Speaker 1  00:05
Lange, welcome to HelixTalk, a podcast presented by the Rosalind Franklin University College of Pharmacy.

Narrator - Dr. Abel  00:11
This podcast is produced by pharmacy faculty to supplement study material and provide relevant drug and professional topics.

Speaker 1  00:19
We're hoping that our real life clinical pearls and discussions will help you stay up to date and improve your pharmacy knowledge.

Narrator - Dr. Abel  00:27
This is an educational production copyright Rosalind Franklin University of Medicine and Science.

Speaker 1  00:32
This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified health care provider.

Narrator - Dr. Abel  00:47
And now on to the show.

Speaker 2  00:51
Welcome to HelixTalk. Episode 21 I'm your co host, Dr. King, and I'm Dr. Schuman. Today we're going to be talking about opioids, but not in the same sense that we have in the past. This time, we're going to talk about some of the adverse effects of opioids, some of the issues in terms of chronic use of opioids, reversal of opioids, and then finally, some of the non opioid analgesics that are available in the market.

Speaker 3  01:13
Alright, so one of the first things we're going to talk about is some statistics with about opioids. And my primary practice site is within a veteran population. So what I have when I've, when I've talked about these things in the past, is to use some of these numbers to let you know, you know, kind of where we stand and what to kind of discuss, you know, how much of a concern these are, to kind of see what it really is. Because I know this has been something that's, you know, comes up in the news from time to time, and we, in a lot of individuals, talk about the concerns with it, but what is, what's really going on? So within the veteran population, we're looking about a 50% prevalence of pain symptoms in general. And so among that, there's about 7.7% when they did a 2012 study, about 7.7% of those veterans that had pain received an outpatient opioid prescription. And of those, one in three received as chronic opioids, and that was defined as more than 90 day use. So instead of just maybe an acute flare up of symptoms for 10 days or 30 days for those that continue to receive it, and then maybe a little bit more concerning is that of those, there was a large number, about 92.6% that also received concurrent benzodiazepines. So Dr. King, any concerns you see with that use combination?

Speaker 2  02:25
Yeah. So as we'll talk about, there's a number of different risk factors for opioid induced respiratory depression and altered mental status. CNS depression, one of those big risk factors is concurrent use of medications in addition to your opioid that causes sedation or somnolence. Benzodiazepines are a great example of that. So a patient who takes benzodiazepines and has frequent use of opioids is at a much higher risk for opioid induced respiratory depression or other adverse events compared to someone just taking an opioid or just taking the benzo alone,

Speaker 3  02:56
right and so and you know, to further illustrate is when and when the doses get higher and higher, that's when we see more concern, or as we talk about as we get older, our body's ability to metabolize these changes. So about 1.2% of individuals, again, during some of those years of 2012 received high dose opioids, and that was determined as a morphine equivalent, greater than 200 milligrams. And those numbers can can vary, though, there was another study that actually estimate follow up, study that estimated as high as 9.7% so the true number may be somewhere within there, depending on where we get our sample size. But what it does mean is there's a decent number of individuals who are getting these higher doses. And as we said, you combine these with other medications, we start adding polypharmacy. We're at a higher risk of side effects. Dr. King, what kind of side effects are we

Speaker 2  03:43
talking about? Yeah. So the main side effect I always would counsel patient on with respect to opioids, is constipation. One thing that I encourage patients to do, especially if they're not opioid tolerant, is to think about a bowel regimen when they initiate opioid therapy. So I like Senna. I like MiraLAX or Senna with docusate. Don't really like docusate on its own, because it doesn't really have any stimulant quality to it. It's just an emollient laxative. But constipation can be very troubling for patients, and

Speaker 3  04:12
this is another point of emphasis that the VA is in 2014 when they release some of their newer recommendations, making sure to have and even in the 2010 recommendations, it was there as well, really making sure to have that bowel regimen on hand. Because, again, you start adding other medications. If somebody's on, you know, diphenhydramine or Benadryl, whether it's for sleep, whether it's for anxiety, whether it's for allergy symptoms. Again, you start adding anticholinergic medications to that mix, and you are further reducing bowel motility. And then you start adding again, in my area, psychiatric medications. And again, that's just another one that adds to that mix some of your antipsychotics, your antidepressants as well can have some anticholinergic effects. So the more you add again, we're further causing some concern. So what other types of. Of concerns that

