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Pharm > analgesics and adjuvants for pain > Flashcards

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
Q

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

A

buccal onset within 5 minutes

patch half life - 17 hours (13-22, half life is influenced b y absorption rate)

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26
Q

what is the duration, half-life of methadone?

A

duration: 4-8 hr. inc to 22048 hours with repeated doses.

half life- 8-150 hours

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27
Q

which of the pain med drugs are the fastest acting?

A

fentanyl

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28
Q

which of the pain med drugs the longest acting?

A

methadone

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29
Q

what are some system effects of morphine?

A

Produce analgesia, CNS depression, respiratory depression and GI depression.

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30
Q

does morphine active the exogenous or endogenous analgesia system?

A

endogenous

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31
Q

route of morphine?

A

PO,IM, SC, IV, buccal

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32
Q

what are some contraindications for morphine?

A

liver disease, resp depression, lung disease, prostatic hypertrophy, ICP, or hypersensitivity

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33
Q

what are the major opioid receptors in the brain?

A

Mu, Kappa, delta

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34
Q

what does Mu do?

A

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

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35
Q

what does kappa do?

A

dec GI motility (as well as u).

. Analgesia, sedation, and decreased GI motility occur with activation of kappa receptors.

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36
Q

what does delta do?

A

involved with the endogenous analgesia system. may not bind with opioid drugs

37
Q

do you use opioids for severe, unproductive cough?

A

yes

38
Q

big side effects for opiates?

A

Drowsiness
N&V
Constipation
Respiratory depression

39
Q

signs and symp of withdrawal from opiates?

A

diarrhea, N+V, muscle pain, anxiety, and irritatbilty

40
Q

what are the two main subgroups of opioid analgesics?

A

agonists and agonist/antagonists

41
Q

what receptors and what kinds of drugs are agonists?

A

morphone and oirphine like drugs

mu and kappa opioids receptor

42
Q

what are some examples of agonist/antagonist?

A

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
Q

what are antagonists? how do they work? example? duration of action of example

A

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
Q

example of natural health product

A

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
Q

treatment for mild pain?

A

ASA, acetaminophen, NSAIDs

46
Q

treatment for moderate pain?

A

codeine, hydrocodone, oxycodone, tramadol + adjuvant

47
Q

treatment for severe pain?

A

morphine, hydromorph, oxygen, levorphanol, methadone + adjuvant

48
Q

what are some examples of adjuvant analgesics?

A 
Corticosteroids
anti-psychotics
Antidepressants
anti-convulsants
Bisphosphonates
Cannabinoids

Radiation
intrathecal and epidural analgesia
nerve blocks
surgery

49
Q

what are adjuvant analgesics?

A

(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
Q

which is the most widely used adjuvant?

A

corticosteroids

51
Q

what do corticosteroids do in regards to pain?

A

reduce pain by reducing inflm and deem associated with tumors and depolarization of damaged nerves

52
Q

what is the most commonly used corticosteroids?

A

dexamethasone owing to its lack of mineralocorticoid effects, long half-life, and higher potency compared with other corticosteroids

53
Q

what are some side effects of corticosteroids?

A 
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
Q

are corticosteroids used long term or short term?

A

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
Q

can you withdrawal from corticosteroids?

A

d/c corticosteroids used for longer than 2 weeks should involve tapering to deuce the risk of steroid withdrawal

56
Q

what are some withdrawal symptoms of corticosteroids ?

A

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
Q

what is addison ian crisis?

A

life-threatening complication that can cause confusion, coma, cardiovascular shock, and even death.

58
Q

what is psuedo-addiction?

A

physical dependence confused with psychological dependence. pain-relief seeking, nor drug seeking

59
Q

how can you allow a physical dependent patient function

A

use the right dose- functions better in life whereas, opposite true with an addict

60
Q

what is the ceiling effect of tylenol?

A

1000mg

61
Q

is acetaminophen adequate for severe pain?

A

no but effective for mild pain

62
Q

difference between tylenol and NSAIDs like ibuprofen?

A

just treats pain but not inflm. NSAIDs treat inflm

63
Q

do NSAIDs have a ceiling? what is the analgesic dose for NSAIDS? inflm dose? (high or low)

A

yes they do and the dose is small for analgesic and high for inflm

64
Q

is there a ceiling effect for pure opioid agonists?

A

no

65
Q

what is end of dose failure?

A

trough- where they are experiencing pain. it is where the duration of opioid effect falls before next regular dose is absorbed

66
Q

what are some options for managing pain in palliative care in re: dosing?

A

inc the initial dose so that extends the effect and eliminates the trough or increase freq

67
Q

how can you titrate opiates in palliative care?

A

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
Q

what are three complications of chronic high dose opioid therapy?

A

neurotoxicity, tolerance, opioid inducted hyperalgesia

69
Q

what is opioid induced neurotoxicity?

A

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
Q

what symptoms occur from opioid induced neurotoxicity?

A

mild confusion or drowsiness to hallucinations, delirium and seizures

71
Q

what metabolites are responsible for opioid induced neurotoxicity?

A

due to neuro-excitatory metabolites of opioids (morphine-6-glucuronide, oxymorphone-3-glucuronide)

72
Q

what other factors can tip a frail older adult into opioid toxicity?

A

dehydration, infection or adding drugs

73
Q

how is OIN managed?

A

opioid rotation, dose or freq, reduction, and rehydration

74
Q

when should opioids not be discontinued in re OIN?

A

if needed for pain or dyspnea

75
Q

what is anti-nociciceptive tolerance?

A

due to prolonged use of opiates.

occurs when there is a progressive lack of response to a drug requiring inc dosing

76
Q

how do you manage anti-nociceptive tolerance?

A

higher doses of opiates are required to elicit same amount of analgesia or antinociception

77
Q

what is opioid induced hyoperalgesia?

A

The mechanism by which prolonged opiate exposure induces hyperalgesia and the relationship of this state to antinociceptive tolerance remain unclear

78
Q

how does opioid induced hyperalgesia present?

A

hyperalgesia and allodynia (hyper sensitivityy to pain basically), myoclonus, confusion

79
Q

can OIH be overcome by inc the dosage? how do you treat the pain?

A

no. pain is worsened by inc the dose. treat the pain by reducing/eliminating opioid

80
Q

treatment for OIH?

A

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
Q

what are two main considerations for use in opiate tolerant patients?

A

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
Q

are children pain often over or under treated?

A

often under

83
Q

T or F expression of pain differs by age

A

T

84
Q

what opiates are not recommended for children?

A

Hydromorphone, methadone, oxycodone, and oxymorphone

85
Q

what are some recommendations for opiate admin for the older adult?

A

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
Q

is meperidine used for pt with renal impairment? why or why not?

A

not used due to toxic metabolite

87
Q

what drug accumulates in patients with renal impatient?

A

morphine

88
Q

what is preferred for patients with critical illness (agonist/antagonist?)

A

opioid agonist drugs

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