Lecture 75 - Non-Malignant Pain Part 1 Flashcards

1
Q

What is pain?

A
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2
Q

Why Does Pain Matter?

A

1 reason that patients seek

medical care
*75 - 100 million in US have chronic pain (~30% of Americans)
*40 million adults experience severe pain
Interferes with quality of life and productivity
*half of patients with low back pain report interference with basic and complex activities
Annual cost in the US exceeds 500 billion dollars Opioid epidemic
*Need for increased safety due to elevated opioid related deaths

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3
Q

Role of Pharmacists

A

Assessment of pain
Recommend OTC medications
Refer patients to prescribers
Recommend initial prescription analgesics to providers
Educate patients on analgesic therapy
Evaluate safe and effective use (abuse, side effects, etc.)
Adjust medication therapy based on response

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4
Q

Assessment of Pain

A

What questions would you want to ask to subjectively assess a patient’s pain?:
“PQRSTU” Mnemonic
Palliative or Precipitating factors
Quality of pain
Region of pain location
Severity (pain assessment instruments)
Time-related nature of pain
U Impact of pain on yoU
What have you tried to control the pain?

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5
Q

Assessment of Pain

A

Objective information to assess pain
Behavioral changes
Physiological changes: Dilated pupils (mydriasis); Paleness (pallor); Sweating (diaphoresis); Tachycardia; Tachypnea
Pain intensity scales: Verbal; Numeric; Visual; Wong-Baker

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6
Q

Classifying Pain

A

Pain:
acute - <3 months
chronic - >3 months –> nociceptive (tissue), neuropathic (nerve), mixed (tissue and nerve)
malignant

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7
Q

Guidelines

A

Center for Disease Control (CDC) Guideline for Prescribing Opioids for Pain (US, 2022): Outpatients aged ≥18 years with acute (duration of <1 month), subacute (duration of 1–3 months), or chronic (duration of >3 months) pain; Excludes pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care.
Society of Critical Care Medicine (SCCM) Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (US, 2018): Referred to as PADIS Guideline
National Institute for Health and Care Excellence (NICE) Neuropathic pain in adults (UK, 2020)
Management of Acute Pain From Non–Low Back, Musculoskeletal Injuries in Adults: Academy of Family Physicians (AAFP) (US, 2020)

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8
Q

Goals of Therapy

A

Correct: Correct underlying cause of pain if possible
Minimize: Minimize pain and symptoms from pain/injury (May not be possible to be free of pain)
Improve: Improve quality of life (QOL) and activities of daily living (ADLs)
Limit: Limit pharmacotherapy side effects

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9
Q

Selecting an Analgesic - patient factors

A

Hepatic/renal function
Past medical history
Previous analgesic therapy
Routes for medication administration
Type of pain (neuropathic vs. nociceptive
Severity of pain

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10
Q

Selecting an Analgesic - medications factors

A

Allergies
Cost
Drug-drug interactions
Duration of action/dosing frequency
Potency
Route of administration
Side effects

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11
Q

Non-Pharmacologic Therapy

A

Can be used in combination with analgesics
Physical manipulation
Heat or ice
Massage
Acupuncture
Exercise
Correct the underlying cause (surgery, avoidance)

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12
Q

Treatment approach

A

step 1: non-opioid +/- adjuvant analgesic
step 2: opioid for mild-moderate pain + non-opiod +/- adjuvant analgesic
step 3: opioid for moderate-severe pain + non-opioid +/- adjuvant analagesic
step up if pain is persisting or increasing
step down if pain is resolving or toxicity occurs

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13
Q

Step 1: Non-opioid Analgesics

A

Non-opioids
* Acetaminophen
* Non-steroidal anti-inflammatory drugs (NSAIDS)
Adjuvant therapies
* Gabapentinoids
* Serotonin norepinephrine reuptake inhibitors (SNRIs)
* Tricyclic antidepressants (TCAs)
* Skeletal muscle relaxants
* Antiepileptics
* Topical agents