Speaker 2  05:01
we have. Yeah, so going along the anticholinergic route, we can see urinary retention with these agents. This is not uncommon in my field, for patients that have semi elective procedures where the next day they have difficulty urinating, especially men with or without BPH, because sometimes the opioids can make it more difficult to urinate as we increase our dose, and kind of get to the top end of our therapeutic threshold, we see miosis, which is where patients' pupils become very constricted, or pinpoint pupils. We can see altered mental status, where patients can start having slurred speech. They can have slowed motor movements as again, as we're getting kind of to the toxic range, we can start seeing cold, clammy skin, hypothermia. We can see hypotension, bradycardia, and then finally, at the highest and definitely the most concerning safety issue with opioids is depressed respiratory drive, causing CO2 retention and also death. Patients die from prescription and illicit drug use of opioids like heroin, but even Norco, oxycodone, morphine, it's not just a rare event. It's actually fairly common that patients are having some of these high risk adverse events related

Speaker 3  06:15
to opioids. And when we talk about respiratory drive, what we're referring to is the fact that the body has the ability to sense its levels of oxygen and carbon dioxide, and so what happens is it loses its ability to kind of compensate. So when the body gets a high level of carbon dioxide, instead of the receptors recognizing that and then increasing your respiration rate, what you end up doing is you seeing seeing, no change. So those levels rise, and your body's not actually doing anything about it. So that's especially where this is concerning, and then that's what leads to later on to that respiratory failure and death. And then also, with the hypotension of bradycardia, there's maybe some release of histamine and things like that, to open up some of those vessels, and then that decreases this overall pressure.

Speaker 2  07:00
And just to point out, aside from the physiologic adverse effects that we see, all of these agents are DEA schedule II, III, maybe IV, for a reason: it's because they have abuse potential. Because of their abuse potential, because of their narrow therapeutic window, opioids have been a huge target for the FDA and for many hospital systems to try to decrease the risk of opioid induced adverse events. As an example, just last October, the DEA rescheduled hydrocodone products from DEA Schedule III to DEA Schedule II, making it much more difficult for patients to acquire larger quantities of Norco or Vicodin because of this new DEA scheduling.

Speaker 3  07:43
And then another example was in the last few years, what has been the case of Tramadol, a medication that, up to a few years ago, was unscheduled as a type of almost a hybrid, both with an opioid as well as an agent which has effects on serotonin and norepinephrine reuptake. It kind of had this, this dual purpose, and was used a lot, and we'll talk about some of those neurotransmitters later, is they can have some nice involvement in low back pain in treating that. But that medication began to be relied upon, and it's some of its use in certain areas got got a little bit out of control, so they ended up having to dial it back and making that one scheduled as well. And so Dr. Kane, if we're looking at risk factors for those individuals to having those adverse effects, anything in particular? So we talk about what it is, anything that can lend somebody to maybe more or less likely to have some of those.

Speaker 2  08:31
Yeah. So there's actually a lot of data surrounding risk factors associated with opioid induced respiratory depression or opioid induced over sedation. Most of the data comes from the hospital setting, where these patients are more closely monitored. But of the data that we do have, I think it can be extrapolated to the outpatient environment as well. So as an example, elderly patients, you would assume would be a higher risk for opioid induced sedation and respiratory depression, and that's absolutely true. So anyone 61 to 70 years old, the risk of an adverse event from an opioid is about 2.8 times higher if they're in their 70s, it's 5.4 times higher if they're 80 years or older, the risk of an opioid related adverse event is 8.7 times higher than the cohort less than 80 years of age. So there's a dose response curve, if you will, that the older you are, the more likely you are to have adverse events. This is related both to elderly patients are more sensitive to opioids, but also kinetically, they don't do as good of a job metabolizing off these drugs. Are more susceptible to the active metabolites of certain opioids. So there's a lot of factors that play into age, but the take home point is that elderly patients need less frequent dosing and lower doses because the risk is a lot higher of an adverse event.

