L23: Pain Meds I Flashcards
Side effects of opioids
Nausea/vomiting Constipation Pruritus Dry mouth Altered mental status Respiratory depression Tolerance Dependence
What’s a risk of long term opioid use?
Masks pain, as in the case of the old lady with hip pain who actually had a massive abscess
Undertreated pain resulting in red flag behaviors
Pseudo-addiction
3 types of pain etiologies
Nociceptive
Neuropathic
Psychogenic
Withdrawal symptoms with abrupt discontinuation/decrease in opioid (usually chronic pain)
Physical dependence
Need increased dose for pain relief/or reduced effect of constant dose over time
Tolerance
Impaired control over drug use/craving, Compulsive and continued use despite harm
Addiction characteristics
Nociceptive pain
Caused by injury to tissues:
Activation of peripheral pain receptors, somatic or visceral: Laceration or injury involving the skin Fractures, strains, sprains Surgery (post/op) Tumors/cancer Internal organ injury
Neuropathic pain
Results from damage to or dysfunction of nerves, the spinal cord or brain:
Post-herpetic neuralgia Cervical/thoracic/lumbar radiculopathy Trigeminal neuralgia Diabetic neuropathy Phantom limb pain (post-amputation) Central pain syndrome (CVA, traumatic spinal cord injury)
Psychogenic pain
Patient with persistent pain typically w/evidence of psychological disturbance
No evidence of disorder that could account for the pain or its severity
Neuropathic pain is treated with
Neurontin, lyrica
TCAs
Tramadol, Nucynta
Opioids with some SNRI properties
Tramadol, Nucynta
Interventional pain management for neuropathic pain may include
Epidural Steroid injection Joint injections Intrathecal Pump Implant Spinal Cord Stimulator Implant Peripheral Nerve Blocks Sympathetic Nerve Blocks and Neurolysis
Goals of psychogenic pain tx
improving comfort/ psychological function
Psychogenic pain tx
Biofeedback/distraction techniques
Encourage exercise
Psychological/Psychiatric evaluation and therapy
Probably don’t give opioids if…..
History of addictive behavior
Caring for small children at home
Teenagers in home
Muscle relaxant + lower back pain + firefighter
Not ideal bc they sedate and probably don’t help that much
Always _____ acute pain to prevent ____-
Treat it! Follow up! Can evolve into chronic pain
Ongoing myofascial pain can be treated with _____
Transcutaneous electrical nerve stimulator (TENS) unit
Muscle spasms may be treated with
Muscles relaxants vs trigger point injections
lecture seemed to favor trigger point injections
Should imaging be done right away for the firefighter with low back pain?
Nah, maybe do it at follow up if he hasn’t improved
Example RA medication regiment
Celebrex 200 mg daily
Prednisone 5mg daily
Long acting opioid
Tolerance to opioids is faster with ______-
high dose short acting opioids
switch patients to long acting
While a patient is converting from short acting to long acting opioids: do these things
Reduce daily dose by 50-75% when converting to a new pain medication
+/- lower dose opioid for breakthrough pain while converting→ no more than 20-25% of daily long acting dose
RA adjunct therapies
topical compound cream for joint pain→ Lidocaine, ibuprofen or diclofenac
TENs unit for myofascial pain
Aqua therapy
gradual onset of burning pain in feet bilaterally.
Worse at night/walking long distances
Diabetic neuropathy
Fibromyalgia tx
ncourage physical activity (#1 in treatment of fibromyalgia!)
Aqua therapy (often covered by insurance)
Encourage them that they can work their way up to land exercise
Support→ referral for counseling if depression is a concern
Pregabalin (Lyrica) or gabapentin (Neurontin)
Cymbalta for pain control and to help with mood
Are opioids recommended for fibromyalgia?
NOT recommended, but many patients with fibromyalgia are on them
Are opioids recommended for fibromyalgia?
