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
Adj_____ analg_____:
Medications possessing analgesic properties but developed for purposes other than pain relief (e.g.. Gabapentin or lidocaine patch for post-herpetic neuralgia, duloxetine for DPN, TCAs for trigeminal neuralgia, etc.). Consider co-morbidities for guidance in choice of possible agents
Adjuvant analgesics
Regarding adj_____ analg_____:
As with NSAIDs and opioids, failure to achieve an adequate response to one agent does not necessarily mean that patients will fail to respond to another. Patients may have variable responses to different agents among and within classes.
Adjuvant analgesics
Examples of adjuvant analgesis:
- Antic__________
- Antid__________
- L________ p______
- C______________
- M_____ r________
- Anticonvulsants
- Antidepressants
- Lidocaine patches
- Corticosteroids
- Muscle relaxants
O_____s: Term to describe all compounds that work at opioid receptors. Most used opioid analgesic drugs are selective for the mu receptor type.
Opioids
Regarding o_____s, the μ1-receptor produces the effects of analgesia.
Opioids
Regarding o_____s, the μ2-receptor is also associated with other effects such as “sedation, reduced blood pressure, itching, nausea, euphoria, decreased respiration, miosis (constricted pupils) and decreased bowel motility often leading to constipation”
Opioids
O_____s are agents of choice for:
- Severe acute pain
- Moderate to severe cancer pain
- Moderate to severe chronic non-malignant & severe neuropathic pain (third or fourth line) has gained more acceptance in recent years
- Reserved for moderate to severe infrequent headaches as “Last resort” due to contraindication or failed response to conventional therapies (eg “triptans”)
Opioids
Opioids are agents of choice for:
- Moderate to severe cancer pain
- Moderate to severe chronic non-malignant & severe neuropathic pain (third or fourth line) has gained more acceptance in recent years
- Reserved for moderate to severe infrequent headaches as “Last resort” due to contraindication or failed response to conventional therapies (eg “triptans”)
Severe acute pain
Opioids are agents of choice for:
- Severe acute pain
- Moderate to severe cancer pain
- Moderate to severe chronic non-malignant & severe neuropathic pain (third or fourth line) has gained more acceptance in recent years
- Reserved for moderate to severe infrequent headaches as “Last resort” due to contraindication or failed response to conventional therapies (eg “triptans”)
-
Opioids are agents of choice for:
- Severe acute pain
- Moderate to severe cancer pain
- Reserved for moderate to severe infrequent headaches as “Last resort” due to contraindication or failed response to conventional therapies (eg “triptans”)
Moderate to severe chronic non-malignant & severe neuropathic pain (third or fourth line) has gained more acceptance in recent years
Opioids are agents of choice for:
- Severe acute pain
- Moderate to severe cancer pain
- Moderate to severe chronic non-malignant & severe neuropathic pain (third or fourth line) has gained more acceptance in recent years
-
Reserved for moderate to severe infrequent headaches as “Last resort” due to contraindication or failed response to conventional therapies (eg “triptans”)
O_____s do not have a “ceiling effect.”
Opioids
The analgesic ce_____ ef____ of a drug refers to the dose beyond which there is no additional analgesic effect.
ceiling effect
Regarding pharmacological effects of o_____s: tolerance to most side effects occurs within first week.
Opioids
Pharmacological effects of o_____s:
- analgesia
- euphoria
- cough suppression
- sedation
- respiratory depression
- nausea/vomiting
- CNS irritability
- pruritis
- constipation
Opioids
Pharmacological effects of opioids:
- a________
- e_______
- c____ s__________
- s_______
- r__________ d_________
- n_____/v_______
- C__ i___________
- p_______
- c___________
- analgesia
- euphoria
- cough suppression
- sedation
- respiratory depression
- nausea/vomiting
- CNS irritability
- pruritis
- constipation
Regarding opioids and con_________, tolerance does not develop to this side effect.
constipation
Because ____________ is a predictable effect of opioid therapy, providers should advise patients to begin using laxatives prophylactically when initiating treatment.
constipation
Although first-line therapy for constipation generally involves increasing exercise, fluid intake, and dietary fiber, these interventions are usually not effective for preventing or treating o_____-induced constipation, and pharmacological management is indicated.