Speaker 3  09:48
And then there are a few other conditions that that can be associated with an increased risk, and a lot of these next few are going to be more about difficulty with breathing or with difficulty with circulation of blood and getting that through the body. So one example would be obesity, though we, you know, we think, okay, individuals who are obese, larger body area, maybe larger foot volume, but in this case, again, that extra adipose tissue and difficulty breathing, you know, you make it worse, because, again, you're having to, you know, it's something that's gonna be difficult to draw on breath. If there's just, you know, a larger that central adiposity around those, those organs there, and then also a similar way obstructive sleep apnea. If you've got that difficult you already have issues with that respiratory drive, and what wakes you up is that stop breathing, and if that drive is decreased, then you're not going to have those wake up as you would. And that's the safety issue with, oh, with OSA, and again, we're making it worse. There's that something to really be careful of is, is, you know, is your body going to respond when the oxygen is low,

Speaker 2  10:48
again, going off? The idea of oxygenation, patients with COPD, or even patients that have a 20 pack year history of smoking or greater, are about double the risk of having a respiratory event because they do have impaired oxygenation, they have typically chronic CO two retention or carbon dioxide retention. So these patients are at a higher risk because of the damage that has been done to their lungs.

Speaker 3  11:12
You can also see an increased risk of about 4.7 times the risk with heart failure, 2.1 times the risk with renal impairment, and that not just renal impairment, meaning you know you're on dialysis. On dialysis, but even having a b u n that that's elevated above 20, which is not, not uncommon, can confer some of these issues as well.

Speaker 2  11:31
Then finally, at least in the hospitalized setting, the two biggest risk factors, independent of all of the factors that we've already discussed, if a patient is going to have an opioid related adverse event. The most common time that that will happen is if they're a post op patient within the first 24 hours of a post operative period, or within the first 24 hours of initiating a new opioid regimen. Typically this is going to be an IV analgesic, opioid analgesic. So within that first 24 hour period, that's kind of the worst time period in terms of if an ADR is going to happen, it's most likely going to happen during that time period.

Speaker 3  12:05
And then one other one that we've already touched on a little bit, and I'll just be brief with it, is concurrent sedating agents. And so with pain, you're also you may see depression, you may see anxiety. You may see insomnia, if, depending on the position, whether it's your hip pain or whether it's a back or a neck pain. Sure, you may have some of those other concerns. And so again, our antidepressants, some of our sleep meds, and, you know, and other types of medications, they can they can add some of those sedating effects, some of them that have a general CNS depressant effect. So we do have to be aware of those things when we're taking care of a regimen that we have to think about, not just each agent separately, but what they do as a as a sum total when they're when they're put

Speaker 2  12:47
together absolutely so Dr. Schuman in your practice, either inpatient or outpatient, if we do have a patient that experiences severe respiratory depression, what is the treatment of choice for these patients and how is it given?

Speaker 3  12:59
So that's a great question. So what we're doing right now is part of this opioid safety initiative, and we're really trying to take seriously about preventing these things and even even addressing them before they happen. So if we have individuals that are considered to be at high risk for an opioid overdose, again, whether that's, you know, accidental, or whether that's from from drug abuse of street drugs, then then we have couple of options using naloxone. And we also state this is not just even with just within the VA, but this is something that's growing even outside the VA. I know in certain cities, I believe Boston, Philadelphia, they're even looking at giving firefighters, police officers, even family members who know that you know a loved one is you know you at risk or is misusing, you know, again, whether it's prescription or street agents giving these medications. So it's becoming a push, not just with the VA, but nationwide. And again, naloxone is that agent, and it's, it's a pure competitive antagonist of those opioid receptors. And so it's not something that just kind of partially gets in there or works a little bit differently than opioid this one will get in there and block the opioid effect. And the thing about it is it usually works for about 30 to 120 minutes when you give it. So usually you can kind of reverse somebody out of that opioid effect. And again, especially that respiratory depression. But we got to be careful, though, with some of these, such as methadone, that can be a little bit longer acting. You know, you give somebody this injection, it's a point four milligram injection, and you give that, you know, again in the leg or part of the fatty tissue in the thigh, and then you can reverse it, but you have to make sure, then they're not going to come back and if they're still opioid around it, can then overcome that blockade, you can still go right back into that situation. So this is not something that you give the injection and then send them. This is something more along the lines of, you know what we're doing with nitroglycerin or even with an EpiPen, you know, you go ahead and you give it, and it's not made to be a. Substitute for hospital treatment, but to be something there in that time period while you get them to see a safe provider. So I can't emphasize that enough Absolutely.

