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Neurology > Chronic Pain Management > Flashcards

Chronic Pain Management Flashcards

1
Q

What is pain?

A

Chronic pain is defined as pain lasting > 12 weeks or > 3 months

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2
Q

Somatic Pain

A

Pain arising from damage to muscle, bone, or skin; well-localized

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3
Q

What are some descriptors of somatic pain?

A

Sharp, intense, throbbing, localized

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4
Q

Visceral Pain

A

Pain arising from damage to organs; not well localized – can be referred

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5
Q

What are some descriptors of visceral pain?

A

Gnawing, cramping, squeezing, diffuse, distant

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6
Q

Neuropathic pain

A

Pain arising from a lesion or disease of the somatosensory nervous system

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7
Q

What are some descriptors of neuropathic pain?

A

Shooting, burning, numb, tingling, enhanced sensitivity to heat/cool

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8
Q

What are the chronic non-cancer pain syndromes?

A
  • Osteoarthritis
  • Diabetic Neuropathy
  • Fibromyalgia
  • Post-Herpetic Neuralgia
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9
Q

Osteoarthritis (OA)

A
  • Common degenerative disorder or the joints leading to hypertrophic bone changes
  • Most common in hands, knees, hips, and spine (asymmetric)
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10
Q

What are some symptoms of Osteoarthritis (OA)?

A
  • Persistent joint pain
  • Stiffness
  • Locomotor restriction
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11
Q

Diabetic Neuropathy

A
  • Nerve damage caused by poorly controlled diabetes that leads to numbness in extremities
  • Most common microvascular complication of diabetes
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12
Q

What are some symptoms of diabetic neuropathy?

A
  • Unprompted numbness
  • Tingling
  • Burning
  • Shooting (symmetrical)
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13
Q

What are some risk factors of diabetic neuropathy?

A
  • Poor blood sugar control
  • Longer duration of diabetes
  • Kidney disease
  • Obesity
  • Cigarette smoking
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14
Q

What are the first line pharmacological treatments for Diabetic Neuropathy?

A
  • Duloxetine (SNRI) - FDA approved
  • Pregabalin - FDA approved
  • Gabapentin
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15
Q

What are the second line pharmacological treatments for Diabetic Neuropathy?

A
  • Venlafaxine (SNRI)
  • Amitriptyline (TCA)
  • Lidocaine patch
  • Capsaicin cream/patch - FDA approved
  • Tramadol (last line)
  • Tapentadol (last line)
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16
Q

Fibromyalgia

A

Widespread soft tissue pain affecting muscles, ligaments, tendons with no obvious objective abnormalities

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17
Q

What are some symptoms of fibromyalgia?

A

Diffuse musculoskeletal pain present for > 3 months, often accompanied by fatigue, headache, cognitive disturbance, and sleep disturbances

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18
Q

What are some treatment to target sleep disturbances of fibromyalgia?

A
  • Amitriptyline
  • Cyclobenzaprine
  • Gabapentinoid (pregabalin-FDA approved, gabapentin)
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19
Q

What are some treatment to target depression/anxiety of fibromyalgia?

A
  • SNRIs - duloxetine (FDA approved), milnacipran (FDA approved)
  • Amitriptyline
  • Pregabalin
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20
Q

Postherpetic Neuralgia

A

Pain in a dermatomal distribution caused by nerve damage secondary to an inflammatory response induced by viral replication (herpes zoster-shingles) within a nerve sustained for at least 90 days after acute herpes zoster

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21
Q

What are some symptoms of postherpetic neuralgia?

A
  • Burning
  • Shock-like pain
  • May be associated with allodynia or hyperalgesia
22
Q

Allodynia

A

Pain from stimuli which are not normally painful

23
Q

Hyperalgesia

A

Abnormally heigtened sensitivity to pain

24
Q

What are the first line pharmacological treatments for Postherpetic Neuralgia?

A
  • Gabapentin (FDA approved)
  • Pregabalin (FDA approved)
  • Lidocaine patch (FDA approved)
  • Capsaicin patch (FDA approved)/cream
25
Q

What are the second line pharmacological treatments for Postherpetic Neuralgia?

