ORTHO PAIN MANAGEMENT Flashcards

1
Q

INPATIENT PAIN MANAGEMENT

A
  • controlled environment: the need for pain control over at least 12 hours
  • PCA = patient controlled analgesia
  • usually written on pre-printed order sets
    o loading dose, PCA dose, lockout interval, and 4hr limit
  • Choice of morphine, fentanyl, hydromorphone (dilaudid), or meperidine (Demerol)
- Inpatient pain management requires
o coherent patient
o attentive staff
o naloxone (narcan) taped to pump
o bowel program
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2
Q

Inpatients that need sporadic pain control adjustments

A
Toradol IM/IV
Morphine IM/IV
Dilaudid IM/IV (hydromorphone)
Demerol / Phenergan IM
	- most patients, however, can usually be controlled with oral medications
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3
Q

MANAGEMENT OF ACUTE PAIN

A
  • usually in an ambulatory setting following injury or post-op
  • combination of narcotic & non-narcotic medication
  • don’t forget the importance of splinting / bracing / immobilization in orthopedic pain management
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4
Q

MANAGEMENT OF CHRONIC PAIN

A
  • ground rules need to be established early; most cases are better dealt with through chronic pain providers
  • Need pain contracts: pain med, amount (dose), and time period
  • Drug testing (to make sure the pt is actually taking the meds and not selling them)
  • Providers (primary & secondary - can’t go to anyone else to get meds)
  • Ancillary services such as
    behavioral health
    biofeedback
    PT
    OT
    hypnosis
    Osteopathic manipulation
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5
Q

several narcotics come in combination with

A

APAP (acetaminophen / Tylenol)

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6
Q

most common narcotics

A
⦁	Codeine
⦁	Morphine
⦁	Hydrocodone
⦁	Oxycodone (oxycontin)
⦁	Tramadol (ultram); (tramadol + APAP = Ultracet)
⦁	Hydromorphone (dilaudid)
⦁	Meperidine (Demerol)
⦁	Fentanyl
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7
Q

hydrocodone + APAP

A

vicodin / Norco / lorcet / Lortab = schedule II

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8
Q

codeine + APAP

A

Tylenol #3 = schedule III

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9
Q

oxycodone + APAP

A

percocet

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10
Q

hydromorphone also known as

A

dilaudid

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11
Q

hydromorphone vs hydrocodone - which is combined with APAP?

A

hydrocodone

hydrocodone + APAP = vicodin

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12
Q

SCHEDULE I DEA DRUGS

A

⦁ Use = illegal or restricted to research. No accepted medical use
⦁ High potential for abuse
⦁ Lack of accepted safety for use

EXAMPLES

a. Hallucinogens
b. Heroin
c. Peyote
d. Psilocybin Mushrooms
e. Marijuana

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13
Q

illegal or restricted to research; no accepted medical use
high abuse potential
lack of accepted safety for use

A

schedule I drugs

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14
Q

examples of schedule I drugs

A

a. Hallucinogens
b. Heroin
c. Peyote
d. Psilocybin Mushrooms
e. Marijuana

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15
Q

SCHEDULE II DRUGS

A

⦁ Use - requires a prescription
⦁ High abuse potential - psychological or physical dependence risk
NO REFILLS OR VERBAL ORDERS

EXAMPLES (opioids & some combos)

a. Codeine
b. Hydrocodone
c. Hydromorphone (dilaudid)
d. Morphine
e. Cocaine
f. Fentanyl
g. Methadone
h. Meperidine (Demerol)

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16
Q

⦁ Use - requires a prescription
⦁ High abuse potential - psychological or physical dependence risk
NO REFILLS OR VERBAL ORDERS

A

schedule II

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17
Q

examples of schedule II

A

a. Codeine
b. Hydrocodone
c. Hydromorphone (dilaudid)
d. Morphine
e. Cocaine
f. Fentanyl
g. Methadone
h. Meperidine (Demerol)

also Adderall & ritalin

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18
Q

SCHEDULE III DRUGS

A

⦁ Use - requires a prescription (like schedule II)
⦁ Moderate abuse potential (less than I and II)
⦁ Max = 5 refills / 6 months (none in schedule II)
⦁ verbal orders allowed (not in schedule II)
⦁ ex = some opioid combos