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14
Q

Acetaminophen (Tylenol)

A

Analgesic and antipyretic
Available formulations: Tablet (regular strength = 325mg, extra strength = 500mg, arthritis = 650mg ER tablet); Capsule; Chewable tablet (80mg or 160mg); Liquid/gel; IV solution; Suppository
Recommended dosing: Adults: 325 -1000mg PO Q4-6H PRN (max dose ≤3-4
g/day); In liver disease, decrease max ≤2 g/day); Pediatrics: 10-15 mg/kg PO Q4H PRN (max dose 75mg/kg/day or ≤3-4 g/day)
Side effects: Hepatotoxicity (acute liver failure most likely with ≥10g dose)

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15
Q

Acetaminophen clinical pearls

A

Gold standard for osteoarthritis due to fewer side effects in geriatric patients than NSAIDs
Educate patients about max daily doses, including combination products
Injection is expensive (often restricted use)

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16
Q

NSAIDS

A

Analgesic, antipyretic and anti-inflammatory
Side effects: GI bleeding (black box warning); Nephrotoxicity; Fluid retention; Increase CV events (black box warning)
Clinical Pearls: Take with food; Caution use in geriatric patients due to increased side effects (Beer’s list); Avoid systemic NSAIDs in patients with cardiac history (can use topical NSAIDs); Avoid in severe liver disease or chronic kidney disease

17
Q

NSAIDS: Aspirin (Bayer)

A

Available formulations: Chewable tablet; Tablet; EC tablet; Capsule; ER capsule; Suppository
Recommended dosing: Adults: 325mg-1000mg PO q4-6h PRN (max 4g/day); Pediatrics: Avoid (Reye’s syndrome)
Clinical pearls: Avoid using for pain in patients taking blood thinners or antiplatelets; Some formulations available OTC

18
Q

Reye’s Syndrome

A

Rare but serious condition that causes swelling in the brain and liver
Associated with children/teens using aspirin when they have viral infections such as flu or chickenpox (with or without fever)

19
Q

NSAIDS: Ibuprofen (Advil, Motrin)

A

Available formulations: Capsule; Tablet (regular strength = 200mg); Chewable tablet; Suspension; IV solution
Recommended dosing: Adults: 200-800mg PO q6-8h PRN (max 3200mg/day); Pediatrics (>6 months): 5-10 mg/kg PO Q4-6H PRN (max 40mg/kg/day or 2400mg, whichever is less)
Clinical Pearls: Some formulations available OTC

20
Q

NSAIDS: Diclofenac (Voltaren)

A

Available formulations: Capsule; Tablet; IV solution; Suppository; Topical gel (Voltaren 1% gel); Topical solution; Ophthalmic solution; Patch
Recommended dosing: Adults: 50mg PO q8h or 2-4 g applied topically 4 times/day
Clinical pearls: Minimal systemic side effects with topical gel; Some formulations available OTC

21
Q

NSAIDS: Naproxen (Aleve, Naprosyn)

A

Available formulations: Capsule; Tablet; DR/ER tablet; Suspension
Recommended dosing: Adults: 220-500mg PO q6-12h (max 1000mg/day)
Clinical Pearls: Some formulations available OTC

22
Q

NSAIDS: Ketorolac (Toradol)

A

Available formulations: Tablet; IV/IM solution; Nasal spray; Ophthalmic solution
Recommended dosing: Adults: 15-30mg IV/IV q6h prn or 10mg PO q6h prn; Pediatrics: 0.5mg/kg/dose IM/IV q6h prn
Clinical pearls: Maximum duration is 5 days (parenteral + oral); Increased risk of GI bleed when used longer; Oral dosing is intended a as a continuation of IM or IV therapy

23
Q

NSAIDS: Celecoxib (Celebrex)

A

Available formulations: Capsule; Oral solution (less common)
Recommended dosing: Adults: 200mg PO BID Clinical pearls: COX 2 selective- less GI toxicity