
Flushed and warm skin
Triad in case
poisoning with
morphine
Acute miosis
(Pinpoint
pupils)
Cheyne Stokes
respiration
deep tendon
reflexes
increased
Treatment of acute poisoning
Naloxon (antagonist of opioid receptors)
intravenously - 0,4-1,2 mg
general dose of naloxon should not overcome 10 mg
stomach lavage (for morphine enterohepatic circulation
is typical) with 0,05-0,1% solution of potassium
permanganate and 0,5 % tannin solution
NON-OPIOID
ANALGESICS
Pharmacodynamic Effects
Analgesic
Antipyretic
Anti-inflammatory
(except paracetamol)
Mechanism of action of non-opioid analgesics
COX-1 COX-2
Kidney vasodilation
Indications for administration of non-
narcotic analgesics
headache
toothache
backache
neuralgias
pulled muscles
joint pain
dysmenorrhea
for potentiating of their action combinations
paracetamol with codeine,
metamizol with dimedrol, metamizol with codeine
Paracetamol
(Acetaminophen)
analgesic and antipyretic drug
maximal effect if the drug is introduced
orally after 2 hours, lasts approximately
for 4 hours
in case of durable administration of big
doses damaging of liver and kidneys
Paracetamol (Acetaminophen)
N-Acetyl-P-Aminophenol
Tablets
Suppositories
Syrups
Capsules
PARACETAMOL
Pharmacokinetics: paracetamol
Ampoules
tablets
suppositories
Analgesic and
spasmolytic
activity
Traditional and selective COX-2
inhibitors
Ketorolak (ketanov)
according to analgesic activity it
prevails over effect of acetylsalicylic
acid, indometacin and equals to
opioid analgesics
moderate anti-inflammatory,
antipyretic and anti-aggregate effects
high effectiveness in case of pain in
postoperative period, in oncology,
during child delivery, traumas, colic
i/m, i/v, orally
NOT indicated
for chronic pain syndrome
Ketoprophen (ketonal)
strong analgesic, anti-inflammatory and
antipyretic agent
administered in case of arthroses and
arthritis, ancilizing spondilitis, pain of
different genesis (after surgeries, in case
of traumas, painful menstruations etc.)
administered orally, intramuscularly, in
forms of suppositories and ointments
TRAMADOL
Analgesic activity is similar to the activity
of morphine
Abuse potential is low
Less respiratory depression
Hemodynamic effects are minimal
In case of intravenous administration effect
develops after 5-10 min, if administered
orally after 30-40 min, action lasts for
3-5 hours.
QUESTIONS?!