Analgesics

Question 1

Overview

Answer 1

Pain relief w/o loss of consciousness.

Question 2

Pain Types

Answer 2

Nociceptive: Damage to body tissue
Neuropathic: Damaged or incorrectly functioning nervous system
Central: Increased response of pain receptors; hypersensitivity. Response to non-noxious stimuli, or an expanded receptive field

Question 3

Most effective pain relievers

Answer 3

Opioids

Question 4

Inhibit Ascending Pain Tx

Answer 4

Nociceptive Pain
Acetaminophen, NSAIDs, Lidocaine, Capsaicin, Menthol, Opioids, Cannabinoids, Ketamine

Question 5

Facilitate Descending Pain Modulation

Answer 5

Neuropathic Pain
Anti-epileptics, Gabapentinoids, Na Channel Agents, Antidepressants (TCAs, SNRIs), Cannabinoids, Ketamine

Question 6

First Lines

Answer 6

Nociceptive: NSAIDs; decrease inflammation, swelling, PG release, and pain
Neuropathic: Antidepressants/antiepileptics
Central: Antidepressants/antiepileptics

Opioids used as first line: Severe pain, long term treatment, immediate treatment

Question 7

Nociceptive Pain

Answer 7

NSAIDS = Mainstay
Efficacy of NSAIDs on non-inflammatory, chronic pain is low and requires combination with other agents
Localized involvement = Use of topicals is preferred.
If pt responds poorly to NSAIDs, consider other treatments in the Neuropathic pain path
Opioids are last line and lowest dose possible, for the shortest amount of time

Question 8

Neuropathic Pain

Answer 8

First: antidepressants/antiepileptics
Other conditions than pain determine choice of agent
Combo therapy of antidepressant/antiepileptic is common
Opioids: last line, small and short

Question 9

Central

Answer 9

Treatment guided toward the more prominent underlying factor, tends to be Neuro path but can be inflammatory (Nociceptive) as well.
Opioids: Last, small, and short

Question 10

NSAIDs

Answer 10

IND: Pain, gout, dysmenorrhea, anti-inflammation, osteoarthritis
MOA: COX 1 and 2 inhibitors; decrease PG synthesis
BOX: Serious CV risk (Stroke/MI) can be fatal
Serious GI risk (increased bleeding, ulceration, perforation of GI tract; can be fatal
CON: Use in Coronary Artery Bypass Graft
ADR: n/a

Question 11

NSAIDs, Non-prescription

Answer 11

Aspirin, Ibuprofen, Naproxen, Diclofenac

Question 12

NSAIDs, Prescription

Answer 12

Ketorolac: Common in ER/inpatient/Sx
Meloxicam: Most commonly prescribed NSAIDs
Celecoxib: Most commonly prescribed NSAIDs, least likely for CV events d/t selective COX2I

Question 13

TCA

Answer 13

Amitriptyline, Nortriptyline
IND: Depression, BPD, Fibromyalgia, Neuropathic pain, insomnia, ADHD, Panic Disorder, OCD
MOA: Norepinephrine (and some serotonin) reuptake inhibitors
CON: MAOIs
ADR: Ortho HYPOtension, sedation, Anticholinergic, Cardiac toxicity, Seizures

Question 14

SNRIs

Answer 14

MOA: Inhibit serotonin and Norepinephrine reuptake
CON: MAOIs
Similar efficacy to SSRI, 2nd line tho

Question 15

Duloxetine

Answer 15

IND: Fibromyalgia, m/s pain, Neuropathic pain, depression, GAD
MOA: SNRI
BOX: N/a
CON:
ADR: INTENSE WITHDRAWAL SYNDROME w/abrupt d/c; anxiety, agitation, tremors, HA, vertigo, nausea, tachycardia, depression. Taper over 2-4 wks
Weight loss/anorexia, n/v, xerostomia, dizzy, drowsy, fatigue, HTN

Question 16

Antiepileptics

Answer 16

3 approved for neuro pain
Multiple MOAs, don’t memorize. Work on NTx’s to calm them down

Question 17

Carbamazapine

Answer 17

IND: BPD, Trigeminal disorders, Neuralgia pain, seizures
MOA: Limits influx of Na, antiepileptic
BOX: SJS and TEN.
Anaplastic anemia and agranulocytosis
CON: STRONG CYP inducer, MAOIs, Bone marrow depression
ADR: dizzy/drowsy, Ataxia, N/V

Question 18

Gabapentin

Answer 18

IND: Neuro pain, seizures
MOA: Ca channels
BOX: n/a
CON: Controlled in MI
ADR: n/a

Question 19

Pregabalin

Answer 19

IND: Neuro pain
MOA: Inhibits substance P
BOX:
CON: Controlled Federally and in MI
ADR: