Module 5: Pain/Headache Flashcards
____ is the most common symptom prompting patients to visit primary care providers, and more than 80% of patients who visit physicians report it. Although medical advances now allow for adequate management in most affected individuals, it often remains under treated.
Pain
Nocic______ pain: Explained by ongoing tissue injury.
- Thermal, mechanical and chemical nociceptors that engage “withdrawal” reflex followed by inflammatory response to protect injured tissue.
Nociceptive
F_________ pain: Believed to be sustained by abnormal processing or functioning in the peripheral or central nervous system in response to normal stimuli.
Examples include:
Fibromyalgia , IBS
Functional
N__________ pain: spontaneous pain and hypersensitivity to pain associated with damage to or pathological changes in the peripheral nervous system.
Examples include:
- diabetic peripheral neuropathy
- post herpetic neuralgia
- fibromyalgia
- etc.
- Treatment relies heavily on “adjunctive” therapies (e.g. transdermal lidocaine, antidepressants, anticonvulsant, etc.)
Neuropathic
Treatment for neuropathic pain relies heavily on “adj_______” therapies (e.g. transdermal lidocaine, antidepressants, anticonvulsant, etc).
adjunctive
The goal of treatment for ____ is to decrease pain, improve functioning, mood and sleep. Patients should be involved in setting their own goals that are reasonable and attainable. Involving the patient in the establishment of these goals assures that outcomes important to the patient are incorporated into the treatment goals and so that patients have realistic expectations.
pain
When it comes to treating ____, patients should set their own goals.
pain
Example of ____ goals:
- Pain score 3 or less at rest
- Pain score 5 or less with movement
- Able to have 6 hours of uninterrupted sleep
pain
Regarding pain treatment, particularly in patients with chr____ pain, it is likely that pain will not be completely eliminated, but must be managed.
chronic
Non-Pharmacological interventions for p___ should be part of ongoing therapy and may involve modalities such as PT, heat, ice, acupuncture, etc.
pain
Pharmacological interventions for this should resemble the guidance set forth by the World Health Organization’s p___ relief ladder (Table 34-2) and CDC (Table 34-4).
pain
The World Health Organization (WHO) has recommended a three-step ladder approach to ____ management.
- In Step 1, non-opioid analgesics with or without an adjuvant are recommended.
- Step 2 recommends an opioid if this persists or increases, plus a non-opioid and possibly an adjuvant. Depending on the cause, degree and frequency of this, it may be appropriate to try different non-opioid medications or combinations of smaller doses before advancing up the ladder.
- Step 3 recommends the use of a pure opioid agonist and possibly non-opioid (separately) and/or an adjuvant. Fixed combination products at this step may limit the ability to titrate dosages upwards if needed
pain
Step 1 of the three-step ladder approach to pain management:
[Mild pain that’s 1-3/10]
Non-opioid analgesics with or without an adjuvant are recommended.
Preferred options:
- APAP or NSAID
(APAP, naproxen, diclofenac)
Step 2 of the three-step ladder approach to pain management:
[Moderate pain that’s 4-6/10]
An opioid if pain persists or increases, plus a non-opioid and possibly an adjuvant. Depending on the cause, degree and frequency of this, it may be appropriate to try different non-opioid medications or combinations of smaller doses before advancing up the ladder.
Preferred options:
- Opioid +/- APAP or NSAID
(oxycodone/APAP, hydrocodone/APAP, hydrocodone/ibuprofen)
- +/- Adjuvant therapies
Step 3 of the three-step ladder approach to pain management:
[Moderate pain that’s 7-10/10]
A pure opioid agonist and possibly non-opioid (separately) and/or an adjuvant. Fixed combination products at this step may limit the ability to titrate dosages upwards if needed.
Preferred options:
- Pure opioid
(morphine, hydromorphone, fentanyl)
- +/- Adjuvant therapies
Regarding ____ medication treatment:
- Start with PRN then switch to scheduled dosing if patient uses more than occasionally.
- Start with a lower scheduled dose and supplement with PRN for breakthrough ____.
- Adjust scheduled dose depending on frequency/severity of breakthrough ____.
(Same answer for all blanks.)
pain
Start with a ___ pain med then switch to scheduled dosing if patient uses more than occasionally.
(One of three ways to treat pain.)
PRN
Start with a _____ scheduled dose and supplement with PRN for breakthrough pain.
(One of three ways to treat pain.)
lower
Adjust scheduled dose depending on frequency/severity of breakthrough pain.
(One of three ways to treat pain.)
adjust
Monitor the “____ _’s” over time, with frequency of visits appropriate to situation.
Document assessment of the these and interventions to address concerns:
- Analgesia: Is pain relief meaningful?
- Adverse events: Are side effects tolerable?
- Activities: Has functioning improved?
- Aberrant drug-related behavior
“Four A’s”
(One of the “Four A’s” of pain treatment.)