Opioid
Because o_____s affect both peristalsis and the fluid content of the stool, treatment and prophylaxis should target these mechanisms. Stimulant laxatives are commonly used to promote motility; the agents of choice are senna and bisacodyl. A stool softener can be used to counteract the drying and hardening effects of increased transit time; docusate is the most widely used. Other options are available
Opioids
Goal for opioid-induced constipation: _ non-forced BM every 1-2 days in average patient
1
prur____: Occurs more frequently with parenterally administered opioids than oral opioids. Tolerance to this adverse effect usually occurs quickly. Do not confuse this with true allergy.
Pruritis
Two medications that can treat pruritis:
- diphe_________e
- prome______e
- diphenhydramine
- promethazine
CN_ irr_________: Usually abates soon after initiation of opioid therapy. If confusion or delirium persists for more than 2 weeks, it usually can be attributed to other factors.
CNS irritability
Regarding CNS irritability and opioids: If opioid treatment appears to be the underlying etiology, treatment strategies are similar to those for sedation.
These strategies include:
- d___________ or use a________ o_____
- d___ r________
- t____ with ___
- h__________
- discontinue or use alternate opioid
- dose reduction
- treat with BZD
- haloperidol
Respiratory depression is perhaps the most serious potential adverse event associated with op____ therapy
opioid
O_____s depress all phases of respiratory activity, including rate, minute volume, and tidal exchange; and indiscriminate dosing can lead to serious, and potentially fatal, respiratory depression
Opioids
The risk of respiratory depression is greatest for patients who are ______ naïve, whereas risk is minimized during chronic administration because patients rapidly develop tolerance to this effect.
opioid
Respiratory depression can occur in a patient with chronic pain if the pain is greatly reduced (e.g., following an ablation procedure) and the ______ dosage is not adjusted properly.
opioid
O_____ analgesics normally can be safely titrated upward in chronic-pain patients until pain is adequately controlled with minimal risk of respiratory depression.
Opioid
Regarding opioids and MILD respiratory depression, decrease opiod dose by __%.
25%
Regarding opioids and SEVERE respiratory depression, use nal______e.
naltrexone
Nal_______ is a synthetic drug, similar to morphine, which blocks opiate receptors in the nervous system and is used chiefly in the treatment of heroin addiction and severe respiratory depression caused by opiates.
Naltrexone
Sed_____ is another common adverse event associated with opioids.
Sedation
Regarding o_____s and sedation, initial sleepiness after the implementation of a pain management regimen may result in part from the patient being exhausted from poor sleep during the time that the pain was not well controlled.
opioids
Opiate s_______ usually abates within the first days to weeks of therapy.
sedation
During the initial period of opioid therapy, patients should be cautioned against driving or other activities that could be dangerous if seda____ develops.
sedation
With continued op___e treatment, most patients are able to resume normal activities, even driving.
opiate
Additional interventions for persistent sedation (not for routine use):
– Reduce dose 25% or increase interval
– Caffeine 100-200 mg PO q6h
– Methylphenidate 5-10 mg PO 1-3x/day
– Dextroamphetamine 5-10 mg PO 1-3x/day
– Modafanil 100-200 mg PO daily
–Reduce dose 25% or increase interval
–Caffeine 100-200 mg PO q6h
–Methylphenidate 5-10 mg PO 1-3x/day
–Dextroamphetamine 5-10 mg PO 1-3x/day
–Modafanil 100-200 mg PO daily
Additional interventions for persistent sedation (not for routine use):
–Reduce dose 25% or increase interval
–
–Methylphenidate 5-10 mg PO 1-3x/day
–Dextroamphetamine 5-10 mg PO 1-3x/day
–Modafanil 100-200 mg PO daily
–Reduce dose 25% or increase interval
–Caffeine 100-200 mg PO q6h
–Methylphenidate 5-10 mg PO 1-3x/day
–Dextroamphetamine 5-10 mg PO 1-3x/day
–Modafanil 100-200 mg PO daily
Additional interventions for persistent sedation (not for routine use):
–Reduce dose 25% or increase interval
–Caffeine 100-200 mg PO q6h
–
–Dextroamphetamine 5-10 mg PO 1-3x/day
–Modafanil 100-200 mg PO daily
–Reduce dose 25% or increase interval
–Caffeine 100-200 mg PO q6h
–Methylphenidate 5-10 mg PO 1-3x/day
–Dextroamphetamine 5-10 mg PO 1-3x/day
–Modafanil 100-200 mg PO daily
Additional interventions for persistent sedation (not for routine use):
–Reduce dose 25% or increase interval
–Caffeine 100-200 mg PO q6h
–Methylphenidate 5-10 mg PO 1-3x/day
–
–Modafanil 100-200 mg PO daily
–Reduce dose 25% or increase interval
–Caffeine 100-200 mg PO q6h
–Methylphenidate 5-10 mg PO 1-3x/day
–Dextroamphetamine 5-10 mg PO 1-3x/day
–Modafanil 100-200 mg PO daily
Additional interventions for persistent sedation (not for routine use):
–Reduce dose 25% or increase interval
–Caffeine 100-200 mg PO q6h
–Methylphenidate 5-10 mg PO 1-3x/day
–Dextroamphetamine 5-10 mg PO 1-3x/day
–
–Reduce dose 25% or increase interval
–Caffeine 100-200 mg PO q6h
–Methylphenidate 5-10 mg PO 1-3x/day
–Dextroamphetamine 5-10 mg PO 1-3x/day
–Modafanil 100-200 mg PO daily
Perip_____ opi___ anta______s:
They do not affect analgesic response or promote withdrawal because they do not cross the BBB.
