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Adjunct Agents for Opioid-Sparing Analgesia
Adjunct Agents for Opioid-Sparing Analgesia
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Video Transcription
I'm gonna just wrap up this conversation with talking a little bit about various other adjuncts that are available to us and I'm gonna talk a little bit about multimodal analgesia and other opioid sparing techniques. Now when we do talk about opioid sparing, there is, I am not under the impression that we are going to completely eliminate opioids from our ICU. Opioids still play a big role in our ICU. They work best for acute pain. It can be used in infusions versus oral regimens and in patients that come in with acute and chronic pain. That is where the challenge comes in patients in the opioid epidemic where we, they require a lot and I think many clinicians have been, have found that we end up underdosing those patients with patients who have chronically been on chronic opioids. So it is very important that we calculate the requirements per the patient's needs. A 24-hour oral morphine and then come up with an equi-analgesic dose for those patients knowing that the opioid-tolerant patients will definitely have higher needs and we need to give them higher doses if they need it. There is a long-acting methadone that can be used and with short-acting agents for breakthrough pain in the middle. We do have to monitor these patients for respiratory and hemodynamic instability with very careful titration of medication dosing. We do need to monitor these patients for signs of withdrawal. Now the opioid sparing treatments that I'm going to talk about have been found to first of all improve analgesia, reduce the side effects and there is definitely the concept of opioid-induced hyperalgesia and tolerance to opioids. So the, all these techniques have been found to decrease hyperalgesia and improve tolerance. Now tricyclic antidepressants and SSRIs have been used mainly in chronic pain. The reason why they don't, they're not very well suited to the ICU patients is that they have a very long half-life and undesirable side effects like ICU delirium. Hence, we do not use them a lot in our ICU setting. So what is multimodal analgesia? Multimodal is basically approaching pain through multiple modes or multiple receptors targeting different receptors in the patient's brain and achieving the level of pain control that we desire in the patient. Now that includes the use of adjuncts to minimize opioid doses. We have agents like acetaminophen, non-steroidals, anti-inflammatory agents and gabapentinoids. These are used in most multimodal pain regimens. Almost every institution has an ERAS protocol and they are incorporated into that. Tylenol or acetaminophen, as we all know, is a very good analgesic. It has been proven to be effective in anybody that's an adult over 50 kilograms with a normal hepatic function up to a dose of 4 grams per day. It can be combined with opioids, hydrocodone, acetaminophen or oxycodone acetaminophen combinations. In patients with hepatic dysfunction, they can be used also but we need to be very careful about monitoring the acetaminophen levels in those patients. There has always been a controversy about oral versus IV acetaminophen and there have been studies back and forth about which one is more effective and as of now I think the conclusion that we have all come to is that they are equally effective oral versus IV acetaminophen and I've listed some studies over there which have been systematic reviews of current evidence to support the clinical decision-making. These oral is preferred obviously because of the cost. It's preferred in patients but IV acetaminophen is would be obviously used a lot in patients in our ICUs that we see that cannot have oral medications being given to them or the gut cannot be used for effective pain control. NSAIDs. NSAIDs are the COX inhibitors. They have very good anti-inflammatory properties. They come in the selective and the COX2 which are the more selective ones and non-selective inhibitors. They are the most controversial of the multimodal pain regimens predominantly due to their side effects of post-operative bleeding, impaired bone healing in orthopedic surgeries, the GI side effects and there have been some studies showing association with AKI and myocardial infarction in these patients. Though I do have to mention that the evidence is lacking to support or refute many of these side effects. These are mainly retrospective or observational data. So but they do the very big benefit is had it has a proven efficacy and it so I do definitely use NSAIDs in my patient population though we do we are very careful about using the lowest possible dose for the shortest period of time. Gabapentin. Now gabapentin mainly involve, gabapentinoids involve gabapentin and pregabel. They were initially approved for use in chronic neuropathic pain or though are being increasingly being used for for acute pain. They are controversial. Some studies have shown benefit in some patients and some studies have shown lack of benefit in a different patient population. So I think given if you know well versed, if you're well versed with the side effect panel mainly older patients, patients with a possibility for confusion, those are the patients that we do not try to use those these agents in them and we do need to balance the side effect versus benefit profile in the of gabapentinoids. Really quickly I just wanted to mention some non pharmacological agents such as music, acupuncture. Now music there has actually been a Cochrane database systematic review done showing music therapy in patients that are even on the ventilators and in the ICU for long periods of time. It has been shown to decrease anxiety and to decrease the the analgesic the doses of opiates that we use in these patients. Acupuncture is another another mortality that has been studied and has been noted to be beneficial for pain control in some patients. So I'm not at our institution we definitely we are not a cure but if you have a system in place where you can use acupuncture in your institution I think it would be good adjunct to have. TENS is also transcutaneous lytic nerve stimulation. It has been noted to work via the central and alpha adrenergic alpha-2 adrenergic receptors in in the brain and that is one agent that can be used. Some people use it in their ICUs. Massage is another therapy that has been shown to help with post-operative pain management in some patients.
Video Summary
In this video transcript, the speaker discusses various adjuncts and opioid sparing techniques for pain management in the ICU. While opioids still play a role in acute pain, there is a challenge in managing patients with chronic opioid use. It is important to calculate the appropriate dosage for these patients and monitor for signs of withdrawal. Other treatments such as tricyclic antidepressants and SSRIs are mainly used for chronic pain but have undesirable side effects for ICU patients. Multimodal analgesia, which involves targeting multiple receptors in the brain, can help improve pain control and reduce side effects. Common adjuncts include acetaminophen, NSAIDs, and gabapentinoids. Non-pharmacological treatments like music therapy, acupuncture, TENS, and massage can also be beneficial.
Asset Subtitle
Pharmacology, 2023
Asset Caption
Type: one-hour concurrent | Innovative Approaches to Acute Pain Management in Critically Ill Patients (SessionID 1144410)
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Presentation
Knowledge Area
Pharmacology
Membership Level
Professional
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Analgesia and Sedation
Year
2023
Keywords
adjuncts
opioid sparing techniques
pain management
ICU
multimodal analgesia
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