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Chronic pain PPT by McDizzle Flashcards

Josh Guide to mind fucking anyone and everyone on issues of chronic pain!!!!!!!! skeet skeet bitches.!!!!!!!!!!!!!!!!

1
Q

What is pain?

A

an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage or both

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2
Q

what is Chronic Pain?

A

persistent or recurrent pain, lasting beyond the usual course of acute illness or injury, or more than 6 months, and adversely affecting the patients well-being

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3
Q

What are the effects of unreleived pain

A 
Delayed healing
altered immunity
Increased stress
anxiety or depression
general physical and psychological decline
Economical adversity
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4
Q

in a study >50% of pts had to change MDs due to lack of pain control? why is this?

A
  • unwilling to treat pain
  • did not take the pt’s pain seriously
  • inadequate knowledge about pain treatment
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5
Q

What contributes to the lack of pain control throughout the world?

A
  • inadequate education
  • poor understanding of pain syndromes
  • lack of diagnostic tools
  • attitudes regarding pain
  • reimbursement barriers
  • inadequate treatment guidelines
  • poor understanding of drugs used
  • reluctance to use certain pharm agents
  • lack of knowledge of complementary therapies
  • drug side effects
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6
Q

Common barriers to treatment of Chronic Pain:

Provider related?

A
  • limited knowledge of pain patho and assessment skills
  • biases against opioid therapy and overestimation of risk
  • fear of regulatory scrutiny/action
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7
Q

Common barriers to treatment of Chronic Pain:

Patient related?

A
  • exaggerated fear of addiction, tolerance, SE
  • reluctance to report pain: stoicsm, desire to please “MD”
  • concerns about “meaning” of pain
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8
Q

Common barriers to treatment of Chronic Pain:

system related

A
  • low priority given to pain and symptom control
  • limits on # of RXs and refills per month
  • reimbursement policies
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9
Q

Common barriers to treatment of Chronic Pain:

economic and racial?

A
  • language and culture differences
  • perceptions and misconceptions
  • lack of assertiveness in seeking treatment
  • unavailability of meds
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10
Q

Pathophysiology of pain:

Types of pain?

A
  • nociceptive
  • neuropathic
  • idiopathic
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11
Q

Pathophysiology of pain:

patho of chronic pain???

A

-the nervous system REMODELS continuously in response to repeated pain signals —> nerves become hypERsensitive to pain & resistant to antinociceptive system

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12
Q

Pathophysiology of pain:

what happens if chronic pain is untreated?

A

pain signals will continue even after injury resolves

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13
Q

Pathophysiology of pain:

Chronic pain signals become embedded in the ___ _____ ______

A

CNS

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14
Q

Which type of pain is pain sensing signals are initiated in response to a stimulus they elict pain relieving responses

A

Acute pin

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15
Q

Which type of pain sends pain signals that are generated for no reason and may be intensified; pain relieving mechanisms may be defective or deactivated

A

Chronic Pain

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16
Q

nociceptive pain pain results from what?

A

ongoing activation of primary afferent neurons responding to noxious stimuli

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17
Q

nociceptive pain is consistant with what?

A

degree of tissue injury

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18
Q

nociceptive pain is described as what?

A

aching
squeezing
stabbing
throbbing

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19
Q

nociceptive pain 2 subtypes

A

Somatic (r/t activation of somatic afferent neurons)

Visceral (r/t activation of Visceral afferent neurons)

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20
Q

Somatic pain:

characteristics

A 
well localized
Continuous or intermittent
aching
dull
gnawing
nagging
sharp
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21
Q

Somatic pain

examples

A

Bone fracture
arthritis
Bone metastasis

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22
Q

Visceral Pain:

Characteristics

A 
poorly localized
referred to distant sites
Sharp
gnawing
vague
deep
pressure
may become worse with movement/inhale
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23
Q

Visceral Pain:

examples

A

gallbladder
pancreatitis
Cancer

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24
Q

What type of pain is initiated by primary lesion in the nervous system; beleived to be sustained by aberrant somatosensory processing in the peripheral and CNS

A

Neuropathic pain

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25
Q

Neuropathic pain:

characteristics

A 
burning
shooting
electrical quality
aching
throbbing
sharp
Constant or intermittant
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26
Q

Neuropathic pain is independent of obvious ongoing _____ activation

A

nociceptive

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27
Q

Neuropathic pain

examples

A

post herpatic neuralgia

diabetic neuropathy

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28
Q

2 subtypes of Neuropathic pain

A

Presumed “central generator”

Presumed “peripheral generator”

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29
Q

Idiopathic pain what is it?