Peripheral opioid antagonists
Two common peripheral opioid antagonists:
n_______
n_________
naloxone
naltrexone
Regarding opioids:
All_________y: For a patient with a true allergy to codeine (or related compound), the risk of cross-reactivity with another opioid can be reduced if an analgesic from a different chemical class is used.
Allergenicity
It is important to note that use of an opioid from a different chemical class does not eliminate the risk of an a_______ reaction.
allergic
Regarding o_____s, for patients with severe or life-threatening reactions, non-narcotic analgesics, such as non steroidal anti-inflammatory agents or acetaminophen, should be considered.
opioids
Regarding cro__-all__________ of compounds in the same column:
Example - If a patient has a true documented allergy to fentanyl (phenylpiperidine), then hydromorphone (phenanthrenes) might be a reasonable alternative.
cross-allergenicity
[Cross-allergenicity test] [Y/N Q]
Swap Fentanyl with meperidine?
No. Both phenylpiperidines.
[Cross-allergenicity test] [Y/N Q]
Swap morphine with oxycodone?
No. Both phenanthrenes.
[Cross-allergenicity test] [Y/N Q]
Swap methadone with oxycodone?
Yes. Different classes.
[Cross-allergenicity test] [Y/N Q]
Swap morphine with fentanyl?
Yes. Different classes.
[Cross-allergenicity test] [Y/N Q]
Swap methadone with levomethadyl?
No. Both phenylheptanones.
- Conversion guidance
- Determine the total 24-hour dose of current opioid
- Using the estimated equi-analgesic dose (see attached), calculate the equivalent dose of new analgesic for the desired route of administration
- Converting dose should be decreased by 1/2-2/3 to allow for incomplete cross-tolerance
- Take the 24 hour starting dose of new opioid and divide by the frequency of administration to give the new dose
- Consider rescue opioid therapy during the conversion process
- Please be sure you are comfortable with conversions such as seen in the practice conversions discussion thread
-
Look more into conversion guidance.
Ad_______:
A primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. Characterized by one or more of the following: impaired control over drug use, compulsive use, continued use despite harm and craving
Addiction
Phy_____ de________:
A state of adaptation manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood levels, and/or administration of an antagonist
Physical Dependence
Tol______:
A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more opioid effects over time
Tolerance
Aber____ d___-r______ be______:
A behavior outside the boundaries of the agreed on treatment plan which is established as early as possible in the doctor-patient relationship
Aberrant drug-related behavior
Ab___:
Any use of an illegal drug, or the intentional self-administration of a medication for a non-medical purpose such as altering one’s state of consciousness
Abuse
o The issue of adjusting for incomplete cross tolerance is for those who are defined as being o_____ t_______. The FDA specifically defines this as “The FDA defines a patient as o_____ t_______ if for at least 1 week he or she has been receiving oral morphine 60 mg/day; transdermal fentanyl 25 mcg/hour; oral oxycodone 30 mg/day; oral hydromorphone 8 mg/day; oral oxymorphone 25 mg/day; or an equianalgesic dose of any other opioid.