A
  • TCAs
26
Q

What are the third line pharmacological treatments for Postherpetic Neuralgia?

A

Opioids (not preferred)

27
Q

Topical NSAIDs

A
  • Typically utilized for localized pain (OA-related pain)
  • Miniscule systemic absorption; generally well-tolerated, see benefit in 10-14 days
  • Apply the gel (2-4g) to affected area 4x/day; max dose: 32 g/day
28
Q

For systemic NSAIDs, order from COX1 selectivity to COX2 selectivity based on:
-Naproxen, Ibuprofen, Meloxicam, Ketorolac, Celecoxib, Indomethacin, Diclofenac

A
  • Ketorolac
  • Indomethacin
  • Naproxen
  • Ibuprofen
  • Diclofenac
  • Celecoxib
  • Meloxicam
29
Q

Which systemic NSAIDs is the worst for cardiovascular-related ADE?

A

Celecoxib and Diclofenac

30
Q

Which systemic NSAIDs is the safest for cardiovascular-related ADE?

A

Naproxen

31
Q

Which systemic NSAIDs is the worst for renal-related ADE?

A

Naproxen and ibuprofen

32
Q

Which systemic NSAIDs is the safest for renal-related ADE?

A

Celecoxib and diclofenac

33
Q

Which systemic NSAIDs is the worst for GI-related ADE?

A

Ketorolac

34
Q

Which systemic NSAIDs is the safest for GI-related ADE?

A

Celecoxib and ibuprofen

35
Q

What are some GI risk factors?

A
  • Age ≥ 65
  • History of ulcer disease
  • Previous GI bleeding
  • DAPT
  • Anticoagulant therapy
  • Corticosteroid use, GERD
36
Q

Topical (non-NSAID) agents

A

Superficial pain/localized, neuropatic pain, OA

37
Q

Capsaicin patch (Qutenza)

A
  • FDA approved for diabetic neuropathy and postherpetic neuralgia
  • Apply (up to 4 patches) to most painful areas for 30 mins; treatment may be repeated for more than 3 months
38
Q

Capsaicin Cream

A

Diabetic neuropathy
* Apply for 4x daily

39
Q

What are some expectations when taking capsaicin?

A

Helpful for pain that responds to heat
* See relief in 2-4 weeks

40
Q

What are some counseling points for capsaicin?

A
  • Do NOT use heating pads or apply bandages where you applied project
  • Wash hands after
  • Administer “quarter size” amt of cream
41
Q

Lidocaine

A

Localized, superficial neuropathic pain

42
Q

Lidoderm Patch

A

Approved for postherpetic neuralgia
* Apply for 12 hours then remove for 12 hours

43
Q

What are the counseling points of Lidocaine?

A
  • Max 3 patches per day
  • Can cut patches and place on different sites
  • Apply to intact skin
44
Q

Antidepressants

A

Neuropathic pain

45
Q

What are some advantages of pregabalin?

A
  • Faster onset of pain relief
  • Higher bioavailablity
  • Dose can be titrated to “effective dose” more rapidly
  • Less pill burden (BID dosing)
46
Q

What are the disadvantages of pregabalin?

A
  • Higher risk of peripheral edema
  • Schedule V medication
  • More expensive, prior authorization
  • Dose reduction necessary for renal impairment
47
Q

What anticonvulsants treat trigeminal neuralgia?

A
  • Carbamazepine
  • Oxcarbazepine
48
Q

What anticonvulsants treat migraine prophylaxis?

A
  • Valproic acid
  • Topiramate
49
Q

What anticonvulsants treat other neuropathic syndromes?

A
  • Carbamazepine
  • Oxcarbazepine
  • Phenytoin
50
Q

What do you monitor for in controlled substances for chronic non-cancer pain?

A
  • Analgesia
  • Affect
  • Activities
  • Adjuncts
  • Adverse effects
  • Aberrant behavior

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