Lecture 2: pain treatment and pain research Flashcards
What was the treatment of pain ins antiquity
-trephination
-pain was thought to be caused by eveil spirits in the brain so they had to let them out
-made holes in people’s skulls
-also used theriac
when was Theriac used and what is the main active ingredient
-in antiquity
-OPIUM
how was pain treated in 1500 AD
-willow bark made into tea
-opium poppy
what was the first pharmaceutical company
Merk KGaA in germany
what did the first pharmaceutical companies do in the 1500’s
-they knew we could take opium and make it into morphine
-but were unable to make the same dosage
-they came up a process to always have the same dosage
-all about control dosage
what is the greatest advance in medecine
anasthesia in 1846
before we had no anesthetic only analgesic
what is the ether dome
it is a surgical amphiteater in Boston
-it showed that “ether” existed aka ether puts you to sleep and that it was hard to die from it
Equianalgesic dosing, compared to 10 mg IM morphine: Codeine
-IM: 130
-PO: 200
-Half-life: 2-3
-Duration of action: 2-4
-Comments: usually combined with a nonopiod
Equianalgesic dosing, compared to 10 mg IM morphine: oxycodone
-IM: 15
-PO: 20-30
-Half-life: 2-3
-Duration of action: 2-4
-Comments: combined with a nonopiod or as a controlled release tablet
Equianalgesic dosing, compared to 10 mg IM morphine: : propoxyphene
-IM: 100
-PO: 50
-Half-life: 2-3
-Duration of action: 2-4
-Comments: usually combined with nonopiod, norproxyphene toxicity may cause seizure
Equianalgesic dosing, compared to 10 mg IM morphine: morphine
-IM: 10
-PO: 30
-Half-life: 2-3
-Duration of action: 3-4
-Comments:multiple routes of administration available. controlled release availabke
Equianalgesic dosing, compared to 10 mg IM morphine: Methadone
-IM: 1-3
-PO: 2-6
-Half-life: 15-190
-Duration of action: 4-8
-Comments: since it has a longer half life it is less adictive
plasma accumulation may lead to delayed toxicity
Equianalgesic dosing, compared to 10 mg IM morphine: fentanyl
-IM: it depends on what you give aka patches or IV
-PO:
-Half-life:
-Duration of action: 48-72
-Comments: lasts so much longer
routes of drug administration
-subcutaneus (end of dermal layer)
-intramusculat aka IM
-intravenous
-transdermal aka on the epidermis
-implantation aka pumps right into the dermis
why is transdermal kinda lit
-long lasting
-lower dose
-lower side effects
what are the major differences between the routes of drug administration
matter of time and where it needs to go
what is pharmacodynamics
what drug does to the body
what is pharmacokinetics
what body does to the drug
what is ADME
-absorbtion
-distribution
-metabolism
-elimination
rue or false: when a med is broken down either the metabolites become eliminated or they are active
true
what is an example of a med that the metabolites are active
codeine becomes morphine
which organ absorbs the drugs
small intestines
what is PCA
-patient controlled analgesia
-people consume less morphine that way because they have more control
opiate side effects
-constipation up to 80%
-nausea or vomiting : 15-30
-sedation 20-60%
-confusion or hallucinations
-myoclonic jerks
-respiration depression
-xerostomia aka dry mouth
-urine retention
what is the best selling drug class
over the counter analgesics
examples of oral otc analgesics
-acetaminophen
-aspirin
-ibuprofen
-naproxen sodium
-dextromethorphan: cough
what does acetaminophen cause
liver damage
the who analgesic ladder for cancer pain
-pain: non-opioid +- adjuvant
-Pain persisting or increasing: opioid for mild to moderate pain, +- non-opioid, +- adjuvant
-freedom from cancer pain: opioid for moderate pain tp severe pain, +- non-opioid, +- adjuvant
other analgesic categories
multipurposes:
cortistereoids ex: pregabalin
antidepressants ex: SNRIs ex: duloxetine
alpha 2 adenergic agonists
neuropathic
-nmda receptor agonists mixed opioids and snri
-anticonvulsants
-oral local anesthetics ex: botox
-cannabinoids
what are the four main categories of pain treatment choices basically
-surgical: but the evidence that it works is mid ex: you cut where the nerve is
-anesthesiological ex: nerve blocks, epidural blockade lidocaine
-psychological: pain management, sensory discrimination, training
-ther like acupuncture and PT
what is the name for the western default medicine
allopathic
Complementary and alternative medecine for pain
-individual practices like spiritual or movement based
-systems of medicine like homeopathy, osteopathy, naturopathy, prayer eyc
-world medicine systems like native amerixcan healing, traditional Chinese medicine, herbal medicine, ayurvedic medicine
why is it hard to prove that alternative medicine works
control for tests: placebo? like peopel already think it work s
true or false: when you swear you feel less pain and with music too
true
why do some patients push back on the idea of pain self management
you come to someone for management and they tell you to just do it on ur own and that if you fail it is your fault
analgesia for babies
-sugar
-breatfeading
-kangaroo care
are opioates a vibe for babies?