opioid tolerant
[Opioid Antagonist]
- Indication: the treatment of opioid agonist-induced respiratory depression and known / suspected overdose of opioid
- Reverses both toxic and clinical effects of opioids
Naloxone
[Opioid Antagonist]
- Indication: the adjuvant treatment of alcoholism and nicotine dependence
- Used off-label for opiate agonist dependence and withdrawal
- Weight loss
Naltrexone
Neuropathic Pain in Diabetes:
There are many types of neuropathic pain, but we will limit to NPD since we have already discussed DM. Treatment modalities are similar regardless of the type. Diabetic neuropathies are the most prevalent chronic complications of diabetes.
Treatment does NOT fall into the WHO step wise approach to other types of pain
-
Consider either preg______ or dulo______ as the initial approach in the symptomatic treatment for neuropathic pain in diabetes.
pregabalin or duloxetine
Gaba_____n may also be used as an effective initial approach for neuropathic pain in diabetes (NPD), taking into account patients’ socioeconomic status, comorbidities, and potential drug interactions.
Gabapentin
Although not approved by the U.S. Food and Drug Administration, tric_____ anti___________ (psych drug class) are also effective for neuropathic pain in diabetes but should be used with caution given the higher risk of serious side effects.
tricyclic antidepressants
Given the high risks of addiction and other complications, the use of o______, including tapentadol or tramadol, is not recommended as first- or second-line agents for treating the pain associated with neuropathic pain in diabetes (NPD).
opioids
h______e: a continuous pain in the head.
One of the most common complaints in 0.2% of all visits to emergency departments. One of the Top 10 presenting complaints in ambulatory care.
headache
International Headache Society (IHS) classifications:
- M_______
- T______-type headache
- C______ headache
- Migraine
- Tension-type headache
- Cluster headache
M_______: a headache that can cause severe throbbing pain or a pulsing sensation, usually on one side of the head.
Migraine
Regarding m_______s:
Goals should include
- provision of rapid and consistent treatment
- restore functional ability
- use lowest, effective dose of abortive therapy
- minimize adverse events
Migraines
Non-pharmacological interventions for m________:
Patients should
- maintain a headache diary as part of the treatment regimen to identify potential triggers
- practice avoidance as well as possibly the use of ice, rest, bio-feedback
migraines
Regarding mig______: urgent medical evaluation is also imperative with “red flag” symptoms.
migraines
H_______ “Red Flags” Indicating Need for Urgent Medical Evaluation:
- new-onset sudden and/or severe pain
- stereotyped pain pattern worsens
- Systemic signs (e.g., fever, weight loss, or accelerated hypertension)
- focal neurologic symptoms (i.e., other than typical visual or sensory aura)
- papilledema
- Cough-/exertion-/or Valsalva-triggered HA
- pregnancy or post-partum state
- patients with cancer, HIV, and other infectious and immunodeficiency disorders
- seizures
Headache
For c______ headaches: abortive therapies (similar abortive therapies [like sumatriptan] + oxygen used, but prophylaxis is key.)
cluster
APAP alone is not recommended for m________.
migraines
Oral NSAIDs and combination analgesics with caffeine:
first-line treatment choices for mild to moderate m_______ attacks or severe attacks that have responded in the past to similar treatment.
migraine
Butal_____-containing products (for headache/migraine):
Limit and monitor use due to overuse, medication-overuse headache, and withdrawal
Butalbital
Treatment choices for h________:
- APAP
- APAP + aspirin 250 mg +caffeine 65 mg
- ASA or APAP with butalbital, caffeine
- isometheptene 65 mg + dichloralphenazone 100 mg + APAP 325 mg
- ASA
- ibuprofen
- naproxen sodium
headaches
Tr_____s (drug class): First line therapy for moderate to severe migraines, especially when nonspecific (including OTCs (e.g. Excedrine Migraine)) medications are ineffective
Triptans
Regarding Tript___:
Clinical response varies among patients. If there is no response to one, it is reasonable to try another.
Triptans
Contraindications of Trip___s: (for headache)
History of ischemic heart disease, uncontrolled hypertension, CAD, stroke, PVD, Prinzmetal’s angina, myocardial infarction, pregnancy
Triptans
T______ medications:
almotriptan (Axert)
eletriptan (Relpax)
frovatriptan (Frova)
naratriptan (Amerge)
rizatriptan (Maxalt)
sumatriptan (Imitrex)
sumatriptan/naproxen sodium (Treximet)
zolmitriptan (Zomig)
Triptans
Trip____:
Mechanism of action will help to explain contraindication in some of the concomitant diseases.