- _________: Is pain relief meaningful?
Analgesia
(One of the “Four A’s” of pain treatment.)
- Adv____ ev____: Are side effects tolerable?
Adverse events
(One of the “Four A’s” of pain treatment.)
- Activ_____: Has functioning improved?
Activities
(One of the “Four A’s” of pain treatment.)
- Ab_____t: drug-related behavior
Aberrant
Inf________n: A vascular and cellular response to trauma. Its purpose is to initiate the healing of the injured tissue. If homeostasis is not restored, organ dysfunction and tissue destruction will ensue
Inflammation
Stage ___ of inflammation:
Following an insult, local cytokine is produced with the goal of inciting an inflammatory response, promoting wound repair and recruitment of the reticular endothelial system.
1
Stage ___ of inflammation:
Small quantities of local cytokines are released into circulation to improve the local response. This leads to growth factor stimulation and the recruitment of macrophages and platelets. This acute phase response is typically well controlled by a decrease in the proinflammatory mediators and by the release of endogenous antagonists. The goal is homeostasis.
2
Stage ___ of inflammation:
If homeostasis is not restored, a significant systemic reaction occurs. The cytokine release leads to destruction rather than protection. A consequence of this is the activation of numerous humoral cascades and the activation of the reticular endothelial system and subsequent loss of circulatory integrity.»_space;» This leads to organ dysfunction / tissue destruction
3
Cycloox____ase enzymes:
- COX 1: Catalyzes the synthesis of PGs used in normal bodily functions (e.g… Gastric cytoprotection). “housekeeping” enzyme. Blockade of COX 1 enzyme by NSAIDs is responsible for the unwanted GI side effects.
- COX 2: Acutely expressed as a part of the inflammatory response to cell damage.
Cyclooxygenase
C__ 1: Catalyzes the synthesis of PGs used in normal bodily functions (e.g… Gastric cytoprotection). “housekeeping” enzyme. Blockade of COX 1 enzyme by NSAIDs is responsible for the unwanted GI side effects.
COX 1
C__ 2: Acutely expressed as a part of the inflammatory response to cell damage.
COX 2
_____s: Used to relieve pain, fever, inflammation and cardio-protection (ASA only).
- They block the synthesis of inflammatory prostaglandins by inhibiting Cyclooxygenase (COX) enzyme to elicit their action.
NSAID
NSAIDs block the synthesis of inflammatory prostaglandins by inhibiting cyclo_________ (___) enzyme to elicit their action.
Cyclooxygenase (COX)
NSAIDs, except COX2 selective inhibitors (c________), block both COX1 and COX2 enzymes to varying degrees and in varying ratios (e.g. ASA is irreversible inhibitor of COX1 and COX2, indomethacin is a reversible inhibitor with greater affinity for COX1, etc).
celecoxib
Ind_________, an NSAID, is a reversible inhibitor with greater affinity for COX1.
indomethacin
As_____, an NSAID, is an irreversible inhibitor of COX1 and COX2.
Aspirin
Cox__s (NSAID-like drug class that is also known as COX-2 Inhibitors):
Selectively block the COX2 enzyme and are used to relieve pain, fever, inflammation, but spare the inhibition of COX1
Examples:
- celecoxib
Coxibs
Coxibs (drug class) example:
- c________
celecoxib
Clinical efficacy of the N____s are equal (Analgesia and anti-inflammatory effects).
NSAIDs
Therapeutic efficacy of N____s is based on patient response
NSAIDs
N____s do display a “ceiling” effect. Higher doses do not provide any additional pain relief but may increase the likelihood of side effects
NSAIDs
All non-selective N____s are associated with GI toxicity.
NSAIDs
All non-selective NSAIDS are associated with G_ t_______.
GI toxicity
All non-se_______ NSAIDS are associated with GI toxicity
non-selective
Regarding NSAIDs, patients are more pre-disposed to GI toxicity if pre-existing ulcer or dyspepsia, H Pylori infection, older age, and some concurrent medications increase risk
GI toxicity
Regarding NSAIDs, management options for GI si__ ef_____ include:
- taking with food or milk
- switching to a different NSAID with better safety profile
- using a COX2 selective agent (celecoxib) and/or gastroprotection (H2RA, PPI, misoprostol)
GI side effects
Cel______ (med) is recommended for patients at increased risk of gastrointestinal bleeding/ulcer who require an NSAID.
Celecoxib
Celecoxib is recommended for patients at increased risk of gastr___________ ble_____/ulc__ who require an NSAID.
gastrointestinal bleeding/ulcer
Celecoxib is recommended for patients at increased risk of gastrointestinal bleeding/ulcer who require an NS___.
NSAID
The use of celec____ in patients with an elevated risk of gastrointestinal bleeding is not entirely without risk.
celecoxib
If the patient has a high risk of gastrointestinal complications, e.g. a history of NSAID-related gastrointestinal bleeding, a P__ should be concurrently prescribed alongside celecoxib.