A

exist in the absence of an identifiable physical or psychological pathology that could account for the pain

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30
Q

Idiopathic pain is uncommon in what types of pt’s

A

pt’s with progressive illness

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31
Q

What is psychogenic pain?

A

pain that shows positive evidence of predominant psychological contribution and may be labeled with a specific phychiatric diagnosis

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32
Q

Pain assessment UPQRST

A 
U-use the pt's self report
P-palliative (provocative)
Q- quality
R- Radiation
S- Severity
T-Temporal
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33
Q

UPQRST +2

what is the +2

A

2 additional questions!

  • what have you tried to relieve your pain
  • how is the pain affecting your life
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34
Q

How can you assess pain in the cognitively impaired?

A 
Ask simple questions yes/no
assess risk factors for pain
Observe for non-verbal signs of pain
Investigate behavior/routine changes
assess function and pain
attempt an analgesic trial
35
Q

The WHO has a ladder that states to start treating the patient based off where their pain is level is at what are the 3 levels

A

mild
moderate
severe

36
Q

What is pain management for mild pain?

A

opioids

37
Q

What is pain management for Moderate pain

A

opioids + something else

38
Q

What is pain management for severe pain (basic don;t name meds yet)

A

opioids + something else + something else

39
Q

What is pharmacological management for mild pain

A

Acetaminaphen
NSAIDs
COX-2 inhibitors
LA injections

40
Q

What is pharmacological management for moderate pain?

A

Step 1 plus step 2
( Acetaminaphen, NSAIDs, COX-2 inhibitors, LA injections)
add intermitant doses of opioids

41
Q

What is pharmacological management for severe pain?

A

Step 1 plus step 2 plus step 3
( Acetaminaphen, NSAIDs, COX-2 inhibitors, LA injections, and intermitant doses of opioids)
add regional block, sustained release opioids

42
Q

Acetaminophen

dose maximum

A

4000 mg/day

43
Q

Acetaminophen adverse reactions are dose dependent but more susceptible in what patents?

A

alcoholics

44
Q 
Acetaminophen facts
Anit-flammatory effects?
adverse effects vs other non-opioids?
effects on platelet fxn?
Adverse effect?
A

minimal
fewer
none
hepatotoxicity (increased with liver disease ETOH)

45
Q

NSAIDs

exert effects at the ______ and _____ levelsls

A

peripheral and central

46
Q

NSAIDs exhibit _______, ________, and _______ effects

A

antipyretic
analgesic
antiflammatory

47
Q

NSAIDs do or do not produce physical or psychological dependence?

A

do not

48
Q

NSAIDs are usefull for acute and chronic pain due to a variety of causes including what?

A

trauma
surgery
arthritis
CA

49
Q

NSAIDs ceiling dose must be monitored to avoid toxicity with a maximum dose of _______mg/day

A

3200

50
Q

combining NSAIDs increases the potential adverse effects! what are the adverse effects of NSAIDs

A

hepatic dysfunction
bleeding
Gastric ulceration
renal failure

51
Q

what are some drug classes used for adjuvant analgesics for neuropathic pain

A 
Anticonvuslants
antidepressents
Corticosteroids
Alpha-2 adrenergic agonist
NMDA receptor agonist
Topicals
52
Q

Adjuvant analgesics: anticonculsants

what are some examples

A 
gabapentin
carbamazepine
phenytoin
valproate
clonazepam
53
Q 
Adjuvant analgesics: antidepressants
what class is best shown to work from evidence
A

tricyclics

54
Q

Adjuvant analgesics: antidepressants

what classes are better tolerated than tricyclics?

A

SSRI and atypicals

55
Q

Adjuvant analgesics: antidepressants

they are proven efficient for all types of neuropathic pain, but often preferred for what?

