Lowry: Pain Flashcards
definition of chronic pain
pain lasting >12 weeks or >3 months
3 types of physical pain
somatic pain
visceral pain
neuropathic pain
somatic pain
pain arising from damage to muscle/bone/skin (LOCALIZED)
descriptors may be sharp, intense, throbbing, localized
visceral pain
pain arising from damage to organs; not well localized (can be referred)
descriptors may be gnawing, cramping, squeezing, diffuse, distant
neuropathic pain
pain arising from a lesion or disease of the somatosensory nervous system
descriptors may be shooting, burning, numb, tingling, enhanced sensitivity to heat/cool
what are the chronic non-cancer pain syndromes
osteoarthritis
diabetic neuropathy
fibromyalgia
post-herpetic neuralgia
what is osteoarthritis
common degenerative disorder of the joints leading to hypertrophic bone changes
ASYMMETRIC
common in hands, knees, hips, spine
symptoms would be persistent joint pain, stiffness, locomotor restriction
general treatment algorithm for osteoarthritis
from first to last line:
-non-pharm: exercise, physical therapy
-acetaminophen
-topical NSAID before systemic NSAID
-consider opioid therapy but not really
-consider corticosteroid injection
-consider hyaluronic injection
-discuss total joint replacement
what is diabetic neuropathy
nerve damage caused by poorly controlled diabetes that leads to numbness in extremities
the most common microvascular complication of diabetes
symptoms are unprompted numbness, tingling, burning, shooting (SYMMETRICAL)
general treatment algorithm for diabetic neuropathy
from first to last line:
-non pharm (optimize glycemic control)
-duloxetine, pregabalin, gabapentin
-venlafaxine, amitriptyline, lidocaine patch, capsaicin cream/patch, tramadol, tapentadol
duloxetine and pregabalin are the drugs actually FDA approved for diabetic neuropathy
OPIOIDS AREN’T RECOMMENDED; last ever line.
what is fibromyalgia
widespread soft tissue pain affecting muscles, ligaments, tendons with no obvious objective abnormalities: unknown pathophysiology but there is diffuse musculoskeletal pain present for >3 months often with fatigue, headache, etc
_____ may exacerbate fibromyalgia
weather
general treatment algorithm for fibromyalgia
Non pharm: education, CBT, physical therapy, exercise, acupuncture, hydrotherapy
Sleep disturbance: amitriptyline, cyclobenzapine, pregabalin (FDA approved), gabapentin
Depression/anxiety: duloxetine (FDA approved), milnacipran (FDA approved), amitriptyline, pregabalin
what is postherpetic neuralgia
pain in a dermatomal distribution caused by nerve damage secondary to an inflammatory response induced by viral replication (herpes zoster shingles) within a nerve sustained for at least 90 days after acute herpes zoster
symptoms are burning, shock like pain may be associated with allodynia or hyperalgesia
allodynia vs hyperalgesia
allodynia: pain from stimuli that are not normally painful
hyperalgesia: abnormally heightened sensitivity to pain
when can you receive shingles vaccine with postherpetic neuralgia
after rash has gone away
general treatment algorithm for postherpetic neuralgia
treat acute herpes zoster with antivirals
first line: gabapentin, pregabalin, lidocaine patch, capsaicin patch all FDA approved
second line: TCAs
third line: opioids, not preferred, why would you do this
when would acetaminophen be used
OA, musculoskeletal pain
3g/day OTC, 4g/day Rx
when would NSAIDs be used
OA, reduce inflammation
Topical for localized pain with miniscule systemic absorption making them well tolerated
counseling points for topical NSAIDS
apply 2-4 g to affected area QID
max dose is 32 g/day
effects will be seen in 10-14 days
cautions with NSAIDs
CV, renal, and GI side effects are super worrisome in older adults
systemic NSAIDs from most COX2 selectivity to most COX1
meloxicam
celecoxib
diclofenac
ibuprofen
naproxen
indomethacin
ketorolac
when are SNRIs used
which SNRIs are used
neuropathic pain
venlafaxine, duloxetine, milnacipran
when is pain improvement seen with SNRIs
4 weeks
pearls for SNRIS
dose adjust CrCL<30
caution in hepatic impairment
can cause wt loss, dec appetite, drowsy, serotonin synd
when are TCAs used
which TCAs are used
neuropathic pain
amitriptyline, nortriptyline, desipramine
when is improvement seen with TCAs
4 weeks
TCA cautions
older adults– anticholinergic (Beers criteria)
sedation, QTc prolongation
what are calcium channel blockers for and which ones are used
neuropathic pain
gabapentin, pregabalin
when is improvement seen with calcium channel blockers
2 weeks
calcium channel blockers pearls/cautions
CNS depression, respiratory depression, drowsiness, peripheral edema
renally adjust
when are sodium channel blockers used
which ones are used
chronic pain syndromes (like migraines, trigeminal neuralgia, etc)
carbamazepine, oxcarbazepine, phenytoin, valproic acid, topiramate
when are skeletal muscle relaxants used
which ones are used
pain related to muscle spasms
cyclobenzaprine, methocarbamol, tizanidine, baclofen, carisoprodol, metaxalone
muscle relaxer pearls
avoid use in elderly
drowsiness, confusion, dizziness, fatigue, Beer’s criteria
when are opioids used for chronic non-cancer pain
LAST line
efficacy is questionable
which NSAIDs are the worst offenders for cardiovascular risk
celecoxib and diclofenac
best is naproxen
which NSAIDs are the worst offenders for AKI
naproxen, ibuprofen
best are celecoxib and diclofenac
which NSAIDs are the worst GI offenders
ketorolac
best are celecoxib and ibuprofen
high GI risk with NSAIDs
age >65, history of ulcer disease, previous GI bleed, DAPT, anticoagulant therapy, corticosteroid use, GERD
prescribe PPI
what are the topical non-NSAID agents
capsaicin (OTC cream, Rx patch called Qutenza applied at Dr. office)
lidocaine
analgesic balms like Tiger Balm, Icy Hot, Bengay
what is the Qutenza patch indicated for
diabetic neuropathy, postherpetic neuralgia
when is capsaicin helpful
pain that responds to heat
when is relief seen with capsaicin
2-4 weeks
counseling for capsaicin
do not use heating pads. wash hands after. ADEs are application site pain, burning, erythema
lidocaine patch counseling points
apply for 12 hours then remove for 12 hours
max 3 patches per day. can cut them and place them on different sites
when is relief seen with analgesic balms like icy hot
x1-3 hours
advantages of pregabalin
faster onset of pain relief
higher bioavailability
dose can be titrated to effective dose more rapidly
less pill burden (BID dosing)
disadvantages of pregabalin
higher risk of peripheral edema
schedule V
more expensive, prior auth
dose reduction necessary for renal impairment (gabapentin requires dose adjustment too tho)