EXAMPLES

  • Stimulants
    a. Benzphetamine
    b. Clortermine
  • Depressants
    a. Ketamine
    b. Pentobarbital
    c. Secobarbital
    d. Sulfomethane

also Tylenol #3

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19
Q

⦁ Use - requires a prescription (like schedule II)
⦁ Moderate abuse potential (less than I and II)
⦁ Max = 5 refills / 6 months (none in schedule II)
⦁ verbal orders allowed (not in schedule II)
⦁ ex = some opioid combos

A

schedule III

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20
Q

examples of schedule III

A
  • Stimulants
    a. Benzphetamine
    b. Clortermine
  • Depressants
    a. Ketamine
    b. Pentobarbital
    c. Secobarbital
    d. Sulfomethane
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21
Q

benzodiazepines are schedule _______ drugs

A

IV

and also tramadol

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22
Q

examples of schedule IV drugs

A
Alprazolam
Barbital
Clonazepam
Lorazepam
Midazolam
Phenobarbital
Diazepam
Tramadol
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23
Q

SCHEDULE IV DRUGS

A

⦁ Use - Requires prescription (just like II & III)
⦁ Lower abuse potential than I / II / III
⦁ Max = 5 refills / 6 months
⦁ verbal orders allowed
⦁ Examples: benzodiazepines, sedatives/hypnotics, and now tramadol

EXAMPLES

a. Alprazolam
b. Barbital
c. Clonazepam
d. Lorazepam
e. Midazolam
f. Phenobarbital
g. Diazepam
h. Tramadol

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24
Q

⦁ Use - Requires prescription (just like II & III)
⦁ Lower abuse potential than I / II / III
⦁ Max = 5 refills / 6 months
⦁ verbal orders allowed
⦁ Examples: benzodiazepines, sedatives/hypnotics, and now tramadol

A

schedule IV drugs

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25
Q

SCHEDULE V DRUGS

A

⦁ Use - Requires a prescription (like II / III / IV)
⦁ Lower abuse potential
⦁ currently accepted medical use in treatment

EXAMPLES

a. Robitussin AC (antitussive)
b. Lyrica (anticonvulsant)
c. Lomotil (antidiarrheal)
d. Potiga (anticonvulsant)

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26
Q

EXAMPLES OF SCHEDULE V DRUGS

A

a. Robitussin AC (antitussive)
b. Lyrica (anticonvulsant)
c. Lomotil (antidiarrheal)
d. Potiga (anticonvulsant)

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27
Q

TYLENOL #3

A

codeine + APAP

  • opioid agonist (binds to opioid receptors)
  • 15-60mg / 325mg APAP
  • USED AS AN ANTITUSSIVE AS WELL
  • schedule III
  • good choice for pediatric orthopedic pain
  • pretty inexpensive (about $15 for 30 tabs)
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28
Q

opioid combos are schedule

A

3

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29
Q

Tylenol #3 schedule

A

3

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30
Q
  • USED AS AN ANTITUSSIVE AS WELL
A

Tylenol #3

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31
Q

good choice for pediatric orthopedic pain

A

Tylenol #3

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32
Q

hydrocodone + APAP = Vicodin, lorcet, Lortab, Norco = schedule

A

2

both hydrocodone and Vicodin = schedule II

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33
Q

combos with hydrocodone + APAP (schedule II)

A
- many combo formulations (vary in APAP)
⦁	Lorcet (10/325)
⦁	Vicodin (5/325)
⦁	Norco (5, 7.5, 10 / 325)
⦁	Lortab (5, 7.5, 10 / 325)
- more expensive than tylenol #3 - $55 for 30 tabs (tylenol #3 was $15 for 30 tabs)
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34
Q

codeine is schedule ________

Tylenol #3 is schedule _______

A

codeine = schedule II

Tylenol #3 = schedule III

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35
Q

oxycodone + ASA

A

percodan

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36
Q

Percocet =

Percodan =

A

Percocet = oxycodone (oxycontin) + APAP

Percodan = oxycodone (oxycontin) + ASA

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37
Q

Oxycodone
Oxycontin
Percocet
Percodan

all are schedule

A

2

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38
Q

OXYODONE

A

(Oxycontin) = opioid agonist (binds to opioid receptors)

  • can be a combo or not: combo = Percocet; Oxycontin = no APAP
  • schedule II drug
  • Percodan = Oxycodone + ASA (instead of APAP)
  • expensive: $100 for 30 tabs
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39
Q

