Non-Opioids and Opiods Flashcards
How does the WHO define pain?
“An unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage”
Further Defining pain
Physical Well-Being:
Stamina/strength Appetite Sleep Elimination functional capacity comfort
Further Defining Pain
Psychologica Well-being:
Coping Control Concentration Enjoyment/happiness Sense of usefulness Anxiety/depression/fear
Further Defining Pain
Social Well-being:
Social support/family sexuality/affection employment finances appearances roles and relationships Isolation/dependence/burden
Further Defining Pain
Spiritual well-being:
Religion Sense of purpose/meaning Hopefulness Uncertainty Suffering
Pain Pathway:
What is Transduction?
A physiological process whereby a noxious mechanical, chemical or thermal stimulus is transduced via specialed receptors on primary afferents into an electrical impulse up to the brain.
Pain Pathway
What is transmission?
Once transduced and generated, nerve impulses are conducted to the central nervous system using specific sodium channels. - Opioids try to prevent transmission to the brain.
Pain Pathway
What is perception?
The process by which a noxious event is recognized as pain by a conscious person
Pain Pathway
What is descending modulation?
Inhibition of nociceptive impulses. Descending input from the brainstem influences central nociceptive transmission in the spinal cord. Neurons from the brain stem release 5 HT and NE.
EX: Tricyclic antidepressants enhance normal modulation by interfering with reuptake of 5 HT and NE. In turn, decreases the perception of pain.
Categorizing Pain
What is Visceral Pain? + example
Visceral pain is referred, colicky, diffuse in organs such as gallbladder, liver, intestines
*squeezing, cramping, bloating
EX: US, cholecystitis, peptic ulcer
Categorizing Pain:
What is somatic pain?
Somatic pain is well-localized pain caused by tissue damage to skin, soft tissue, muscle or bone.
*Stabbing, aching, sharp
Ex: trauma and arthritis
Categorizing Pain:
What is Neuropathic pain?
Neuropathic pain is injury or inflammation of nerves. Often coexists with somatic and or visceral pain.
*Radicular, stocking-like, burning numb, electric, tingling.
Ex: phantom limb syndrome, diabetic neuropathy, postherpetic neuralgia.
What is Acute Pain?
- Less than 3 months
- Changes in vital signs, brief duration, subsides with healing, treated with PRN medications
What is Chronic pain?
- Greater than 3 months
- Vital sign within normal limits, continuous duration, treated with around-the-clock medications
Pediatric pain
When is the nociceptor system functional by?
24 weeks gestation
Pediatric Pain
What are pediatric indicators of pain:
vocalizations, social withdrawal, changes in sleep pattern, poor feeding, increased HR and RR
Pediatric Pain
What can be used for pediatric pain control?
Sucrose Acetaminophen Aspirin NSAIDS Opioids Topical analgesia/local analgesia Psychotropic medications Nonpharmacologic measures
Pediatric Pain: Sucrose
When is used as an effective pain medication?
When should it be given?
Most effective under 1 month of age, but some up to 6 months.
Should be given 2 minutes before painful procedure
Aging and Pain:
What should you take into consideration with the elderly?
- Increase in pain threshold (skin thickness changes, peripheral neuropathies
- Reduced pain tolerance
- changes in the metabolism of drugs
- comorbidities causing pain
- comorbidities impacting the pharmacokinetics of prescribing
What is the structured pain protocol?
- Complete pain assessment (OLDCART)
- Match appropriate durg to pain type
- Consider potential side effects and risks
- Assess safest route of delivery. Provide clear instructions
- Determine financial burden and access
WHO Pain ladder:
What is Step 1 of the ladder?
Mild to moderate pain:
treat with non-opioid +/- adjuvant
WHO Pain ladder:
What is Step 2 of the ladder?
Moderate to severe pain or fail Step 1:
- use oral opioid + non-opioid
- +/- adjuvant
WHO Pain ladder:
What is Step 3 of the ladder?
