Chronic Pain Management Flashcards
when does acute pain become chronic
if it lasts more than 6 months or the time it would take for the connective tissue to heal
many TMJ disorders are ____ and ______
mild and self limiting
how long do CHRONIC pain syndromes last
more than 6 months
depressive symptoms and _____ pain have a direct correlation
chronic musculoskeletal pain
_____ increases the patients self reporting of pain especially skeltal muscle pain
anxiety
________ approach is best for management of TMD
multi modality
what are the multi modality approaches to TMD management
- medications
- splint therapy
- physical therapy
- acupuncture
- psychotherapy
- arthrocentesis or surgery
what are the common co existing pain conditions
- TMD
- fibromyalgia
- headaches (migraine, tension type, and TACs)
- IBS
team approach for chronic pain has best treatment outcome involving multi specialities such as:
- orofacial pain
- PT
- pain psychologist
- rhuematologist
- neurologist
what other diagnoses can cause head and facial pain
- migraine headache
- tension headahce
- trigeminal autonomic cephalgias
- temporal arteritis
- ear infection
- sinus infection or tumors
- tooth infection
- jaw joint sprain
- neuralgia
- jaw joint disk displacement
- may not be painful
what diagnoses can cause malocclusion
- oral cancer
- jaw joint tumors (osteochondromas)
- dental malocclusion especially secondary to osteoarthritis or rheumatoid arthritis
- facial muscle spasm
- jaw fracture
what is the PT for TMD chronic pain
- treat 2 times per week for 12 sessions
- add CC
- add diagnoses
- add tx recommendations such as:
- ultrasound to masseters
- massage jaw muscles
- mandibular mobilization to increase range of mouth oepning
- evaluate pressure
what are the txs for mild-moderate pain
- NSAIDs, muscle relaxants
- mixed analgesics
- class III narcotics
what is the tx for severe pain
- steroids, muscle relaxants
- sleep medications, antidepressants, neuropathic pain medications
- mixed analgesics, class II narcotics
what types of acetominophens are given what are the effects and overdose effects
- paracetamol (generic in foreign countries)
- APAP (acetyl- para- aminophenol)
- no anti inflammaotry effects
- minimal increased risk of bleeding
- overdose: hepatotoxicity
what is the max daily dose for acetominophen
4000 mg per day in divided doses except in chronic pain: 3000 mg per day in divided doses
what is the dosage for caplet, tablet of acetominophen
325mg, 500mg, 650mg XR (lasts 8 hours
what is the dosage for an acetominophen elixir
160mg/5mL
- 500mg/5mL
what is the dosage of the injectable acetominophen
10mg/mL
what is the suppository acetominophen dose
120mg,325mg, 650mg
what is the acetominophen combination with opioids
- hydrocodone- acetominophen
- norco 5mg, 7.5mg, 10mg/ 325mg
- vicodin 5mg, 7.5mg, 10mg/300mg
- endocet, roxicet 5mg,7.5mg, 10mg/ 325 mg
- percocet: 5mg, 7.5mg, 10mg/ 325mg
- watch for concurrent medications containing acetominophen especially OTC products such as sleep aids
what is the max dose for acetominophen (tylenol) for select pts and what is the risk
3-4g/day
- hepatic failure/toxicity
what is the max dose ibuprofen (motrin)
3.2g/day
what is the max dose for aspirin
4g/day
what is the combination of tylenol with codeine no. 2
300mg/15mg
what is the combination of tylenol with codeine no. 3
300mg/30mg
what is the combination of tylenol with codeine no.4
300mg/60mg
what is the combination with tramadol
ultracet
- acetominophen/tramadol
- 320mg/37.5mg
what are the advantages of long acting opioids
- more consistent analgesia
- fewer adverse effects
- more tolerance to adverse effects
- better sleep -> better daytime function
- less euphoria, addiction, diversion
what ist he dose of narcan with opioids
- 4mg/actuation
- one spray (4 or 8mg) into one nostril if opioid overdose
- may repeat every 2-3 minutes in alternate nostril. family member must know instructions
- rx for 2 pack - give 4 plus one refill
what are the OTC products containing acetominophen
- excedrin, extra strength, excedrin migraine: acetominophen/Aspirin/Caffeine: 250mg/250mg/ 65mg
- comtrex: acetominophen/dextromethorphan/phenylephrine: 325mg/10mg/5mg
what are the NSAIDs
- aspirin
- IBU
- naproxen
- meloxicam
- celecoxib
describe NSAIDs
- anti inflammatory effects
- analgesic effects
- antipyretic effects
what is the inhibition cascade
- arachidonic acid -> COX-1 -> homeostatic functions -> GI tract, renal tract, platelet function, macrophage differentiation
- arachidonic acid -> COX-2 -> inflammation
what are the effects of NSAIDs at low dose
antipyretic effects
- analgesic effects
what are the effects of NSAIDs at high doses
more anti inflammatory effects besides mentioned effects
what is the OTC dosage, RX, max dose and toxicity of IBU
- OTC: 200mg
- RX: 400mg, 600mg, 800mg
- Max dose: 3200 mg per day in divided doses
-toxicity: GI ulcer
to reach anti inflammatory effects with IBU must use:
1800mg- 3200mg/day in divided doses
what is the dose for oxycodone/ibuprofen
5mg/400mg
- maximum of 4 tablets/day in divided doses
what is the dosage for hydrocodone/ibuprofen
- 2.5mg,5mg, 7.5mg, 10mg /200 mg
- maximum of 5 tablets/ day in divided doses
what are the long lasting NSAIDs
naproxen and celecoxib
what is the dose for naproxen, max daily dose, toxicity
- aleve 220mg OTC
- max daily dose: 1500mg per day in divided doses
- toxicity GI ulcer
how do you minimize GI damage with naproxen
combination with PPI esomeprazole
what is celecoxib and what is dose
selective cox 2 inhibitor
- 100mg or 200mg twice daily
when do you avoid celecoxib
if pt has sulfa allergy
topical analgesics are ______ likely than systemic analgesics to produce side effects
less
what areht etopical NSAIDs
- 10 or 20% indomethacin
- 10 or 20% IBU
10, 15, or 20% keoprofen
3,5, or 10 diclofenac
what are the topicals used for musculoskeletal pain
- NSAID with muscle relaants
- 1% flexeril with 10% ketoprofen/10% IBU
- 1% diclofenac sodium gel (voltaren) RX or OTC
describe the limit of acetominophen and NSAIDs
- these analgesics have ceiling effect
- has a limit in relieving pain
- above the limit
- no more analgesic effect
- more toxicity
- no tolerance or dependence happen with these analgesics
- take NSAIDs with food to lower GI ADRs
