Chronic Pain Flashcards
What is the common cause for chronic pain
Cause may not be identifiable
Or result from changes in nerve function and transmission
What are the two classification for chronic pain
Cancer pain and non-cancer pain
When using opioids for non-cancer pain what should you consider?
Risk of substance abuse/ Comorbid mental health issues
What are the symptoms of chronic pain
Occurs without relation to noxious stimuli and generally has no obvious signs
What is the goal for managing chronic pain
Improve functional status
Decrease pain perception
Reduce the use of medication
Improve overall quality of life
Why should comprehensive care be used during management of chronic pain
To address fear, anxiety, fatigue, depression etc should include emotional and mental support
Beside the Assessment tools studied in acute pain what are the other pneumonics for assessing chronic pain - OLDCARTS
O - onset L-location D-Duration C-characteristics A- aggravating factors R- relieving factors T-Timing S-severity
Beside the Assessment tools studied in acute pain what are the other pneumonics for assessing chronic pain - SOCRATES
S-site O-onset C-characteristics R-radiation A- associated sx T-Time E- exacerbating factors S-severity
Adjunctive agents to opioid therapy are administered as
Co-analgesics to address neuropathic pain
Which antidepressants are used as adjunctive
TCA: amitriptyline
SNRI: duloxetine, venlafaxine
Amitriptyline side effect
Sedation
Dry mouth
Constipation
Urinary retention
Cardiac events
Duloxetine or venlafaxine side effect.
Serotonin syndrome
Somnolence
Constipation
HTN
Yenlafaxine: QT prolongation
Anticonvulsants used as adjunctive agents
Gabapentin
Pregabalin
Carbamazepine
Oxcarbazepine
Lamotrigine
Topiramate
Gabapentin dose
100-300mg TID and titrate to max dose as patient can tolerate
Pregabaliclosen
150mg daily divided as TID or BID
Max: 300mg daily
Gabapentin / pregabalin side effect
Sedation/CNS
Carbamazepine side effect
CNS and GI
Steven Johnson syndrome (rare)
Cardiac
Hematologic rxn
Oxcarbazepine side effect
CNS and GI
Serious Dermatologic or Hematologic (rare)
Lamotrigine side effect
Steven Johnson Syndrome
Blood dyscrasias
Topiramate is mainly used for?
Prophyleris migraine
Antispacity skeletal muscle relaxant adjunctive agent
Baclofen
Dantrolene
Diazepam
Tizanidine
Antispasmodic adjunctive agents
Carisoprodal
Chlorzoxazone
Cyclobenzaprine
Orphenadrine
Tizanidine
Diazepam
Methocarbamol
Metaxalone
What are the side effects of antispasmodic and antispacity adjunctive agents
Sedation
With-drawl with abrupt discontinuation
Respiratory depression when administered with opioids
How are antispasity or antispasmodics dosed to reduce additive side effects
Short term use as needed
What other agents can be used adjunctive agents
Corticosteroids
Lidocaine or Topical capsaicin for local pain
Cannabidol
Why should we be cautious with using sleep- aids, anxiolytics or antispasmodic as adjunctive agents
Sedation
Non-pharmacologic intervention: Physical/occupational rehabilitation (PT/OT)
Ergonomic considerations
Non- Pharmacologic interventions: Complementary and alternative medicine
Chiropractic
acupuncture
hypnotherapy/mind-body therapy
massage
other holistic methods
Non-pharmacologic intervention: Interventional pain management techniques
Local corticosteroid injections
Nerve/spinal block via anesthesiology
Implanted intraspinal pump/catheter
Implanted nerve stimulators; Electroanalgesia (TENS/PENS)
Neuroablative procedures
Non-pharmacologic intervention: Surgical interventions
Kyphoplasty
What is the general opioids principles
Start at low doses and go slow
Consider previous opioid exposure and patient preference
Who might need immediate-release and short acting opioid
Opioid naive
Pho might need higher dose
Non-opioid naive
Which opioids are good for renal failure patient
Oxycodone
Fentanyl
Methadone
Which is not safe for use in renal failure
Morphine
Hydromorphone
Which is not safe for hepatic failure
Oxycodone
Which cytochrome converts codeine, hydroco done and tramadol to active form
CYP2D6
CYP2D6 inhibitors
Fluoxetine
Paroxetine
Haloperidol
Which medication is a central acting analgesic with low affinity for the mu receptor