MORPHINE

A

MS-Contin = oral morphine sulfate

  • controlled release formulation for moderate to severe chronic pain
  • $100 for 60 tabs of 15mg

SCHEDULE II

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40
Q

tramadol + APAP

A

ultracet

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41
Q

tramadol = schedule

A

4

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42
Q

TRAMADOL (ultram)

A
  • Tramadol + APAP = Ultracet
  • MOA = unknown - binds to opioid receptors and inhibits NE / serotonin reuptake
  • caution with seizure history, and can cause serotonin syndrome
  • schedule 4 (along with benzos)
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43
Q

caution with tramadol

A
  • caution with seizure history, and can cause serotonin syndrome
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44
Q
  • caution with seizure history, and can cause serotonin syndrome
A

tramadol

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45
Q

hydromorphone (dilaudid) is schedule

A

2

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46
Q

need to taper dose to d/c

A

hydromorphone (dilaudid)

47
Q

HYDROMORPHONE (DILAUDID)

A
  • opioid agonist - binds to opioid receptors
  • high abuse potential & highly sedative
  • available in immediate release, ER, IM, IV, PO, or PR
  • TAPER DOSE to d/c
  • schedule II
48
Q

*seizure risk over time & dose**

lowers seizure threshold

A

meperidine (Demerol)

49
Q

which 2 meds are you concerned about with seizures

A

tramadol/ultram (seizure hx)

meperidine/Demerol (seizure risk)

50
Q

lowers seizure threshold
dysphoric effects
N/V

A

meperidine (Demerol)

51
Q

meperidine (Demerol) causes N/V, so it is given with

52
Q

MEPERIDINE/DEMEROL IS SCHEDULE

53
Q

MEPERIDINE / DEMEROL

A
  • opioid agonist - binds to opioid receptors
  • very sedative, but not very good for pain control
  • seizure risk over time & dose - lowers seizure threshold
  • also has dysphoric effects
  • oral route is least effective (also available in IV or IM)
  • avoid abrupt cessation
  • schedule II
  • Often causes N/V - give with phenergan
  • not used very much anymore (seizures & dysphoria & N/V)
54
Q

FOR OPIOID TOLERANT PATIENTS ONLY

A

FENTANYL (DURAGESIC)

for chronic pain*

55
Q

FENTANYL IS SCHEDULE

56
Q

FENTANYL (DURAGESIC)

A
  • for chronic pain
  • patches - good for 72 hours
  • for OPIOID TOLERANT PATIENTS ONLY
  • major abuse potential
  • need responsible patients and/or caregiver to administer
  • schedule II
  • risk of respiratory depression
57
Q

caution with concomitant anticoagulation

58
Q

some studies have suggested that NSAIDS may slow down _______________

A

fracture healing

59
Q

NSAIDS

A
  • good use in orthopedics
  • anti-inflammatory properties
  • caution with concomitant anticoagulation
  • some studies have suggested that NSAIDS may slow down fracture healing
  • all NSAIDS have warnings pertaining to CV risk, GI bleeding, kidney risk
60
Q

acetic acid group of NSAIDS

A
  • Diclofenac
  • Etodolac
  • Indomethacin
  • Ketorolac
  • through to inhibit cyclooxygenase (COX) - reducing prostaglandin & thromboxane synthesis
  • usually fairly cheap
  • this class is effective for management of arthritis associated pain (RA, OA, Ankylosing spondylitis)
61
Q

examples of acetic acid NSAIDS

A
  • Diclofenac
  • Etodolac
  • Indomethacin
  • Ketorolac
62
Q

examples of propionic acid NSAIDS

A
  • Naproxen (Aleve, Naprosyn)

- Ibuprofen (Advil, Motrin)

63
Q

propionic acid group of NSAIDS

A
  • Naproxen (Aleve, Naprosyn)
  • Ibuprofen (Advil, Motrin)
  • Most common OTC grouping
  • still has black box warnings
  • messes with prostaglandins
  • can cause GI issues, kidney issues
64
Q

COX 2 INHIBITORS (SELECTIVE NSAIDS)

A
  • COX- 2 = enzyme responsible for inflammation & pain;
    cox 1 & 2 inhibitors (non-selective NSAIDS = inhibit fever / pain / inflammation, but Cox 1 protects stomach/intestinal lining, so by inhibiting Cox 1 = prone to GI bleeding/ulcers,etc)