PPI
BLACK BOX WARNING:
Gastrointestinal: NS___s cause an increased risk of serious gastrointestinal adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients are at greater risk for serious gastrointestinal events.”
NSAIDs
BLACK BOX WARNING:
Gastrointestinal: “NSAIDs cause an increased risk of serious gastrointestinal adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. _______ patients are at greater risk for serious gastrointestinal events.”
Elderly
_____s may be associated with dose dependent renal toxicity
NSAIDs
NSAIDs and COXibs are associated with an increased car___vas____r risk.
(Fitzgerald Hypothesis)
CV
BLACK BOX WARNING:
Cardiovascular: “_____s may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction and stroke, which can be fatal. This risk may increase with duration of use. Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk.
NSAIDs
BLACK BOX WARNING:
Cardiovascular: “NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction and stroke, which can be fatal. This risk may increase with duration of use. Patients with card__________ di_____ or risk factors for it may be at greater risk
cardiovascular disease
NSAIDs and COXibs are associated with an increased bl_____g risk.
bleeding
NS___s are associated with several clinically significant contraindications and drug interactions
NSAIDs
N____s are equally effective in analgesia, antipyretic and anti-inflammatory effects.
Choice should include STEPS (simplicity, tolerability, evidence, price, safety).
If patient fails therapy with an agent from one class of NSAIDs, use of an agent from another class is reasonable.
NSAIDs
NSAIDS are equally effective in analgesia, antipyretic and anti-inflammatory effects.
Choice should include _____ (simplicity, tolerability, evidence, price, safety).
If patient fails therapy with an agent from one class of NSAIDs, use of an agent from another class is reasonable.
STEPS
NSAIDS are equally effective in analgesia, antipyretic and anti-inflammatory effects.
Choice should include STEPS (simplicity, tolerability, evidence, price, safety).
If patient fails therapy with an agent from one class of NSAIDs, use of an agent from _______ class is reasonable.
another
COX-2 sel______ i_____ have ideal indication in patients with high risk for GI bleed, high intolerance of non-selective NSAIDS, or treatment failure with non-selective agents
COX2 selective agents
_____s are of minimal value in neuropathic pain.
NSAIDs
_____s produce a flat dose response curve (ceiling effect) with higher doses providing no greater efficacy than moderate doses.
NSAIDs
A___: blocks PG synthesis in CNS, inhibits peripheral pain impulses.
APAP
A___ does not interfere with COX 1 or COX2 and thus has no anti-inflammatory benefit.
APAP
A___: Initial therapy for mild-moderate pain
APAP
A___: This medication is antipyretic.
APAP
Regarding A___:
In 2011, McNeil Consumer Healthcare reduced the maximum doses (3000mg) and increased the dosing interval (Q6h vs Q4-6h) on the labeling of some of their acetaminophen OTC products used in older pediatric patients (usually children ≥ 12 years and adolescents) and adults in an attempt to protect consumers from inadvertent overdoses.
APAP
All providers and patients should be aware of the maximum daily doses of APAP (____ mg) and be conscious of the fact APAP can be found in many products in combination with other medications.
4,000 mg
Regarding A___:
- Potential for severe liver damage associated with exceeding the MDD or taking three or more alcoholic drinks a day while taking acetaminophen.
- Warning to avoid use of other same products.
- Warning to avoid use in the presence of liver disease
APAP
Regarding A___:
American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons recommend less than 2 g per day in frail patients, those over 80 years of age (or consume alcohol).
APAP
Regarding APAP:
American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons recommend less than 2 g per day in frail patients, those over __ years of age (or consume alcohol).
80
Regarding APAP:
American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons recommend less than _ g per day in frail patients, those over 80 years of age (or consume alcohol).
2
Regarding APAP:
American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons recommend less than 2 g per day in frail patients, those over 80 years of age (or consume _______).
alcohol
A___-induced hepatotoxicity, which can be life threatening, has been associated with doses >4 g/day. Although doses up to 4 g/day are generally well tolerated, hepatotoxicity has been reported rarely at this dose limit.
APAP
APAP-induced hepatotoxicity, which can be life threatening, has been associated with doses >_ g/day. Although doses up to _ g/day are generally well tolerated, hepatotoxicity has been reported rarely at this dose limit.
(Same answer for both blanks.)
4
Due to this risk of hepatotoxicity involving APAP, some experts recommend a lower maximum dose of _ g/day in adults with normal liver function, particularly when used for longer durations (eg, >7 days) for pain.
3
Heavy alcohol use, malnutrition, fasting, low body weight, advanced age, febrile illness, select liver disease, and use of drugs that interact with AP__ metabolism may increase risk of hepatotoxicity; a lower total daily dose (eg, 2 g/day) or avoidance may be preferred.
APAP