Tramadol
Which medication inhibits reuptake of norepinephrine and serotonin
Tramadol
Tramadol has less of these side effects compared to opioids
Nausea
Constipation
Drowsiness/Dizziness
Headache
How is immediate release tramadol dosed
25-100mg every 4-6 hours
Max dose of immediate release tramadol
400mg daily
What is the extended release dose of tramadol
100 mg daily
What is the max dose of extended release tramadol
300 mg daily
What are the long acting opioids for chronic pain
Morphine
Oxycontin (oxycodone)
What is the frequency of dosing for long acting oxycontin and morphine
Every 12 hours
But morphine can be giving at every 8 hours if needed
How is long acting oral opioid morphine and oxycontin administered
Swallow whole. Do not crush, chew or open
Which opioid is active at the mu receptors and NMDA receptors
Methadone
How is methadone better than other opioids
Reduced tolerance and improved responsiveness to pain
Why is methadone a long acting medication
Half life: 128hours and very lipophilic
Titrate slowly
True/ false: methadone is available as a tablet which can be chewed or crushed and as an oral solution
True
Is renal adjustment needed for methadone
No
What should be monitored in patients taking methadone
EKG: check QT baseline on day 30 followed by an annual check up due to arrhythmia risk
Drug interaction
What are the strength of fentanyl transdermal patches
12.5,25,50,75,100 mg
How often can transdermal fentanyl patch be replaced
Every 72 hours or 3 days
When can fentanyl transdermal patch be changed every 48 hours
If patient is tolerating every 72 hours but pain returns at the end of 72 hours
How often should fentanyl transdermal patch be titrated
No faster than 3-6 days
What are the important counseling point when initiating fentanyl transdermal patch
Take last oral long acting dose when placing first patch
When taking off patch give half of longacting oral dose at every 12-18 hours
Do not ever cut patch
Always dispose properly
How is fatalities from dose overestimation of fentanyl transdermal patches avoided
Double check conversions
Never round up and always provide breakthrough medication
Titrate patch size if needed
What is a Patient controlled analgesia (PCA)
It is a process that uses an individualized computerized system program to administer analgesics for institutionalized patients needing IV therapy
What and who is involved in pla therapy
Requires regular monitoring and dosage adjustment
Nurse, patient, pharmacist and prescriber
What are the components of a PCA order
Drug chosen
Basal rate
Bolus dose and dose interval
Lockouts
Prn orders for side effect
Naloxone prn order
Nursing assessment
What should a nurse assess when using PCA
RR
O2
Pain score
How is the opioid side effect of constipation managed
Bowel regimen: Stool Softener +/- Stimulant
Docusate 1-4 caps/day +/- senna 2 tabs/day to start
The/False: patient develop tolerance to constipation side effect
False
May need to add more laxatives (miralax, milk of mag, lactulose)
Other constipation relievers
Methylnaltrexone
Lubiprostone
Movantik (naloxegel)
Reverses GI mu receptor to help with constipation
Methylnaltrexone
Should laxative be used with methylnaltrexone
No. D/C all laxative upon initiation
How are non-cancer patient dosed with methylnaltrexone
450mg by mouth daily
Or
12 mg SubQ daily
How are advanced ill patient dosed with methylnaltrexone
Weight based
Methylnaltrexone dose for patient weighing < 38kg
0.15 mg/kg
Methylnaltrexone dose for patient weighing 38 to <62 kg
8 mg
Methylnaltrexone dose for patient weighing 62 to 114 kg
12 mg
Methylnaltrexone dose for patient weighing > 114kg
0.15 mg/kg
What is the mechanism of action for the constipation relieving agent lubiprostone
Calcium channel activator
How is lubiprostone dosed
24 mcg twice daily by mouth
What are side effects associated with lubiprostone
GI
Hypotension/syncope
Dyspnea
What is the mechanism of action for the constipation relieving agent movantik
Mu opioid receptor antagonist
Should laxative be D/C/ when starting movantik
Yes. But can restart if needed
How is movantik dosed and administered
25 mg daily by mouth on empty stomach
Should movantik be really adjusted
Yes.
