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Clinical 2 (Part B) > 16 - Intro to Pain > Flashcards

16 - Intro to Pain Flashcards

1
Q

List the 3 types of pain

A

Neuropathic Pain

Nociceptive Pain

Mixed Pain

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2
Q

Describe Neuropathic pain

A

Pain initiated or caused by a primary lesion or dysfunction in the nervous system (either peripheral or CNS)

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3
Q

Describe Nociceptive pain

A

Pain caused by injury to body tissues (MSK, cutaneous or visceral)

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4
Q

Describe Mixed pain

A

Pain with neuropathic and nociceptive components

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5
Q

Examples of neuropathic pain

A
  • postherpetic neuralgia
  • trigeminal neuralgia
  • diabetic peripheral neuropathy
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6
Q

Common descriptors of neuropathic pain

A
  • burning

- shooting

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7
Q

Examples of mixed pain

A
  • lumbar radiculopathy
  • cervical radiculopathy
  • cancer pain
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8
Q

Examples of nociceptive pain

A
  • pain due to inflammation
  • limb pain after a fracture
  • joint pain in OA
  • postoperative visceral pain
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9
Q

Common descriptors of nociceptive pain

A
  • aching
  • sharp
  • throbbing
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10
Q

List examples of pain that don’t fit into a previously listed category

A
  • migraines
  • tension headaches
  • fibromyalgia
  • interstitial cystitis
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11
Q

What is the goal in acute pain?

A

pain reduction

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12
Q

What is the goal in chronic pain?

A

functionality

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13
Q

What is the PQRST mnemonic ?

A

P: Provoking/preciptates?
-What brings it on and takes it away?

Q: Quality
-In the patient’s own words (prompt only if necessary - ex. dull, sharp, stabbing, burning, etc.)

R: Radiation, referral

  • Does the pain move to another spot?
  • Are there other symptoms associated with the pain (ex. nausea, SOB)

S: Severity
-Rate the pain on a scale of 1-10

T: Timing

  • When did it start?
  • Has it occurred before?
  • Is it constant or does it come and go?
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14
Q

What is the problem with using exogenous opioids chronically?

A

we sacrifice normal healthy motivational behaviours, socialization & coping

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15
Q

What are some key questions to ask for pain?

A
  • How does the patient look and mobilize?
  • Are they able to perform valued activities?
  • Are they dysphoric, irritable, depressed?
  • How are they sleeping?
  • Do they feel well enough to socialize?
  • Are they enjoying life?
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16
Q

Acetaminophen:

Dose?

A

325-1000mg q4-6h

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17
Q

Acetaminophen:

Onset?

A

15-30 mins

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18
Q

Acetaminophen:

Max dose?

A

3-4g/day depending on age

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19
Q

Acetaminophen:

SE?

A

liver toxicity in high doses

*avoid with warfarin

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20
Q

Effectiveness:

Acetaminophen or Ibuprofen for headache?

A

same

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21
Q

Effectiveness:

Acetaminophen or Ibuprofen for post-dental surgery?

A

ibuprofen better

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22
Q

Effectiveness:

Acetaminophen or Ibuprofen for OA?

A

NSAIDs better for pain and function

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23
Q

Effectiveness:

Acetaminophen or Ibuprofen for back pain?

A

no effect vs placebo

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24
Q

Main concern with acetaminophen ?

A

hepatotoxicity

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25
Q

> 50% of serious liver injury associated with ________ overdoses

A

unintentional

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26
Q

Up to 1/5 of acetaminophen related liver injuries reported to Canada Vigilance mention doses of ?

A

<4 g/day

*but in many of these cases, patients had identifiable risk factors for acetaminophen liver injury (ex. alcoholism or viral liver disease)

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27
Q

______ stores are responsible for taking care of tylenol toxicity

A

glutathione

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28
Q

When should we decrease the daily dose to 3g/day ?

A
  • Old age
  • Poor nutritional status
  • Fasting/anorexia
  • *Lead to lower glutathione stores

Concurrent use of glucuronidation inhibitors and/or CYP2E1-inducing drugs (ex. phenobarbital, primidone, probably isoniazid, and possibly St. John’s wort). Chronic alcohol use

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29
Q

When is acetaminophen contraindicated?