Severe pain or fail Step 2:
-Treat with opioid for severe pain with or without non-opioid
-Practice around-the-clock dosing
Adjuvant medications
Acetaminophen:
Use and MOA
Mild pain treatment; for moderate pain would combine with oxy or hydro
Believed to inhibit the synthesis of prostaglandins in teh central nervous system and work peripherally to block pain impulse generation
Acetaminophen:
Dosage
Max: 4g in 24 with monitoring. 3 g in 24 with no monitoring
Pediatric: 10-15 mg/kg/ dose every 4-6 hours
Acetaminophen:
Safe In: Pregnancy? Lactation? Elderly?
Yes to all 3
Acetaminophen:
Side Effects
Skin rash
Increased ALT
Increased bilirubin
Acetaminophen:
Monitoring
LFT
Acetaminophen:
Contraindications
Liver impairment
NSAIDS:
Use and MOA
Mild pain treatment; for moderate pain would combine with oxy or hydro
MOA: reversibly inhibits COX 1 and COX 2 enzymes, which results in decreased formation of prostaglandin precursors.
NSAIDS:
Dose
Max: 3,200 mg /day
Naproxin is 1,250 mg/day
KIDS: 2,400 mg/day
Pediatric: 5-10 mg/kg/dose every 4-6 hours
NSAIDS:
Side Effects
Edema
skin rash
epigastric
heartburn
NSAIDS:
Monitoring parameters
Renal panel
CBC
GI disturbances
NSAIDS:
Caution in what patients
Hypertension - Ace and Arbs
Renal Disease -
Blood disorder - affects plts
Avoid in pregnancy- preterm labor
Local Anesthetics:
What is EMLA?
Topical eutectic mixture of lidocaine and prilocaine
Local Anesthetics:
When should EMLA be placed on infants and children?
Infants: 1 hour before
Older children: Up to 4 hours
Local Anesthetics:
SE of EMLA?
Neonates: Methemoglobinemia
Redness and blistering with circumcision
Local Anesthetics:
Indication for EMLA?
anesthetizes skin before painful procedures
Local Anesthetics:
What is Voltaren Gel?
NSAID gel
Local Anesthetics:
Indication for Voltaren Gel?
Acute pain related to sprains, strains
Osteoarthritis
Local Anesthetics:
How often can Voltaren gel be used?
4 times per day
List adjuvant medications
Antidepressants - Cymbalta and Effexor, Amitriptyline
Anticonvulsants - Gabapentin, Pregabalin
Serotonin and NE reuptake inhibitors (SNRI’s)
MOA:
MOA of SNRI’s: Cymbalta and Effexor
Potent inhibitor of neuronal serotonin and NE reuptake and a weak inhibitor of dopamine reuptake
Serotonin and NE reuptake inhibitors (SNRI’s)
Side Effects:
Nausea
HA
Drowsiness
Xerostomia - dry mouth
Serotonin and NE reuptake inhibitors (SNRI’s)
Clinical Indication:
Neuropathic pain
Chronic MS pain
Tricyclic antidepressants (TCA's): Amitriptyline MOA
MOA of TCA’s: Amitriptyline
Central inhibition of NE and serotonin reuptake
Tricyclic antidepressants (TCA's): Amitriptyline Side Effects
Sedation Anticholinergic effects Postural Hypotension Cognitive impairment **Avoid in Elderly: check EKG for conduction ABN prior to initiation
Tricyclic antidepressants (TCA's): Amitriptyline Monitoring parameters:
Mental status
Suicidal ideation
HR
BP
Tricyclic antidepressants (TCA's): Amitriptyline Clinical Indication
Neuropathic pain
Chronic pain
Anticonvulsants: Gabapentin
MOA
Anticonvulsants: Gabapentin
MOA: high affinity-binding sites are located throughout the brain; sites correspond to the presence of voltage-gated calcium channels which may modulate the release of excitatory neurotransmitters which participate in norcicption
Anticonvulsants: Gabapentin
Side effects
Dizziness Drowsiness ATaxia - muscle coordination fatigue peripheral edema
Anticonvulsants: Gabapentin
Monitoring parameters
Sedation
Renal function
Suicidality
Anticonvulsants: Gabapentin
Clinical indications
Neuropathic pain