What are the side effects of movantik
GI
Risk of perforation or withdraw
How do opioids induce nausea and vomiting
Stimulates chemoreceptor trigger zone, decreases GI motility
How is nausea and vomiting managed and what are therapeutic side effects
Antiemetics:
Prochlorperazine/promethazine
– Side effect: EPS, dizziness/drowsiness
• Ondansetron
– Side effect: constipation, headache
• Dronabinol
– Side effect: increased appetite, CNS disturbances (particularly in elderly)
How is nausea inducing early satiety managed
Metoclopramide
Side effect: Diarrhea
How is nausea inducing vertigo managed
Scopolamine, meclizine
Side effect: impaired eye accommodation, anticholinergic
How is sedation side effect managed
Dose-related, consider hepatic/renal function
Change to alternative opioid; tolerance
How does opioid induce puritus
Central action versus histamine release
Why is antihistamine such as diphenhydramine or hydroxyzine not always effective against opioid induced puritus
Can be sedating
Consider alternative opioid
How is unsay retention side effect managed
Change to alternative opioid because tolerance does not develop
True/False: opioids can cause respiratory depression
True
What is risk mitigating strategies
Check board to lower risk of inducing respiratory depression or over dose
What are the risk mitigating strategies
1) establish realistic goals
2) identify risk prior to initiating opioids
history of substance abuse /comorbidities/ mental health disorders
close monitoring, including random regular urine drug screen
contracts: pill count or prescription monitoring program
What medication is used incase of opioid overdose
Naloxone
How is naloxone available
IM, IV, nasal spray
When should naloxone be used according to CDC guidelines
If ≥ 50mg morphine equivalent per day or if concurrent benzodiazepine
What is the counsel point for naloxone use
. Signs/symptoms of overdose
- Importance of seeking medical care (call 911)
- How to use device
• Availability of drug treatment
programs
What is one general opioid counseling point you would forget
Do not restart opioid at same dose if there is a period
of abstinence as overdose is possible due to lowered
tolerance
What is step 1 of the five step approach to opioid conversion
Assess of uncontrolled is worsening or development of new type of pain.
use assessment tools
What is step 2 of the five step approach to opioid conversion
Determine total daily usage of current opioid
What is step 3 of the five step approach to opioid conversion
Decide which opioid analgesic would be used for the new agent and use conversion table for proper dosage
What is step 4 of the five step approach to opioid conversion
Individualize dosage base on assessment from step 1 and ensure adequate access to breakthrough medication (short acting opioids usually 5-20% of dose for chronic pain )
In step 4: when is 25-50% dose reduction considered
For cross tolerance in controlled patient
At risk of respiratory depression or sedation
If no side effect and pain is adequately controlled
In steps: when is dose increase considered
If patient is tolerating but ineffective baseline analgesia
If in severe pain
Closely monitor
What is step 5 of the five step approach to opioid conversion
Patient follow up and continual reassessment during the first 7-14 days
What is special about methadone conversion
ALWAYS triple check the math with peer evaluation
- Always reduce calculated dose (up to 90%) to avoid overdose
- Divide dose into q8h
• Monitor closely, titrate slowly
– Do NOT titrate any faster than every 3-5 days (may need to only
titrate every 1-2 weeks)
– Delayed effect: steady state after 3-5 days
– Duration analgesia shorter than half-life
• In general, max starting dose is 40mg/day
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