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MNI (pain pharm) > L44- Pain Management > Flashcards

L44- Pain Management Flashcards

1
Q

list the types of pain

A
  • nociceptive
  • inflammatory
  • neuropathic
  • functional
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2
Q

define:

  • (1) nociceptive pain

- (2) inflammatory pain

A

1- response to noxious stimulus – somatic or visceral

2- tissues damage occurring despite nociceptive defense system

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3
Q

define:

  • (1) neuropathic pain

- (2) functional pain

A

1- damage or dysfunction of PNS or CNS (rather than pain receptor stimulation)

2- pain sensitivity due to abnormal processing or function of CNS –> in response to normal stimulus

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4
Q

define Acute Pain and the usual types of pain

A
  • usually result of injury or surgery
  • self-limiting pain

-usually Nociceptive, can be Neuropathic

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5
Q

define the types of Chronic Pain

A

All- persistent pain for mos-yrs // all pain types (nociceptive, inflammatory, neuropathic, functional)

Chronic Malignant pain: associated with progressive disease like AIDS, cancer

Chronic Non-Malignant pain: pain not associated with life-threatening condition, duration >6mos

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6
Q

correlate pain scale with mild, moderate, severe pain and include the general therapy for each pain categorization

A

Mild, 1-3/10: non-opioids +/- adjuvant

Moderate, 4-6/10: opioids (medium potency) +/- adjuvant and or non-opioid

Severe, 7-10/10: opioids (high potency) +/- adjuvant and or non-opioid

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7
Q

list the mild-to-moderate analgesics

A

NSAIDs, acetaminophen

codeine
tramadol

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8
Q

list the moderate-to-severe analgesics

A

-Morphine, oxymorphone, hydromorphone

  • meperidine, fentanyl, levorphanol, methadone
  • oxycodone, hydrocodone

mixed agonists:

  • 2nd line: butorphanol, nalbuphine, buprenorphine
  • 3rd line: pentazocine
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9
Q

(1) is first-line for OA

(2) is preferred in gouty arthritis

A

1- acetaminophen (NSAIDs if there are signs of inflammation)

2- NSAIDs

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10
Q

describe the principles to starting opioid therapy

A

-give orally at fixed intervals
-start at low dose and gradually inc to higher dose
(give next dose before previous dose effect has worn off)

-as pain subsides –> use prn

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11
Q

Breakthrough pain is defines as (1) and is often seen in (2) patients. (3) is usually given to relieve this pain, include dose and all formulations.

A

1- severe acute pain in background of chronic pain
2- cancer

3: Fentanyl at 5-15% normal dose (rapid and short acting agent)
- nasal spray, sublingual spray
- oral transmucosal lozenge (lolipop)
- immediate release transmucosal tablet, effervescent buccal tablet
- buccal soluble film

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12
Q

describe analgesic ceiling effect

A

Tolerance to agent where higher doses:

  • do not relieve pain or improve Sxs
  • toxicity continues to inc with higher doses

NOTE:

  • Pure Opioid Agonists – no analgesic ceiling effect
  • Non-Opioids – have analgesic ceiling effect
  • Mixed Agonists – have analgesic ceiling effect
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13
Q

describe PCA and the associated analgesics

A
  • self-administration of parenteral analgesics by Pt as needed
  • Agents: morphine, hydromorphone, fentanyl, methadone
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14
Q

list the two analgesics that are not recommended for routine dosing and explain for each

A

Meperidine: (1-2 day use in young Pts)
-1/2 life 3hrs –> metabolite Normeperidine 1/2 life 15-20hrs –> dysphoria, myoclonus, seizures

Mixed Agonists:

  • ceiling effect
  • only for naive-opioid Pts => withdrawal reaction if not
  • psychotomimetic effects w/ pentazocin, nalbuphine, butorphanol
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15
Q

list the 4 common and 1 uncommon AEs of opioids that can be modulated with other drugs

A

Common:

  • pruritus
  • sedation
  • n/v
  • constipation

Uncommon: respiratory depression

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16
Q

pruritus from opioids occurs in response to (1) actions and can be managed via (2) administration

A

1- release of Histamine from mast cells

2- hydroxyzine, diphenhydramine

17
Q
  • (1) describe sedation effects of opioid

- (2) may be used if needed to prevent this sedation

A

1- usually disappears with tolerance over several days

2- Methylphenidate, Modafinil if sedation persists

18
Q
  • (1) describe nausea and vomiting effects of opioids

- (2) may be used to prevent and treat n/v

A

1- usually disappears with tolerance over w/in a few days

2- hydroxyzine, metoclopramide, prochlorperazine

19
Q

(1) is the almost hallmark or universal side-effect of opioid use, so (2) is often given at the start of opioid therapy

A

1- constipation; doesn’t really dec that much with tolerance

2- laxative — stool softener if needed

20
Q

Tolerance to (1), an uncommon opioid side-effect, develops quickly, although if severe enough, (2) is administered.

