Intro to pain Flashcards
difference of chronic compared to acute pain
chronic more dependence to meds, psychological component, no organic cause, family issues, insomnia common, depression
treatment goal is just to improve functionality and pain reduction
PQRST stands for
provkes/precipitates quality radiation, referal severity timing
how can continuous opioids worsen the patients quality of life
using exogenous opioids chronically sacrifice normal healthy motivational behaviors, socialization, coping becuase the bodies ability to produce endogenous endorphins is decreased
what are wrong situations to throw opioids at
pain linked with emotional and psychosocial factors
helplessness and hoplessness root cause of suffering
more important questiona about function rather than pain severity
mobility able to perform activities irritability or depression how are they sleeping socializing enjoying life
problems with the WHO ladder
created for cancer patient which is different
assumes that if were in pain we take something
when do we come back down
does a step up = better analgesic
pros of acetaminophen
safe well tolerated high does for toxicity few DI cheap and accessible (bad?)
cons of acetaminophen
mild benefit
found in many products
interaction with warfarin increases INR
acetaminopehn effectiveness in headache
NNT = 8 but prob high bc placebos good at reducing pain and most people feel better in 2hr anyway
prob works much better
effectiveness of of acet in post dental surgery
NNT 3 for 50% reduction
ibuprofen is better
acet efficacy in osteo
min benefit in short term
acet efficacy in back pain
no effect vs placebo
risk factors for acet hepatotoxicity
old age poor nutritional status fastin/anorexia glucuronidation inhibitors chronic alcohol use
NSAID pros
can be given topically
many to choose from
OTC
better than acet sometimes
nsaid cons
no readily available injectable
safety….
baseline risk of upper GI event when using conventional dose
2.5%
risk factors for UGI event when using nsaids
>65yoa use of anticoagulant or steroids histoyr of peptic ulcer disease high dose of nsaid presence of hpylori
which treatments reduce UGI event risk in nsaid use
PPI cotherapy
coxib
hpylori treatment
misoprostol
risk of renal issues with nsaids use and risk factors
increase 2x volume depletion CHF acei, arb use renal disease, cirrhosis >70yoa
low dose ____ are CV neutral
naproxen (750-850/d)
ibuprofen (1200-2000/d)
celecoxib (<200/d)
nsaids that increase cardiac risk 2-4x
diclofenac and high dose celecoxib
nsaid effectiveness in OA
NNT4
similar to opioids
better than acet
nsaid effectiveness in low back pain
similar to opioids but based on few trials
reduce 3.3 points of 100pain scale
reduce ,9 points of 24 diability scale
dont know numbers just know not that great
open label placebo treatment in chronic low back pain efficacy
compared to treatment as usual elicited better pain reduction with moderate to large effect sizes
advantage of topical nsaids
less adverse effects bc very little systemically available
disadvantage of topical nsaids
local skin reaction
stickiness
what strength of topical nsaid
1-1.5% bid - tid
increasing dose not sure if it helps but prob still safe
topical nsaid effectivness for osteo
as good as oral for hands and knees initially as time goes on effect decreases
topical nsaid efficacy in acute pain - sprain, strain
very good NNT2
topical nsaid for back pain, neuropathic, or widespread efficacy
no evidence to support use
opioid advantages
highly effective for some types
high dose ceiling for effect - cancer
IV/SC improved access and quick onset
opioid disadvantages
dose related SE
threshold for serious toxicity can be long in some
tolerance, dependence
abuse
long term SE - dry mouth, androgen deficiency
thoughts about tyelenol 1
useless
8mg no pain relief so increase to try get relief and end up taking way too much acet and caffiene
opioid for mild-mod pain
codeiene
tramadol
buprenorphine patch
opioid for mod-sev
morphine
hydromorph
oxycodone
later fentanyl patch or methadone
difference between morphine and hydromorphone
active metabolites of morphine renally eliminated caution with accumulation in renal dysfunction, less caution in hydro
morphine histamine release causes itchiness
why wouldnt we use oxycodone
similar hepatic/renal considerations as mirphine
big street value
safest way to switch opioids
convert based on the table then decrease the dose by 25%
use of cyclobenzaprine
only is muscle spasm present
most benefit in 4-7 days cane use up to 2 weeks
drowsiness major SE
non pharms
heat/cold physio massage chiropractor acupuncture exercise music yoga CBT
things you should consider before the who pain ladder
education and non pharms
monitoring pain
PQRST
analgesic use dose and frequency
non drug being used
pain diary
wehn is a pain diary useful
when looking how to dose long acting meds
determining what causes pain
help patient understand their pain
document what theyre able to do
monitoring function
ability to perform activities and exercise relief from irritability or depression sleep min med side effects financial
poor pain control in elderly can result in
weight loss decrease mobility falls depression alcohol consumption malnutrition
dosing in elderly
dose titration
start half of usual dose
go slow review often
nsaids use in elderly
increased risk of GI bleed, CV, and renal events
add a PPI
monitor renal function
use topical instead
opioid use in elderly
uncommon
do 3 day tolerance check - sedation, imbalance, confusion, constipation**
sedation occurs before resp depression
skeletal muscle relaxant use in elderly
avoid