Anticonvulsants: Pregabalin
MOA
Anticonvulsants: Pregabalin
MOA: exerts antinociceptive and anticonvulsant activity; may also affect descending noradrenergic and serotonergic pain transmission pathways from the brainstem to the spinal cord
Anticonvulsants: Pregabalin
Side Effects
Peripheral edema Dizziness drowsiness HA Fatigue
Anticonvulsants: Pregabalin
Monitoring parameters
Sedation
Weight gain
Suicidality
Anticonvulsants: Pregabalin
Clinical indication:
Neuropathic pain
Tramadol
Use
Moderate pain option that is a non-opioid that works on the opioid receptor
Tramadol MOA
Tramadol and its active metabolite M1 binds to mu-opioid receptors in the CNS causing inhibition of ascending pain pathways, altering the perception of and response to pain: also inhibits the reuptake of NE and serotonin, which are neurotransmitters involved in the descending inhibitory pain pathway responsible for pain relief.
Tramadol Side Effects
Can lower seizure threshold Flushing Dizziness HA Nause Constipation
Tramadol Monitoring parameters:
Sedation
Suicidal ideation
Tramadol Cautions
Risk for serotonin syndrome when combined with TCA’s, SSRIs, SNRIs, triptans
**Needs to be tapered if will be discontinued after chronic use
Opioid MOA
Binds to opioid receptors in the CNS causing inhibition of ascending pain pathways, altering the perception of an response to pain; produces generalized CNS depression
Opioid Major receptor subtypes:
mu, kappa, mu is primary receptor
Opioid Side Effects
Sedation respiratory depression nausea vomiting constipation urinary retention pruritus confusion hypotension
Opioid Special considerations
Morphine, Dilaudid, and codeine have active metabolites can accumulate in renal impairment
Fentanyl is NOT to be used in opioid-naive patients.
Naloxone MOA
Pure opioid antagonist that competes and displaces opioid at opioid receptor sites
Naloxone Dose
Naloxone 0.4-2 mg may need to repeat doses every 2-3 minutes
Naloxone side effects
Flushing
Hypertension
Tachycardia
agitation
Naloxone monitoring parameters:
RR HR BP Temp LOC ABG's or SpO2
Naloxone Caution
patients with CV disease
What is Incomplete Cross-Tolerance
A patient who is tolerant to the effects and side effects of one opioid may not be equally tolerant to the effects and side effects of another opioid
Decrease equianalgesic dose by 1/3 to 1/2 because of incomplete cross-tolerance.
What types of meds should be used for constipation caused by opioids? Give Examples
Prophylactic motility-focused laxatives for patients on opioid therapy Like:
Senna
Dulcolax
Miralax
What types of meds for constipation should be avoided by opioid users? Give Examples
Bulk-forming laxatives including Metamucil, Citrucel
Define addiction:
Psychological dependence on the drug.
Using drug for psychic effects
Often associated with drug-seeking behaviors
Drug use continues despite negative legal, social and economic effects.
Define Tolerance:
Tolerance: Expected effect of chronic opioid use
Presents as decreased duration of analgesia
Need of more frequent dosing and or higher doses to maintain analgesia
Define: Physical dependence:
- Expected effect of chronic use
- Not a sign of addiction.
- Withdrawal symptoms; when opioid dose is markedly decreased or stopped abruptly.
- Symptoms: increased pain, anxiety, lacrimation, rhinorrhea, nausea or diarrhea.
What are some Alternative Treatments for pain?
RICE massage Heat application Physical therapy TENS therapy (Transcutaneous Electrical Nerve Stimulator) Acupuncture Reiki Distraction/relaxation/music therapy/medication Yoga