no
opioids, analgesics, acetaminophen and aspirin are all and for babies
what was the name of the dude that came up with the idea for multidisciplinary pain clinics
-john J bonica
-wrote the first pain book: the management of pain
what is a part of multidisciplinary clinics
-primary care physician
-psychological therapied
-educational programming
-advice, appropriate medications
-appropriate medical procedures
-PT, structured & alternatives movement therapies
when do we switch from curative intent to palliative care
-when they will die soon and you wanna make them as confy as they can be
-switch them to an hospice care or a palliative facility
pain the fifth vital soign
-now nurses are required to write down the pain levels since if there is a repid change it is a really and thing
pulse
temperature
-blood pressure
respiratory rate
pain
why did people not like pain as the fifth vital sign
pain is not objective measure
-measure pain= augmentation to treat it=over treatment
evidence based medecine the lil pyramid top to bottom of how I can trust that
-systematic reviews and meta analysises
-randomized control double blind studies aka RTCS
-case control studies
-case studies: whole series of published patients
-case reports: doctors wrote down what happened to a patient
-expert opinion: aka your doc
-personal opinion aka tiktok
what is the cochrane collaboration
-the best way to make meta analysis
why are meta analysis kinda mid
because they always get to mid comclusions like yes this affects this but like we also saw that this affects that
explain RTC
mmm
what are common exclusion criteria for pain trials
-if you already have treatment
-haven’t have pain for long enough
-co morbidities that you have
does it really matter that we say why did someone quit a trial
yeah we need to know why
what are the 2 types of inteversions usually in a trial
the treatment aka the drug and the placebo
what are the 3 types of RTC design
-parallel design; you can also add the active control which is the control that people use now
-crossover design
-enriched design
what is an advantage of crossover design
-participants like it more because they can get the drug either ways
-you can use A WITHIN SUBJECT DESIGN AS OPPOSED TO A WIDE SUBJECT design and a within is more statistically relevant
what is the potential confound of crossovermethod
-it matters when the drug us give
-we dunno if the washout period will 100% wash out the effects of the medication
what is one measure of protection that pharmaceutical companies have to put so that they can prove that their drug works
they put like a thing that says like our drug works if the patients have a 50% reduction in pain
explain odds ration and what would the column and row labels be for an analgesic study
mmam
plots you can have in meta analysis
-forest plots
-l’abbe plots
what does the number needed to treat works + how to calculate it
how much an extra advantage does the drug give to the population 1/ (numbve of people got the treatment and worked/people who got the treatment minus people who got control and got smth/ people who got control
true or false: NNTs will depend on the medication and the needs of the population
true
most common pain medication of neuropathic pain
gabapentin/ pregabalin and TCAs
why is gabapebtin so common
because pfizer put a lot of money in there
true or fakse: are antidepressabts good for painful diabetic neuropathy compared to triple therapy for peptic ulcers
false they are less good because the NNT is lower than the triple therapy
what is number needed to harm
whate side effects are we gonna overlook
usually opioids have a lower NNH
where does the perfect analgesic reside
top left aka high NNH and low NNT
true or false: we only care about NNT
false we also care about
-effect size
-tolerability and safety
-cost and resource allocation
-strenght of recommendation
whats is the name for the pain association
the inernational association for the study of pain
publishes in journals like pain and pain reports