A

1- respiratory depression

2- naloxone

21
Q

______ are the mainstay treatments drugs for neuropathic pain

A

Antidepressants: TCAs, SNRIs

Anticonvulsants:

  • gabapentin, pregabalin
  • carbamazepine, oxycarbazepine
22
Q

list the main or common causes of Neuropathic pain

A
  • diabetic peripheral neuropathy
  • postherpetic neuralgia
  • cancer
  • spinal cord injury
  • MS
  • trigeminal neuralgia
23
Q

explain why antidepressants (and which agents) help treat neuropathic pain

A
  • Descending pain pathway is Serotonergic and Noradrenergic –> inhibits pain signaling
  • Anti-depressants modulate and inc 5-HT and NE transmission

-TCAs and SNRIs modulate both 5-HT and NE –> so very useful for modulating descending pain pathway [SSRIs not as effective since only works on 5-HT]

24
Q
  • (1) TCAs are commonly used for neuropathic pain

- (2) list the many AEs

A

1:
Tertiary- amitriptyline, imipramine
Secondary- nortriptyline, desipramine

2:

  • Anti-mAChR: constipation, xerostomia, tachycardia, blurred vision, cognitive changes, urinary retention
  • Anti-H1R: sedation, weight gain
  • Anti-5-HT: sexual dysfunction
  • Anti-α1: hypotension, reflex tachycardia
25
Q

______ are the preferred TCAs, explain

A

Secondary Amines: nortriptyline, desipramine

  • fewer anti-AChR effects
  • fewer anti-H1R / sedation effects
  • **critical for elderly population

Tertiary Amine are tend to be avoided, especially in older patients

26
Q

TCAs are given cautiously in the following conditions….

A
  • angle-closure glaucoma
  • BPH, urinary retention
  • constipation
  • CV disease
  • impaired hepatic function
27
Q

TCAs are contraindicated in the following conditions….

A
  • arrhythmias
  • 2nd/3rd degree heart block
  • prolonged QT
  • recent acute MI

-severe liver disease

28
Q

SNRIs:

  • (1) agents
  • (2) advantage over TCAs
  • (3) AEs
A

1- venlafaxine, duloxetine

2- no antihistamine, antiadrenergic, anticholinergic activity as with TCAs —> fewer AEs

3- nausea, somnolence, sexual dysfunction

29
Q

list the anticonvulsants used to treat neuropathic pain

A
  • gabapentin, pregablin

- carbamazepine, oxcarbazepine

30
Q

Gabapentin, Pregablin for neuropathic pain:

  • (1) MOA
  • (2) AEs
A

1- blocks V-gated Ca channels –> dec release of Glu, NE, substance P

2- dizziness, somnolence, peripheral edema

31
Q

______ is drug of choice for trigeminal neuralgia

A

carbamazepine

32
Q

______ is the advantage of oxcarbazepine over carbamazepine

A

near equal efficacy

better tolerated

33
Q

Carbamazepine, Oxcarbazepine for neuropathic pain:

  • (1) MOA
  • (2) AEs
A

1- blocks V-gated Na channels –> dec sensory neuron firing

2:

  • n/v, drowsiness, dizziness
  • Rare: anemia
  • Carbamazepine-induced leukopenia is uncommon and benign
34
Q

list and define some of the common topical therapies for neuropathic pain

A

Lidocaine: localized peripheral neuropathy, particularly postherpetic neuralgia

Capsaicin:

  • depletes substance P from terminals of C fibers
  • high concentrations used for postherpetic neuralgia

Clonidine:

  • α2 agonist (note- multiple routes of administration)
  • for sympathetically maintained pain
35
Q

Glucocorticoids as pain adjuncts:

  • (1) is drug of choice, explain
  • (2) are alternate agents
  • used to improve (3) symptoms (in advanced illnesses)
A

1- dexamethasone
2- prednisone, methylprednisone
3- appetite, nausea, malaise, overall quality of life

36
Q

list some of the predominant uses of glucocorticoids as adjuncts in pain therapy

A
  • acute nerve compression
  • inc ICP

-bone pain, visceral pain

  • anorexia, nausea
  • depressed mood
37
Q

(1) is the main Bisphosphatase used for (2) pain, particularly in (3) conditions

A

1- Zoledronate (maybe pamidronate)
2- bone pain
3- bone metastasis, multiple myeloma

MNI (pain pharm) (8 decks)

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