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analgesics and adjuvants for pain Flashcards

1
Q

one in ___ canadian adults suffer from chronic pain

A

5

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2
Q

the prevalence of chronic pain inc or dec with age? what % in seniors and older adults?

A

The prevalence of chronic pain increases with age with the prevalence of chronic pain as high as 65% in community dwelling seniors and 80% of older adults living in long term care facilities and this pain is under recognized and undertreated

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3
Q

what are the aetiologies of pain?

A

headaches, ascetic episodes, visceral pain and somatic pain

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4
Q

what is visceral pain?

A

being internal organs and can be localized or referred.

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5
Q

what is somatic pain?

A

being skin, bone, muscle, connective tissue, or joints described as localized and throbbing

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6
Q

what are some examples of visceral pain?

A

biliary colic, irritable bowel, menstrual pain, renal colic

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7
Q

what are some examples of somatic pain?

A

degenerative and inflammatory arthritis, trauma, vertebral compression fractures, boney metastases, fibromyalgia
, gout

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8
Q

what kind of pain treatment do you use for somatic pain? visceral pain?

A

visceral pain- usually opioids and somatic is usually nonopioid analgesics (NSAIDS)

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9
Q

what are the two source s of pain?

A

nociceptive and neuropathic

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10
Q

what is nociceptive pain?

A

somatic or visceral. can be referred pain, superficial, vascular

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11
Q

what is referred pain caused by?

A

occurs bc visceral nerve fibres synapse at a level in the spinal cord close to fibres that supply specific SC tissues in the body

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12
Q

of the different types of nociceptive pain- which usually causes migraines?

A

vascular (nociceptive)

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13
Q

what is neuropathic pain?

A

abnormal processing of sensory input by the peripheral or CNS causes nerve dysfx resulting in numbness, loss of deep tendon reflexes in affected area

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14
Q

what causes neuropathic pain? how long does it last? how do you treat it?

A

may be present in the absence of dx

severe, persistant and resistant to OTC meds

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15
Q

what is phantom pain?

A

a type of neuropathic pain in body part that has been removed, surgically or traumatically and char as burning itching, tingling or stabbing

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16
Q

what is cancer pain? what does it stem from?

A

can be acute, persistent or both. Stems from pressure on nerves, organs or tissues. Other causes: hypoxia, blockage to organ, mets, fractures, muscle spasms, AE from radiation, and chemo

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17
Q

what is psychogenic pain?

A

originates from psychological factors not physical condition or disorders

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18
Q

examples of neuropathic pain?

A

diabetic neuropathy, phantom limb pain, spinal stenosis/sciatica, spinal mets, HIV, drug induced

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19
Q

chronic pain is multi-factored- what are these factors?

A

psychological factors (depresision, anxiety, somatization), socioeconomic factors (cultural differences, urban poor, gender), spiritual factors (spiritual suffering, meaning of pain), physical factors

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20
Q

who tolerates visceral pain better? somatic? (male or female)

A

male- tolerate somatic and females tolerate visceral pain

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21
Q

what are the two classifications of pain?

A

acute and chronic

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22
Q

does chronic pain persist after healing? acute?

A

yes.

acute- no

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23
Q

what is the onset, duration, half-life of hydromorph?

A

onset- 30 min
duration- 2-3 hours
half life- 2.6 hr

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24
Q

what is the onset, duration, half-life of morphine?