Speaker 2  15:07
So for those patients that do have a massive overdose of a longer acting agent, you know that one time dose, as you said, Dr. Schuman, won't be very long lasting. So it's not uncommon that if someone has a longer acting, let's say, a CR agent or an SR agent sustained release. They may even need a Naloxone or Narcan continuous infusion for a day, even until the opioid that they ingested is completely gone from the system. So there's a lot of factors, but regardless, as you said, and I think we should emphasize it, any patient who's receiving Naloxone outside of the hospital. Setting is a medical emergency equivalent to getting an EpiPen. They need to be seen in the hospital, right?

Speaker 3  15:52
So we have these injection kits which are generally made for, I believe, intramuscular injection, and these will contain a vial which has about one milliliter point four milligram solution, a syringe, needle, alcohol swabs, as well as a disposable face shield, because, you know, if an individual is having difficulty breathing, there may be some need for rescue breathing. So they put those in that kit as well. And then there's this other agent, which is the Naloxone or the evzio kit. And this is something very interesting. This is an auto injector. And so rather than having a separate needle and a syringe that have to be put together, this is a single unit, and there's a needle that's within there, but it's housed in this protective case. And so what you do when you take off the the end of it, it actually has some voice activated, some instructions, and so it will guide you through the process. And this is something that can actually be put in to the side of it. It can be put either through the clothing, or again, if you can remove the clothing on the leg, you can that's fine. But if you need to go right through the gene material or a thin layer of clothing, you can do that. And then once again, if you need to give a repeat dose, that's something that can be done. But the injection that that kid is made to be something more comfortable for a family member or a rescue personnel to be able to use it.

Speaker 2  17:09
So the goal of opioid reversal is that you stop the respiratory depression, wake the patient up a little bit, but ideally, you don't want to bring them into opioid withdrawal. The problem, though, is that point four milligrams is kind of how the dose is given. You can give smaller doses on the inpatient side, but especially with the auto injector, you're stuck with this one dose. Very commonly, patients who are reversed with Naloxone or Narcan or evzio will actually have withdrawal symptoms as soon as the agent is given, or within a few minutes of it being given. So this could be a synigne as some body aches and pain the patient will commonly have, yawning, shivering, trembling, sometimes, if it's severe enough, the trembling can actually look like a seizure. So that can really mix up the picture of a patient who received Naloxone again. Basically, once you give the Naloxone, you're putting the patient into an opioid withdrawal state. So the symptoms that they'll have like diarrhea, cramping, irritability, goose bumps, or piloerection, sweating, tachycardia, runny nose, all of these are symptoms that you would normally see in someone going through opioid withdrawal. It's just that we're acutely giving them a pretty severe withdrawal syndrome by giving them this competitive antagonist of the opioid receptor.

Speaker 3  18:25
And as I said before, there's, you know, a number of individuals who, right now can't, can obtain these kits right now. You know, we're thinking individuals at high risk, so that some of those diseases, disease states that Dr. Kane and I mentioned, high dose opioids, sleep apnea, that concomitant benzo use, as well as those who do have high risk drug use.

Speaker 2  18:44
So Dr. Schuman, can anyone prescribe this? Or do you have to be a specialist in opioid addiction with, you know, a specific DEA number, like Suboxone or buprenorphine or kind of who can give this agent out?