A

severe hepatic impairment

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30
Q

Pros of NSAIDs

A
  • Analgesic & anti-inflammatory
  • More effective than acetaminophen for certain conditions
  • Can be given topically (less systemic absorption)
  • Many to choose from (10 different classes)
  • Minimal differences in effect, a few differences in harms
  • Ibuprofen & naproxen available OTC
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31
Q

Cons of NSAIDs

A
  • No readily available injection

- Affects gut, kidneys, and heart

32
Q

NSAID Harms:

What increases risk for GI event (ulcer or bleed) ?

A
  • age > 65
  • use of anticoagulants
  • use of steroids
  • history of PUD
  • high dose of NSAID
  • presence of H. pylori
33
Q

NSAID Harms:

What can reduce the risk for GI bleed while on NSAIDs?

A
  • PPI co-therapy
  • celecoxib
  • H. pylori treatment
  • misoprostol cotherapy
34
Q

NSAID Harms:

Any better than others for reducing renal event (AKI) ?

A

not likely

35
Q

NSAID Harms:

What increases the risk for renal events (AKI) ?

A
  • volume depletion
  • CHF
  • ACEi, ARB use
  • renal disease, cirrhosis
  • > 70 yrs old
36
Q

NSAID Harms:

What are the NSAIDs that are worst for cardiac events?

A
  • diclofenac

- high dose celecoxib

37
Q

NSAID Harms:

What NSAIDs appear CV “neutral” ?

A
  • low-dose naproxen (750-850 mg/day)
  • ibuprofen (1200-2000mg/day)
  • celecoxib (<200 mg/day)
38
Q

NSAID Harms:

Again, absolute CV risk depends on other risks such as ?

A
  • CHF
  • CAD
  • high risk for CVD (smoker, high cholesterol, etc.)
39
Q

NSAID Effectiveness:

Is it effective for dental surgery?

A

Yes

  • effective vs placebo
  • more effective than acetaminophen
40
Q

NSAID Effectiveness:

Is it effective for OA?

A

Yes

  • effective vs placebo
  • similar pain decrease vs opioids
  • better vs acetaminophen for pain, global improvement & function
41
Q

NSAID Effectiveness:

Is it effective for chronic low back pain?

A

similar pain decrease vs opioids

42
Q

Advantage of topical NSAIDs?

A

Major adverse effects comparable to placebo!
-2-15% systemically available vs oral NSAIDs
(but if you’re rubbing it over entire back, you will increase systemic absorption)

43
Q

Disadvantage of topical NSAIDs?

A
  • local skin reaction

- stickiness

44
Q

What strength of topical NSAID (diclofenac) commonly used?

A

diclofenac 1% - 1.5% solution or gel most commonly studied, dosed BID - TID

Does increase % work better?

  • He usually starts with 2% and then goes to 4%.
  • Apparently now pharmacare will only cover 4% or higher ?
45
Q

Are topical NSAIDs effective vs oral NSAIDs for OA for hands and knees?

A

equal effectiveness

46
Q

Topical NSAIDs for back pain, neuropathic or widespread pain ?

A

no evidence

47
Q

Are topical NSAIDs effective for acute pain (sprains, strains overuse injuries) ?

A

Yes:

  • diclofenac or ketoprofen vs. placebo
  • > 50% pain relief
48
Q

Pros of opioids ?

A
  • Highly effective for some pain types (ex. nociceptive)
  • High dose ceiling for effect (in some cases - maybe cancer pain?)
  • IV/SC doses for improved access and quicker onset
49
Q

Cons of opioids?

A
  • Addiction
  • Significant dose-related day to day side effects
  • Threshold for serious toxicity can be low in some
  • Tolerance, dependence, hyperalgesia
  • Abuse potential
  • Long term SE (dry mouth - cavities, androgen deficiency)
  • Triplicate Rx
50
Q

Ever recommend tylenol 1’s ?