Triptans
[This one needs elaboration on which exact contraindications.]
Ergota_____: Moderate to severe migraine attacks. Usually considered after other treatment failures
Ergotamines
Ergo______ is in a class of medications called ergot alkaloids. It works together with caffeine by preventing blood vessels in the head from expanding and causing headaches.
Ergotamine
Contraindications of ergot_____s (ergot alkaloid):
Contraindicated among patients with/at risk for CAD, stroke, PVD, uncontrolled HTN, liver/kidney disease, strong inhibitors of CYP3A4, pregnancy (category X)
Ergotamines
List of e____ a________:
- ergotamine (tab/SQ/rectal)
- dihydroergotamine (injection/spray)
ergot alkaloids
O______:
Reserved for moderate to severe infrequent headaches
- “Last resort” due to contraindication or failed response to conventional therapies
Opioids
Lasmi____n (med) is a selective serotonin 1F receptor agonist that lacks vasoconstrictor activity. The role of this med in clinical practice is not yet defined, but it is probably best suited for patients with relative contraindications to triptans due to cardiovascular risk factors.
It may decrease heart rate and/or increase BP.
- monitor closely in patients who may not tolerate these effects.
Lasmiditan
Lasmi_____ (med for HA) may decrease heart rate and/or increase BP; monitor closely in patients who may not tolerate these effects.
Lasmiditan
Lasmi_____ is a selective serotonin 1F receptor agonist that lacks vasoconstrictor activity.
(med for HA)
Lasmiditan
Lasm______ (med for HA):
Has a relatively high rate of adverse events, the most common being dizziness; other relatively frequent adverse events are paresthesia, somnolence, fatigue, and nausea. Dizziness with this med is dose-dependent and largely mild to moderate in severity, with a median duration of 1.5 to 2 hours. The drug may cause driving impairment, and patients should not drive a motor vehicle, operate machinery, or engage in potentially hazardous activities for at least eight hours after each dose of it.
Lasmiditan
Se_______ sy______ (1):
Potentially life-threatening condition has occurred in patients receiving lasmid___n (2) without any other drugs associated with it. This may also occur when used in combination with other serotonergic agents (eg, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, buspirone, St. John’s wort, tryptophan) or agents that impair metabolism of serotonin (eg, monoamine oxidase inhibitors [MAOIs] intended to treat psychiatric disorders, other MAOIs [ie, linezolid and IV methylene blue]).
Monitor patients closely for signs of this, such as mental status changes (eg, agitation, hallucinations, delirium, coma), autonomic instability (eg, tachycardia, labile BP, diaphoresis), neuromuscular changes (eg, tremor, rigidity, myoclonus), GI symptoms (eg, nausea, vomiting, diarrhea), and/or seizures. Discontinue treatment (and any concomitant serotonergic agent) immediately if signs/symptoms arise.
(1) Serotonin syndrome
(2) lasmiditan
CGRP Ant________:
Pharmacologic modulation of calcitonin-gene related peptide (CGRP) activity appears to mediate trigeminovascular pain transmission in migraine. Small-molecule this (also termed “gepants”) are oral options available for the acute treatment of migraine in patients with either insufficient response or contraindication (eg, coronary artery disease) to treatment with triptans.
CGRP Antagonists
CGRP Antagonist med (“-gepant”):
-Ubro______
-Rime______
Ubrogepant
Rimegepant
Ubro______:
received US Food and Drug Administration (FDA) approval for the treatment of acute migraine in adults in December 2019, and rimegepant received similar FDA approval in February 2020. However, given the short-term, single-attack design of these trials , long-term data are needed to determine safety and tolerability. In addition, the efficacy of CGRP antagonists compared with triptans is not yet known.
Ubrogepant
Antie_____s:
adjunctive therapy to relieve nausea/vomiting and migraine attack
- meds include chlorpromazine, prochlorperazine
- IV formulation for refractory, intractable headache
- Administer 15-30 minutes before abortive therapy
- Metoclopramide: IV metoclopramide (a DA receptor blocker) is effective for acute migraine treatment
Antiemetics
Metoc_________ (med for nause & HA):
- IV form (a DA receptor blocker) is effective for acute migraine treatment.
