Exam 3 - Lecture 21 Pain Management

Question 1

Which organization incorporated pain management standards into accreditation requirements in 2000?

Answer 1

JCAHO

Question 2

What are the two components of pain?

Answer 2

• Physiological Sensation
• Emotional psychological reaction to that sensation (most important, represents “suffering”)

Question 3

Approaches to Managing Pain

Answer 3

• Remove cause
• Decrease Inflammation, irritation, and sensitivity of nerve endings (aspirin, NSAIDS, and related agents)
• Block conduction of impulses by pain fibers (local anesthetic, ex. Lidocaine)
• Modify Processing of pain information in the CNS (opioids, aspirin, acetaminophen, NSAIDS and related agents.

Question 4

Aspirin, ibuprofen, NSAIDS, and related agents

Answer 4

• Inhibitors of Prostaglandin synthesis (COX-1 and COX-2)
• Acts on nerve endings and in the CNS to alleviate pain
• Anti-inflammatory effects
• Adverse Effects: GI (irritation, bleeding, etc.), potential serious CV side effects (hypertension, MI, stroke, etc.)

Question 5

What does COX-1 and COX-2 produce from the Arachidonic acid precursor?

Answer 5

Prostaglandins and other similar compounds.

Question 6

What happens when the COX-1 and COX-2 pathways with arachidonic acid are inhibited?

Answer 6

Lipooxygenase Pathway which produces Leukotrienes (involved in the pathology of asthma attacks)

Question 7

Acetaminophen

Answer 7

-Inhibits prostaglandin synthesis in nerve endings and CNS, not in periphery.
-Acts on nerve endings and in CNS (unknown mechanism of action)
- No Anti-inflammatory response
- No GI irritation
- Adverse Effects: Potential Hepatotoxicity at high doses

Question 8

Ketorolac (Toradol)

Answer 8

• Injectable NSAID
• Alternative to opioids for pain
• Adverse Effects: GI irritation
• Short term (<1-2 days) use but not for chronic use.

Question 9

Celocoxib

Answer 9

Selective COX-2 Inhibitor

Question 10

Local Anesthetics

Answer 10

• Block Na channels in nerve endings and axons. Stoping generation and conduction of APs.
• small, unmylenated pain fibers are the most sensitive
• Powerful pain relief with spinal, regional, and nerve block techniques.
• Invasive (may effect motor function and sensory modalities)
• Low doses are used (selective pain relief, less affect on other functions)
• Used for surgical pain and chronic pain syndromes

Question 11

Prototype of Local Anesthetics

Answer 11

Lidocaine

Question 12

Dependence and Addiction

Answer 12

-Drug dependence does not mean addiction.
- Most studies have shown that most patients who take opioids for medical purposes do not become “addicts”
- prescribes must be careful to prevent abuse.

Question 13

Drug dependence

Answer 13

• physiological state resulting from chronic exposure to drug.
• Can go through withdrawal symptoms (usually the opposite effects of drug)

Question 14

Addiction

Answer 14

pattern of behavior in which use of drug becomes a central role in a person’s life

Question 15

Schedule I Drugs

Answer 15

No approved medical use and high abuse potential. Cannot be prescribed (Heroin, LSD, hallucinogenic mushrooms)

Question 16

Schedule II Drugs

Answer 16

significant abuse potential. Can be prescribed (most heavy duty opioids)

Question 17

Adjuvant Drugs

Answer 17

• Not classical analgesics but useful either alone or in combination with other agents for pain.
• Includes Corticosteroids, Disease Modifying Antirheumatic Drugs (DMARDSs) and Immunomodulators.

Question 18

How are adjuvant drugs useful for pain management?

Answer 18

-Act on various components of the immune system
- useful in treatment of inflammatory and autoimmune disorders (ex. rheumatoid arthritis and lupus erythematosis).
- Can have powerful analgesic effects.

Question 19

Antidepressants

Answer 19

• Adjuvant Drugs
• Amitriptyline, Duloxetine
• Alleviate symptoms of depression that commonly occur in patients with chronic pain.
• Enhance analgesic effects of opioids.
• beneficial in treatment of neurogenic pain.

Question 20

Anticonvulsant Drugs

Answer 20

• Adjuvant Drugs
• Carbamazepine, Gabapentin, Pregabalin
• Useful in the management of neurogenic pains.

Question 21

Duloxetine main mechanism of action

Answer 21

inhibits synaptic reuptake of serotonin and norepinephrine

Question 22

Ketamine Adverse effects

Answer 22

• Potential “dissociative” psychiatric effects
• Cardiac Stimulation can be severe

Question 23

Ketamine

Answer 23

• Similar to Phencyclidine (PCP)
• Widely used military in emergency trauma situations
• Lower doses being used increasingly in Pain management and psychiatry

Question 24

General Principles for drug selection

Answer 24

• Assessment of type and level of pain
• if possible, treat or remove cause of pain
• Select appropriate drug for type and level of pain (Consider health status of patient assess potential side effects and potential toxicities)
• Use proper doses
• Consider legal issues related to opioid use

Question 25

Drugs selected for mild pain

Answer 25

• Acetaminophen
• Aspirin
• Ibuprofen, ketoprofen, naproxen

Question 26

Drugs selected for moderate pain

Answer 26

• Oral NSAIDs for arthritis, musculoskeletal, post surgical and dental pain
• Intermediate Potency Opioids (Codeine, Hydrocodone, etc.). Usually given in combination with acetaminophen or aspirin.
• Mixed agonist antagonist opioids like tramadol can also be used

Question 27

Drugs Selected for Severe Pain

Answer 27

• Strong Opioids (morphine, oxycodone, hydromorphone, fentanyl, methadone, etc.) either alone or in combination with other agents.
• NSAIDs
• Adjuvant drugs such as antidepressants, anticonvulsants

Question 28

Cost of treatment vs Cost of inadequate pain management

Answer 28

• Treatment - Cost of Patient evaluation and assesment, cost of medications, and costs of asministering meds/monitering patients (easy to determine)
• Inadequate/Inappropriate Pain management - Cost of increased morbidity in patients (ER visits, prolonged stays, lost time), costs from use of inappropriate drugs (health problems), and cost of human suffering (difficult to determine)