A

onset- 20-45 min
duration 5-7 hours
half life 2-4 hours

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25
what is the onset, duration, half-life of fentanyl?
buccal onset within 5 minutes | patch half life - 17 hours (13-22, half life is influenced b y absorption rate)
26
what is the duration, half-life of methadone?
duration: 4-8 hr. inc to 22048 hours with repeated doses. | half life- 8-150 hours
27
which of the pain med drugs are the fastest acting?
fentanyl
28
which of the pain med drugs the longest acting?
methadone
29
what are some system effects of morphine?
Produce analgesia, CNS depression, respiratory depression and GI depression.
30
does morphine active the exogenous or endogenous analgesia system?
endogenous
31
route of morphine?
PO,IM, SC, IV, buccal
32
what are some contraindications for morphine?
liver disease, resp depression, lung disease, prostatic hypertrophy, ICP, or hypersensitivity
33
what are the major opioid receptors in the brain?
Mu, Kappa, delta
34
what does Mu do?
resp depression, physical dependence. Most of the effects of morphine (analgesia; CNS depression, with respiratory depression and sedation; euphoria; decreased gastrointestinal [GI] motility; and physical dependence) are attributed to activation of the mu receptors
35
what does kappa do?
dec GI motility (as well as u). . Analgesia, sedation, and decreased GI motility occur with activation of kappa receptors.
36
what does delta do?
involved with the endogenous analgesia system. may not bind with opioid drugs
37
do you use opioids for severe, unproductive cough?
yes
38
big side effects for opiates?
Drowsiness N&V Constipation Respiratory depression
39
signs and symp of withdrawal from opiates?
diarrhea, N+V, muscle pain, anxiety, and irritatbilty
40
what are the two main subgroups of opioid analgesics?
agonists and agonist/antagonists
41
what receptors and what kinds of drugs are agonists?
morphone and oirphine like drugs mu and kappa opioids receptor
42
what are some examples of agonist/antagonist?
Buprenorphine (Buprenex) – used to treat opioid addiction butorphanol (stage) and nalbuphine (nubbin) which are used with anesthesia and for pain during labour suboxone (buprenorphine and naloxone)
43
what are antagonists? how do they work? example? duration of action of example
reverse of block analgesia, CNS and resp depresson. they compete with opioid binding receptor or displacing the opioid occupying sites. naloxone. last 1-2 hours.
44
example of natural health product
capsaicin (zostrix) derived from cayenne chili peppers. Applied topically to relieve pain from osteoarthritis, rheumatoid arthritis, postherpetic neuralgia, diabetic neuropathy, postsurgical pain and other neuropathic pain Depletes substance P in nerve endings
45
treatment for mild pain?
ASA, acetaminophen, NSAIDs
46
treatment for moderate pain?
codeine, hydrocodone, oxycodone, tramadol + adjuvant
47
treatment for severe pain?
morphine, hydromorph, oxygen, levorphanol, methadone + adjuvant
48
what are some examples of adjuvant analgesics?
``` Corticosteroids anti-psychotics Antidepressants anti-convulsants Bisphosphonates Cannabinoids ``` Radiation intrathecal and epidural analgesia nerve blocks surgery
49
what are adjuvant analgesics?
(sometimes known as co-analgesics) are medications whose primary indication lies elsewhere, but which have been found to be beneficial in the management of some types of pain.
50
which is the most widely used adjuvant?
corticosteroids
51
what do corticosteroids do in regards to pain?
reduce pain by reducing inflm and deem associated with tumors and depolarization of damaged nerves
52
what is the most commonly used corticosteroids?
dexamethasone owing to its lack of mineralocorticoid effects, long half-life, and higher potency compared with other corticosteroids
53
what are some side effects of corticosteroids?
``` increased appetite or weight gain proximal muscle weakness insomnia gastrointestinal side effects psychiatric side effects, such as delirium, depression, anxiety, and psychosis osteoporosis with long-term use ```
54
are corticosteroids used long term or short term?
Because most of these side effects manifest over the long term, corticosteroids are best used in the short term at the lowest effective dose.
55
can you withdrawal from corticosteroids?
d/c corticosteroids used for longer than 2 weeks should involve tapering to deuce the risk of steroid withdrawal
56
what are some withdrawal symptoms of corticosteroids ?