Speaker 3  18:57
And that's what's interesting. It's becoming a wider net of who can provide it. It's not unlike Suboxone, which is our buprenorphine Naloxone, which is used in treatment of addiction. This is not something that requires the special medical license. With the the X on the license that certain providers have to get credentials for does not require that, so any physician may prescribe it. And in fact, in some states, and this number is growing, a pharmacist may actually prescribe it via a collaborative drug therapy agreement, and that would need an existing pharmacist relationship with a physician.

Speaker 2  19:30
So we've kind of beat up opioids quite a bit here. Clearly, patients still have pain whether you give them opioids or not. Certainly, some patients will require opioids chronically for pain management. But there is a subset of patients that perhaps can either because of an increased risk of adverse events or because of the kind of pain that they have. There are non opioid analgesics that we can attempt for these patients to see if we can't get their pain under control. So Dr. Schuman, do you have any non opioid analgesia? Six that you really like to use in your practice, certainly.

Speaker 3  20:02
And when you look, you know some of the guidelines from, for example, the European Federation of neurological societies, and some of the those released in 2010 and then some of the guidelines released in the journal pain in 2007 for types of low back pain and the these kind of radiating sciatic or neuropathic pain really NSAIDs. So your naproxen, which is your naproxen, or your leave, your Meloxicam or your Mobic, and those other NSAIDs, those as well as Tylenol or acetaminophen, end up really being the backbones to that therapy.

Speaker 2  20:34
So in thinking about NSAIDs as an example, are there any patients that would be poor candidates for an NSA as an example,

Speaker 3  20:40
we have to watch for individuals that do have acute kidney injury, or they do have renal impairment, and we just want to be aware of that, and as we consider the doses again that we're not becoming too aggressive with them, we also want to look for individuals with congestive heart failure, as is generally mentioned, the risk of peptic ulcer disease. And so to be aware of that. You know, if you do have a history of severe drug or severe ulcer disease, that a lot of times, you can either look at using maybe one of the more selective agents, or really one of the first things is to consider use of a ppi, such as misoprostol in combination with that NSAID, yeah.

Speaker 2  21:17
And then, you know, for those patients that can't tolerate an NSAID, as you said, Tylenol or acetaminophen is a great option. You know that Max dose of three to four grams per day, depending on the manufacturer and kind of patient specific risk factors, but for most patients, four grams per day as a maximum is a reasonable recommendation, especially for more severe pain.

Speaker 3  21:36
And as always, when we talk about three to four grams per day, that is including all all places where you can get Tylenol or acetaminophen. So if somebody is already on Vicodin, Norco one of these opioid combinations, each one of those, as it stands now, has 325 milligrams of acetaminophen in it. And if you're, if you're getting over the counter cold or flu products, a good clue that I always think about it is, if it says For severe cold or severe flu, they usually what that kind of is. A clue is it's treating aches and pains. And if it says that, then it's probably going to have acetaminophen in it as well. So you need to be aware of it. It's not just the Tylenol in the in the white tablets that contain it, but these other products. And so when you are factoring in the amount you're taking for pain, you make sure you include all the other sources.

Speaker 2  22:22
So one thing that I've seen a little bit more of in my practice, at least, patients who are admitted to the ICU are Lidoderm or lidocaine patches. So Lidoderm is the transdermal patch formulation of similar stuff that you get from a dentist, you know, for a root canal or something like that. So it's a topical only treatment. It prevents nerve conduction so it makes the area numb, as opposed to be more selective for pain receptors. As an example, there's some kind of neat things that go along with a Lidoderm patch. One thing is that you can use up to three patches per day. In order to not have kind of significant blood levels, you have to have a 12 hour interval of a Lidoderm patch, where you don't have any patch on at all to prevent any systemic adverse events from too much absorption. Really unique with a Lidoderm patch is you can actually cut these so if you have a variety of different areas, or you have an area that isn't a perfect square, and you want to cut that patch, you can do that almost every other patch on the market, you cannot cut or violate the integrity of the patch. So there's some cool things with the Lidoderm patch, a little bit more expensive, perhaps, than some of the other oral options, but certainly something that can be considered. And then