A

continuous dysesthesias

56
Q

Adjuvant analgesics: antidepressants

dose for pain management?

A

less than antidepresssent use

57
Q

Adjuvant analgesics: anticonvulsants dose for pain?

A

similar to anticonvulsant dose

58
Q

Adjuvant analgesics: Corticosteroids

they have been shown to improve what?

A 
pain
appetite
nausea
malaise
quality of life in Ca pt's
59
Q

Adjuvant analgesics: Corticosteroids

In CA pt’s it is indicated for refractory neuropathic pain and also?

A 
bone pain
bowel obstruction
capsular bone
lymphedema
headache
60
Q

Adjuvant analgesics: Corticosteroids

in non-cancer pts it;s use is limited to what?

A

inflammatory conditions

61
Q

Adjuvant analgesics: Corticosteroids

what are the 2 usual drugs used?

A

dexamethasone

prednisione

62
Q

Name 6 short acting opiods

A 
Hydrocodone/APAP
Hydromorphone
Morphine
Oxycodone w or w/o APAP
oral transmucosal fentanyl
tramadol
63
Q

name 4 long acting opioids

A

transdermal fentanyl
methadone
extended release morphine
Oxycodone CR

64
Q

Advantages of long-acting opiods

A

fewer peaks and troughs (sustained pain releif)
dosed less often (improved adherence)
potentially improved satisfactions

65
Q

Elements to consider for drug selection

A 
severity of pain
previous exposure
availability
pt preference
renal and liver fxn
cost
66
Q

how do you dose to optimize effects of medications

A

fixed schedule around the clock vs as needed dosing, rescue doses

67
Q

recomendations for by-the-clock (fixed schedule) dosing

A
  • dose with long acting opiod plus an “asneeded” short acting opioid (usually 5-15% of total daily dose) q 2-3h PRN
  • baseline dose increases 25-100% or equal to rescue dose use
  • increase rescue dose as baseline dose increases
68
Q

equivalent doses put dose into SC/IV/IM dose!

30 mg morphine PO

A

10 mg

69
Q

equivalent doses put dose into SC/IV/IM dose!

4-8mg Hydromorphone

A

1.5 mg

70
Q

equivalent doses put dose into SC/IV/IM dose!

20 mg oxycodone

A

none

71
Q

equivalent doses put dose into SC/IV/IM dose!

20 mg methadone

A

10 mg

72
Q

If a pt is receiving a 24hr done of 180mg PO. what is teh equivalent 24hr dose of PO hydromorphone

A

Morphine 30mg PO = morphine 180mg PO
——————– ———————-
hydromophone 7.5mg x

X= 45 mg PO (6-8mg PO q4)

73
Q

what is the key to successful opiod therapy

A

titration

74
Q

what is the ceiling dose for pure agonist opioids?

A

none

75
Q

Opioid unexpected SE

A 
resp depression
depression
Apnea
Resp arrest
Circ depression
Hypotension
Shock
Constipation
76
Q

What are expected SE of opiods

A 
N/V
Somnolence
Dizziness
Pruritis
Headache
Dry mouth
Sweating
77
Q

what are non pharm ways to manage pain

A 
Lifestyle changes (weight loss)
Rehab therapy
Psychosocial therapies
Interventional tech (TENS, Injections, surgery)
Complementry therapies (massage)
78
Q

How do you measure opioid outcomes?

A 
the 4 A's
Analgesia
ADLs
Adverse effects
Aberrant drug taking (addiction)
79
Q

what is an abstinence syndrome induced by administration of an antagonist or by dose reduction

A

physical dependence

80
Q

What is the diminished drug effect from drug exposure

A

tolerance

81
Q

2 tyoes of tolerance

A

associative and pharmacological

82
Q

what is a disease with pharmacological, genetic, and psychosocial elements, has elements of loss of control, compulsive use, use despite harm

A

Addiction

83
Q

what is aberrant drug-related behaviors driven by uncontrolled pain

A

pseudoaddiction

84
Q

What pts (3) are at low risk for addiction

A

acute pain
Ca pain
pt’s w/o backgrounds of abuse

Regional (24 decks)

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