pain, nausea or vomiting, weight loss, depression, fatigue, fever, dizziness, and rebound symptoms that are unmasked when there is loss of symptom control once the corticosteroid is removed.
57
what is addison ian crisis?
life-threatening complication that can cause confusion, coma, cardiovascular shock, and even death.
58
what is psuedo-addiction?
physical dependence confused with psychological dependence. pain-relief seeking, nor drug seeking
59
how can you allow a physical dependent patient function
use the right dose- functions better in life whereas, opposite true with an addict
60
what is the ceiling effect of tylenol?
1000mg
61
is acetaminophen adequate for severe pain?
no but effective for mild pain
62
difference between tylenol and NSAIDs like ibuprofen?
just treats pain but not inflm. NSAIDs treat inflm
63
do NSAIDs have a ceiling? what is the analgesic dose for NSAIDS? inflm dose? (high or low)
yes they do and the dose is small for analgesic and high for inflm
64
is there a ceiling effect for pure opioid agonists?
no
65
what is end of dose failure?
trough- where they are experiencing pain. it is where the duration of opioid effect falls before next regular dose is absorbed
66
what are some options for managing pain in palliative care in re: dosing?
inc the initial dose so that extends the effect and eliminates the trough or increase freq
67
how can you titrate opiates in palliative care?
start low for opiate naive patients and total up all opiates ofr 24 hours (reg plus breakthrough) to get the total daily dose and dive by total number with 10% of TDD given q1hr for breakthrough pain
68
what are three complications of chronic high dose opioid therapy?
neurotoxicity, tolerance, opioid inducted hyperalgesia
69
what is opioid induced neurotoxicity?
Typically develops on initiation to a week of initiating an opioid or reaching a dose that causes metabolite buildup. mediated trough non-opioidergic mechanisms
70
what symptoms occur from opioid induced neurotoxicity?
mild confusion or drowsiness to hallucinations, delirium and seizures
71
what metabolites are responsible for opioid induced neurotoxicity?
due to neuro-excitatory metabolites of opioids (morphine-6-glucuronide, oxymorphone-3-glucuronide)
72
what other factors can tip a frail older adult into opioid toxicity?
dehydration, infection or adding drugs
73
how is OIN managed?
opioid rotation, dose or freq, reduction, and rehydration
74
when should opioids not be discontinued in re OIN?
if needed for pain or dyspnea
75
what is anti-nociciceptive tolerance?
due to prolonged use of opiates. | occurs when there is a progressive lack of response to a drug requiring inc dosing
76
how do you manage anti-nociceptive tolerance?
higher doses of opiates are required to elicit same amount of analgesia or antinociception
77
what is opioid induced hyoperalgesia?
The mechanism by which prolonged opiate exposure induces hyperalgesia and the relationship of this state to antinociceptive tolerance remain unclear
78
how does opioid induced hyperalgesia present?
hyperalgesia and allodynia (hyper sensitivityy to pain basically), myoclonus, confusion
79
can OIH be overcome by inc the dosage? how do you treat the pain?
no. pain is worsened by inc the dose. treat the pain by reducing/eliminating opioid
80
treatment for OIH?
inc opioid dose and eval for increased efficacy (tolerance), use opioids with unique properties that might mitigate OIH like methadone, utilize NMDA antagonists, respite sedation with propofol, interventional pain techniques or neurosurgical procedures
81
what are two main considerations for use in opiate tolerant patients?
larger than usual doses are required to treat pain, signs and symptoms of withdrawal occur if adequate dosage is not maintained or if opioid antagonists are given
82
are children pain often over or under treated?
often under
83
T or F expression of pain differs by age
T
84
what opiates are not recommended for children?
Hydromorphone, methadone, oxycodone, and oxymorphone
85
what are some recommendations for opiate admin for the older adult?
use opioids w shorter half life, start low and in dose gradually, re-dose less often due to larger action, monitor output, sedation, confusion
86
is meperidine used for pt with renal impairment? why or why not?
not used due to toxic metabolite
87
what drug accumulates in patients with renal impatient?
morphine
88
what is preferred for patients with critical illness (agonist/antagonist?)
opioid agonist drugs

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