Speaker 3  23:32
another medication class that, again, within some of those guidelines, had some some recommendations, as some evidence, would be our tricyclic antidepressants. So this is a class that for treatment of pure depression, really are not getting a whole lot of use, as they've been somewhat supplanted by the use of our SSRI, such as our Paxil or paroxetine or Prozac or fluoxetine. But these two, in particular, amitriptyline or elevil, and then nortriptyline or Pamela, have the ability, at low doses, especially to have both an anti histamine effect for sedating, which we use for insomnia, but then also some effects at that conduction as well, in a similar fashion to what Dr. Kane mentioned with lidom. So what they can do is block some of that, and they're very good for things like a neuro diabetic, neuropathic pain, as well as these radiculopathic pains as well. Think with these, though, we want to watch for and especially at high doses. The nice mnemonic for tricyclic is TCA, so T tonic clonic, meaning that high doses these can potentially lower the seizure threshold. C is going to be cardiac so you have to, you do have to monitor again at high doses if somebody has cardiac disease, we just have to be careful of that. And then a for anticholinergic, so that dry mouth and sedation and at low doses, that's principally going to be the main side effect you would look for would be the dry mouth and the sedation

Speaker 2  24:52
and Dr. Schuman, do you see with these TCAs that you need to bump the dose up pretty high to get efficacy? Or can you get it at lower doses? Or is it very patient specific?

Speaker 3  25:00
Generally patient specific, but for the most part, a 25 milligram dose has been something that's fairly well received. And again, like any antidepressant, you know, within the first week or two, if you start to notice any kind of change in mood, start to feel more agitated or jittery, that would be something you'd want to go ahead and please, please discuss your provider. And that would be the same thing we would say with any of these antidepressants.

Speaker 2  25:24
So a very common alternative to a TCA, especially among patients that may have a stigma associated with an antidepressant, would be Gabapentin. Brand name is Neurontin, or its cousin, pregabalin. Brand name is Lyrica. So both of these are actually FDA approved as anti epileptics, and they're used for that to some degree, not a terrible amount, but they're primarily used for neuropathic pain. The downside to these agents, though, is that they cause a lot of peripheral edema and weight gain. So both of these agents, as you increase the dose, you're going to get more of the this edema and weight gain that patients generally don't appreciate very much, and also because of that peripheral edema, there is, at least in the Lyrica or pregabalin packaging precaution for use in patients with more advanced heart failure. In addition both of these agents, as you bump up the dose, they can be fairly sedating, which is a pretty common theme, I think, with many of our anti epileptics. So you also have to be aware of that, especially if the patient is also receiving an opioid for the reason we mentioned earlier. As you add on more sedating medications from different classes, you increase the risk of opioid related adverse events. And then finally, the last drug class that we're going to talk about would be the SNRIs or serotonin norepinephrine reuptake inhibitors, and I know Cymbalta or duloxetine actually has a lot of FDA approvals for pain related indications, so chronic musculoskeletal pain, diabetic neuropathy, fibromyalgia, but many of these SNRIs have been studied on and off label for pain related indications.

Speaker 3  26:55
And what's interesting about it is that we can use, as Dr. Kanementioned, the ones that have the FDA approval are going to be your Cymbalta, which has approval for chronic musculoskeletal pain, diabetic neuropathy and fibromyalgia, and then Savella, another one that's fairly new, has an FDA approval of fibromyalgia. But really, you know, any of these, these two agents, as well as venlafaxine and then Pristiq or desvenlafaxine, any of them really may be used, and they in studies, for example, they've looked at venlafaxine as well as the duloxetine, and found efficacy with both and with venlafaxine being at this point, a little more cost effective. That's something a lot of places will go to first, and however, it still has the data, the one place where they can be distinguished is going to be in the ratio of their norepinephrine reuptake and their affinity for serotonin reuptake. And so at kind of one end of the spectrum, we have venlafaxine, which at low doses, up to about 150, or 225, milligrams is really almost an SSRI. And then as we go up on the doses, we see a little bit more of this norepinephrine reuptake, but again, still a fair amount of serotonin. And then as we go on to our duloxetine, we see about it, you know, an even almost one to one of our norepinephrine and serotonin reuptake inhibition. And then as we go down the spectrum to Pristiq or desvenlafaxine, and then further on towards Savella or milnacipran, we see a weighting, or the increase towards more norepinephrine. So that's just something, you know, it may mean a little bit of indifference in symptoms, so that may be something beneficial for pain treatment, or it could also mean potentially a little bit more of an increased risk of things like jitteriness or a little bit of blood pressure fluctuation. So it really is important to think about those along that continuum. And so a lot of times, you know, the nice thing about, for example, venlafaxine, is that you can start with that serotonergic activity, and then as you slowly increase the dose, we start engaging the norepinephrine. And then you can kind of see how that goes in terms of tolerability.