Metoclopramide
P___________ t______ (for HA):
there is no commonly accepted indication for starting prophylactic treatment, but should be considered when
- quality of life, business duties, or school attendance are severely impaired
- frequency of attacks ≥ 2 per month
- migraine attacks do not respond to acute drug treatment
- frequent, very long, or uncomfortable auras occur
Prophylactic therapy
B___-b_______ [for HA] (e.g. propranolol):
- ideal for healthy patients or comorbid hypertension, angina, or anxiety
- avoid in reactive airway disease, heart block, bradycardia
Beta-blockers
TC_s [for HA] (e.g. nortriptyline, amitriptyline):
- good choice for patients with comorbid depression or insomnia
- avoid in urinary retention, BPH, glaucoma or where anticholinergic effects are problematic
TCAs
Antico________s [for HA] (e.g. valproate, topirimate):
- good choice for patients with comorbid seizure disorder or manic-depressive illness
- many drug-drug interactions
Anticonvulsants
Cal____ Chan___ Blo____s [for HA] (e.g. verapamil):
- generally considered second or third line for migraine headaches, but first line for prophylaxis of cluster type headache.
Calcium Channel Blockers
First line for prophylaxis of cluster type headache:
V________
Verapamil
N____s [for HA]:
- use for migraines with predictable pattern (Example: menstrual cycle)
- Should be initiated 1-2 days prior to the expected onset of headache
- total duration of use limited due to risk of GI events
NSAIDs
Tr_____s [for HA]:
- use for migraines with predictable pattern (Example: menstrual cycle).
- these can be tried in patients unresponsive to NSAIDs, but generally not considered to standard of practice
Triptans
Bot__ [for HA]:
15 or more headache days a month, each lasting 4 hours or more
Botox
*CGRP An________s [for HA]:
The calcitonin gene-related peptide is a therapeutic target in migraine because of its hypothesized role in mediating trigeminovascular pain transmission and the vasodilatory component of neurogenic inflammation. There is little evidence to guide the use of the this in specific populations (eg, children, elderly, and women during pregnancy and lactation). Effective in randomized trials but are expensive and lack long-term safety data.
CGRP Antagonists
M_________ o______ h_______ (MOH):
is a headache occurring on 15 or more days per month developing as a consequence of regular overuse of acute or symptomatic headache medication for more than 3 months. The precise mechanisms that lead to MOH are still uncertain.
Medication overuse headache (MOH)
Risk of m_________ o______ h_______:
- Highest with opioids, butalbital-containing combination analgesics, and acetaminophen-aspirin-caffeine combinations
- Intermediate to low with triptans
- Likely low with NSAIDs
Medication overuse headache (MOH)
In order to prevent the development of med_______ ove____ head____, most acute medications should be limited to less than 10 days per month (or less than 15 days per month for aspirin, acetaminophen, and NSAIDS), and preventive therapies should be used as the mainstay in patients with frequent headaches.
Medication overuse headache (MOH)
C______ headache:
Is a severe headache on one side of the head with recurrence on fixed time intervals.
Cluster
Symptoms of clu____ headaches:
- swollen or drooping eye
- smaller pupil in the eye
- eye redness or watering
- runny or congested nose
- red, warm face
- sweating
cluster
Causes of c______ headaches:
- cigarette smoke
- alcohol
- disruptions in your circadian rhythm, like sleep deprivation and jet lag.
cluster
Treatment of c______ headaches:
- measures to abort the acute episode with medicine such as sumatriptan, and other treatments, including oxygen therapy, can help reduce the incidence and severity of attacks.
- preventive medicine can be given by the treating doctor as required.
- avoid taking alcohol.
cluster
Chronic pain persists beyond the expected normal time for healing and serves no useful physiologic purpose.
-
Chronic malignant pain is associated with a progressive disease that is usually life threatening such as cancer, AIDs, progressive neurologic diseases, end-stage organ failure, and dementia.
-
Pain not associated with a life-threatening disease and lasting more than 6 months beyond the healing period is referred to as chronic nonmalignant pain.
-
Ketorolac max of 5 days, or you will shit blood. The worst at GI bleeds.
-
