Chronic pain management Flashcards
What is acute pain, subacute/post-acute, chronic
Time limited (up to 7 days after an injury), Up to 6-12 weeks following a severe injury and/or major surgery, pain that last beyond normal expected time of tissue injury
What is the most common type of chronic pain
Back pain
T/F: Chronic pain and mental health are usually tied together
True
What are the causes of chronic pain
nociceptive, neuropathic (nerve damage or abnormal functioning), mixed
T/F: SSRIs such as escitalopram are apporved for neuropathic pain
False: SNRI, duloxetine, is approved for neuropathic pain
The analgesic action of antidepressants occurs under what conditions
Even if patient is not clinically depressed, sooner and at lower doses than doses required to treat depression
What are the first line agents for Neuropathic pain
Secondary amine tricyclic antidepressants (despiramine and nortriptyline), Duloxetine, gabapentin, pregablin
What is the second line of neuropathic pain, concern, other
Tramadol, increased abuse potential for chronic pain and a risk factor for long-term opiod use, licdocaine patch
What is the third line, caveat
Immediate release opiod, effective in the short-term while titrating antidepressants and/or anticonvulsants to optimal dosages
T/F: For treating pain start low and go slow when titrating
True
If partial pain relieft is present and side effects are tolerable what should be done, problematic, pain relief is INADEQUATE
Increase the dose, add a first line agent with a DIFFERENT mechanism of action, adding or switching to a first line agent with a different mechanism of action
What is the symptom duration of acute back pain, subacute, chronic
Greater than 4 weeks, 4 to 12 weeks, greater than 12 weeks
What physiological changes usually causes acute or subacute back pain
Release of inflammatory mediators, muscle spasm in surrounding tissue
What is the first line treatment of acute or subacute lower back pain, second line
Remain active and education/ application of heat, NSAID, spinal manipulation and acupuncture
What are limited use treatment for select patients only
Exercise therapy, skeletal muscle relaxants (acute LBP only), opiods (CAUTION)
What treatment is not recommended for LBP, insufficient evidence
Acetaminophen, SNRI and gabapentinoids
What is the MOA of anitspasticity agents, what are they
Act directly on skeletal muscle or in spinal cord to improve muscle hyertonicity and involuntary spasms/ Baclofen and Dantrolene
What are the antispasomadic agents
Cyclobenazaprine, carisoprodol, metaxalone, methocarbamol
What drugs are antispasmodic and antispasticity
Diazepam and Tizanidine
T/F: Evidence supports a modest benefit of skeletal muscle relaxants for short-term (less than one week) for treatment of acute and is associated with faster functional recovery in LBP
False: Evidence dose support a modest benefit of skeletal muscle relaxants for short term for treatment of acute LBP BUT IS NOT associated with faster functional recovery/ NO STUDIES SUPPORT LONG TERM USE IF SKELETAL MUSCLE RELAXANTS
What is the first-line treatment for chronic LBP
Remain active, exercise, education that includes coping with a long term health problem, cognitive behavioral therapy
What is the first line treatment or adjunctive option for chornic LBP
Spinal manipulation, massage, acupuncture, yoga, stress reduction, rehab, NSAIDS, SNRI (small at best), Tramadol (kinda)
What is not recommended for LBP, insufficient evidence
Acetaminophen/ application of heat and skeletal muscle relaxants
When would gabapentionids be used in chronic LBP
Painful conditions with nerve pathology (sciatica, failed back surgery syndrome)
What are NSIADS first line for
Osteoarthritis, rheumatoid arthritis, back/neck/shoulder pain, inflammatory pain
What are the three types of side ffects for NSAIDs
Gastrointestinal (Hearburn, GI bleeding), Cardiovascular (MI and stroke, heart failure), Renal (AKI)
`What patients should NSAIDs be avoided in
Recent myocardial infarction, unstable angina, poorly compensated heart failure, CKD (3 or worse), Volume depleted
What disease states are associated with opiod-tolerant patingts recieving agents, which agents
Cancer pain and chronic upain unresponsive to nonopiod treatments. transdermal fentanyl patch and methadone
What is the indication for trnasdermal fentanyl patch
Opioid-tolerant patients with pain severe enough to require daily, around the clock, long term opioid treatment
Where and how is the fentanyl patch applied
Chest, back, upper arm or flank/ press patch firmly in place for about 30 seconds
What are the kinetics of the fentanyl patch, mininum and maximum effect, steady state
Simple diffusion with delayed onset and offset of effect 12 hours. 24 hours, 3 to 6 days
The patient should continue oral opioid for 12-24 hours after
True
After the patch is removed how long does it take to for plasma levels to fall by 50%
24 hours (must monitor for a day if oversedation/respiratory depression is seen)
What is patient education for fentanyl patches
DO NOT CUT patch or use altered patch, avoid exposing application site to direct heat, remove old patch once new patch is placed
What metabolizes methadone, adverse effects
CYP 3A4 and CYP2B6, QT prolongation
What are the risk factors of abusing opiods
Family history of substance abuse, personal history of substance abuse, age between 16- 45 years, psycholoigcal disease, history of preadolescent sexual abuse
The CDC guideline for prescribin poiods for chronic pain dose not include which patients
Active cancer treatment, acutesickle cell pain crisis, acute pain after surgery
T/F: Patients should be tapered off opiods in order to lessen withdrawl symptoms
True