NOT recommended, but many patients with fibromyalgia are on them
Cancer pain management
May need to consult with palliative care, pain management, hospice
Can include management of symptoms other then pain (anxiety)
Often involves optimization of opioid therapy + analgesic adjuncts
Consider interventional pain management strategies
Cancer patients should def get
PCA to control their pain
Adjuncts to PCA for cancer patients could include
NSAIDs – Toradol (ketorolac) IV/IM/PO Acetaminophen IV/PO Lidoderm patch Antidepressant - Cymbalta (duloxetine) Neurontin (gabapentin)/Lyrica (pregabalin) Heat packs/ice packs
Describe the PCA system
Short term→ Chronic, high dose opioids pt who is NPO
IV + delivery system→
Managed by anesthesiologist or surgeons
Indications for PCA
Severe post-op pain or intractable cancer pain
PCA dosing
Demand dose q__ minutes
Continuous dose
Continuous + Demad dose
Benefits of PCA
control, do not use while sleeping leads to less use overall, gets pain under control quickly
Risks of PCA
Family members pushing demand dose when pt is a sleep, overdose if not monitored and titrated
Considerations for PCA
Continuous pulse oximetry Orders for naloxone(narcan) prn Discuss with RN, make note that she/he is to monitor for mental status changes, respiratory distress New PCA→ follow up again within 12hrs Titrate PCA if needed Once dosage stable, patient should be monitored at least every 12-24hrs by Anesthesia/Surgery Wean as soon as tolerable
IV to PO morphine conversion is typically ____
3:1
aka the oral dose is three times the IV dose
Converting from PCA to IV
Calculate amount of medication patient was receiving in 24hrs
Convert to oral opioids while reducing PCA/IV pain medication dose
PCA is for short term use only
Consider for “pain emergencies”
Converting from IV to PO (concepts)
Convert to long acting pain medication plus something for
breakthrough pain
Convert while still inpatient to evaluate for tolerance prior to home
Contraindications to opioids
Hepatic disease
Increased intracranial pressure
DOCs (2) for ESRD opioid
Fentanyl (patch or parenteral)
Methadone
Caution with these 2 opioids and ESRD
hydromorphone
oxycodone
Avoid these opioids in ESRD
morphine
demerol
hydrocodone
codeine
In whom is a fentanyl patch less effective, and why?
Cacehctic patients bc fentanyl is lipophilic
Buprenorphine patch
Can cause QT prolongation
Is NOT for use with opioids
Tramadol/Nucynta indications
Consider for neuropathic pain
Can consider in patients with fibromyalgia if absolutely necessary (but don’t)
Tramadol/Nucynta contraindications
Relative: fibromyalgia, antidepressants due to serotonin syndrome
Is a fentanyl patch good for acute pain?
No, it takes 12 hours to reach therapeutic levels
When converting IV opioids to fentanyl patch….
Two step taper (whatever that means)
What increases fentanyl absorption and could even cause fatal OD?
Heat exposure! even sunbathing
Before using methadone, ______
Baseline EKG/check renal/hepatic function
EKG yearly thereafter
Many drug interactions, get a good medication history
Which drug has a 1⁄2 life up to 55 hours, so initiating requires a very SLOW titration, every 3-5 days
Methadone
Benefits of methadone
Decrease neuropathic pain
Inexpensive
Rx for controlled substances must include
Date of issue
Patient’s name and address
Practitioner’s name, address, telephone and DEA registration number
Drug name, strength, form and quantity
Directions for use
Manual signature of prescriber (NOT in EMR)
Don’t use shorthand, write out # of pills per day, quantity and refills in long hand.
Always ask about
constipation
Avoid ______ with other controlled substances
polypharmacy
idk which other substances are controlled for testing purposes though?
ONLY diagnose an opioid if the following questions are all answered with a YES:
Does the patient have a definitive diagnosis?
Has there been a documented work up with abnormal findings?
Is the patient experiencing impairment in function?
Have you evaluated for contraindications to opioid management?
Has the patient tried adjunct treatments and failed?