A

No

  • They will prob just take a bunch
  • Increasing the amount of tylenol and caffeine they’re getting
  • They might as well just take tylenol #3
51
Q

What 2 opioids are not to be used for opioid-naive, and not go be used for Tx of acute pain ?

A
  • Fentanyl patch

- Methadone

52
Q

Morphine:

Caution with accumulation in ____ dysfunction

A

renal

53
Q

Morphine:

Caution with _____

A

cirrhosis

54
Q

Morphine:

Can cause ____ release and cause patient to get itchy

A

histamine

55
Q

Oxycodone:

No _____ or _____ forms

A

liquid or parenteral

56
Q

Oxycodone:

Big _____ value

A

street

  • don’t see why we would ever use oxycodone
  • no advantages over morphine and hydromorphone and there is a big street value
57
Q

Hydromorphone:

Caution in renal dysfunction, but less so than ______

A

morphine

58
Q

Hydromorphone:

Caution with _____

A

cirrhosis

59
Q

Hydromorphone:

Less _____ release than morphine

A

histamine

60
Q

If a patient is feeling itchy on morphine, what do you do?

A

switch to hydromorphone

61
Q

Describe the switching of opioids

A
  • not an exact science
  • safer to under-dose at first
  • 50-75% of the calculated amount
  • use global RPH website is good

**Monitoring is important. For the next few days and who else can monitor them (ex. in hospital, at home, etc?)

62
Q

Should you recommend muscle relaxants for low back pain?

A

No - may consider as add-on for muscle spasm

63
Q

Should you recommend OTC muscle relaxants for pain relief ?

A

Don’t bother with OTC unless patient has a history of good overall effect

64
Q

If you are recommending an Rx muscle relaxant, which one and for how long?

A

cyclobenzaprine - benefit in the first 4-7 days, may use up to 2 weeks

65
Q

Common limitation of muscle relaxants ?

A

drowsiness

66
Q

What are some other adjuvants for pain?

A
  • Anti-epileptics
  • TCAs
  • SNRIs
  • Local corticosteroid
67
Q

What are SNRI’s used for?

A

primarily neuropathic pain, but also in migraine prevention, fibromyalgia, sciatic/radiculopathy, etc.

68
Q

What are local corticosteroid injections used for?

A

Knee (for OA)

Epidural (for sciatica)

69
Q

What are local anesthetics/analgesics used for?

A

epidurals, nerve blocks, topical

70
Q

Explain the impact of pain triad ?

A
  • Pain
  • Depression, Anxiety
  • Sleep issues
71
Q

Describe the input and output of pain

A

Input:

  • Cognitive
  • Emotion
  • Sensory

Output:

  • Pain
  • Motor
  • Stress
  • Emotion
72
Q

Non-pharms for pain

A
  • heat/cold
  • physiotherapy
  • massage
  • exercise (help or worsen)
  • chiropractic
  • acupuncture
  • yoga
  • CBT
  • music
73
Q

What is the PQRST ?

A 
P: Provokes, precipitates
Q: Quality (dull, sharp, stabbing)
R: Radiation, referral
S: Severity
T: Timing
74
Q

Monitoring ?

A
  • Pain diary

- Function

75
Q

What can uncontrolled pain in elderly result in?

A

malnutrition, weight loss, decreased mobility, falls, fractures, decreased socialization, depression, anxiety, increased alcohol consumption

76
Q

Approach to pain in the elderly ?

A
  • vigilant dose titration, start low (1/2 of usual starting dose), go slow and review often
  • caution with oral NSAID use: increased risk of GI bleed, CV & renal events (add PPI if ongoing use, monitor renal function, use topical instead if indicated)
  • caution with opioid use
  • do a 3-day tolerance check after starting
  • ask if they’re constipated (will not go away with time)
  • dizziness/balance
  • ensure care support
  • assess for sedation, imbalance, confusion, constipation
77
Q

When should we caution opioid use?

A
  • elderly
  • increased fracture risk
  • renal or hepatic impairment
  • COPD and sleep apnea
  • cognitive impairment

Clinical 2 (Part B) (30 decks)

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