Speaker 2  28:56
Then, just to point out, Savella or milnacipran, it is an SNRI, but it's actually not FDA approved for depression. Is that correct?

Speaker 3  29:04
Yes. Again, they went because with with the norepinephrine uptake being the main part of it, they thought, Okay, it's gonna be less, you know, of the SSRI type of depression treatment. And they went right for the pain indication, which, yes, it's quite interesting.

Speaker 2  29:18
And then the prestige. Can you tell the audience more about what it is, and it sounds very similar to venlafaxine,

Speaker 3  29:24
yes, and what that is, it's the it's the active metabolite of venlafaxine. So again, venlafaxine has a different ways it's broken down, and one of the ways is, is to this desk venlafaxine. So again, it has a little bit difference of that receptor affinity. So this one's a little bit more norepinephrine than it then its parent, venlafaxine. But beyond that, there's been, you know, not a whole lot, I believe that they've looked, haven't looked at this one as much for pain since it hasn't been on the market that long. But you could roughly expect it to be somewhere around duoxetine In terms of of some of that, that benefit, and some of the, again, that ratio.

Speaker 2  29:59
And, you know, we. Only covered a handful of different therapies for non opioid analgesics. There's a ton of different agents on the market that have been studied, on and off label for pain and neuropathic pain. We've just covered some of the ones that we see more commonly in our clinical practice. To review, we talked a lot about opioid related adverse events and some of the risk factors for those in terms of drug therapy, we started with naloxone. The brand name was Narcan,

Speaker 3  30:24
and then we also talked about evzio being this, this unique formulation of naloxone that's made to be in that auto injector, which is essentially needleless in the fact that it doesn't have that exposed needle, which can be something that may be a little bit more, I guess, something that people are going to be a little less concerned about using. So if somebody using. So if somebody's in the community not trained, that may be something

Speaker 2  30:45
I'm more likely to reach for. And then we moved on to some of our non opioid analgesics. So in terms of NSAIDs just, there's many. A few that we threw out there was naproxen. The brand name was naproxen, or Aleve Meloxicam or Mobic.

Speaker 3  30:59
So we talked about Lidoderm being the brand name for the Lidocaine 5% patch. And we also talked about the two of many tricyclic antidepressants, but the two with some of the most evidence for treatment of pain, amitriptyline, brand name, Elavil and nortriptyline, brand name, Pamelor.

Speaker 2  31:14
And then we talked about two different antiepileptics that are also used on label for neuropathic pain, the two being Gabapentin or Neurontin. And then a similar agent, pregabalin brand name Lyrica. And then

Speaker 3  31:26
finally, we talked about the four SNRIs. And to run through them, from their spectrum of mostly serotonin to mostly norepinephrine reuptake, we have our Effexor brand name, which generic is venlafaxine. We have Cymbalta, brand name, generic duloxetine. We have Pristiq, generic desvenlafaxine, and finally, at the other end of the spectrum, Savella, generic milnacipran.

Speaker 2  31:50
So that concludes episode 21 of HelixTalk. If you haven't done so already, we'd really appreciate a positive review in the iTunes store that helps other listeners find us. We're available at helix. Talk.com with that, I'm Dr. Kaneand I'm Dr. Schuman, we're missing Dr. Patel, but she would normally say, study hard.

Narrator - Dr. Abel  32:12
Thank you for listening to this episode of HelixTalk. For more information about the show, please visit us at helix. Talk.com you