Cox 2 inhibitors = inhibit fever / pain / inflammation, but still get effect of Cox 1 - protects stomach/intestinal lining
⦁ Celebrex (Celexa)
- Bextra & Vioxx were d/c due to increased risk of heart attacks
- Mobic (Meloxicam) = relatively selective Cox-2 inhbitor; may combine anti-inflammatory efficacy with improved tolerability
- many orthopedic surgeons use Cox 2 inhibitors as an adjunct with narcotics following total joint surgery
- may not interfere with anticoagulation as bad as other NSAIDS, or delay fracture repair (depends on who you talk to)
- ***CI in pts with sulfa allergy
- arguably less of a GI profile

65
Q

contraindicated in patients with sulfa allergy

A

Cox 2 inhibitors (NSAIDS)

66
Q

may not interfere with anticoagulation as bad as other NSAIDS, or delay fracture repair

and less of a GI profile

A

Cox 2 inhibitors (NSAIDS) = celexa / celecoxib

67
Q

STEROIDS

A

o ORAL

  • medrol dose pack: methylprednisolone
  • Prednisone
  • for rheumatologic applications = need longer duration (mostly prednisone); need a taper

o Injectable

  • Kenalog
  • Celestone - betamethasone
  • Depomedrol - Methylprednisolone
68
Q

aim of muscle relaxants in ortho

A
  • The aim of centrally acting skeletal muscle relaxants is to produce a decrease in muscle tone & involuntary movement without loss of voluntary motor function or consciousness
  • alters the balance of synaptic excitation & inhibition that the motor neuron receives
  • primarily to elicit varying degrees of skeletal muscle relaxation
69
Q

INDICATIONS FOR MUSCLE RELAXANTS

A
  • For relief of acute painful musculoskeletal conditions of local origin
  • As an adjunct to rest and physical therapy
- For the relief of acute painful musculoskeletal conditions which include:
⦁	 muscle spasm secondary to trauma
⦁	 radiculopathy
⦁	 musculoskeletal strain or sprain
⦁	 herniated intervertebral disc
⦁	 muscle spasm of osteoarthritis
70
Q

All muscle relaxants are CNS depressants….so caution with the

71
Q

All muscle relaxants are ___________….so caution with the elderly

A

CNS depressants

72
Q
  • SE of leukopenia, thrombocytopenia, hemolytic anemia, and bleeding agranulocytosis with long term use; no initial or follow up labs are needed, however, unless
A

symptoms occur

73
Q

caution of muscle relaxants with ______ & ______ insufficiency

A

hepatic & renal insufficiency

(and elderly)

and high abuse potential with alcohol / opioids

and need to taper off - can have withdrawals

74
Q

muscle relaxants are frequently used with ______ or ______ for abusive purposes

A

alcohol
or
opioids

75
Q

can have withdrawal symptoms from muscle relaxants, so need to

76
Q

MUSCLE RELAXANTS

  • not recommended for use in _______
  • not recommended for use in ________
  • do NOT mix with ______ or_______ - will potentiate the effects
A

pregnancy

children

alcohol or other CNS depressants

77
Q

⦁ For patients with anxiety who also can benefit from muscle relaxant

A

diazepam (valium) = only benzo that is proven to help with both

78
Q

guidelines for muscle relaxant use

A

⦁ Combination muscle relaxant and an analgesic agent appear to be preferred

⦁ The most effective therapy should consider drugs in conjunction with various modes of physical therapy**

⦁ All agents have the potential to cause drowsiness, headache, dizziness and blurred vision

⦁ Patients should not be treated with muscle relaxants for protracted periods

- Initial treatment 10-14 days
- Evaluation after to determine need for further drug therapy 

⦁ NSAIDs may be useful where pain predominates

⦁ For patients with anxiety, in whom sedation is desirable, Diazepam (Valium) should be considered

⦁ Combination muscle relaxants/analgesics are available, equally effective and less costly
- Norgesic (asa/caffeine/orphenadrine)

79
Q

The most effective therapy should consider drugs in conjunction with various modes of

A

physical therapy

80
Q

example of combination muscle relaxant/analgesic

A

Norgesic = ASA + caffeine + orphenadrine

81
Q

ADVERSE EFFECTS OF SOMA (CARISOPRODOL)

A
Drowsiness, dizziness***************
Vertigo, ataxia
Nausea and/or vomiting
Hiccups
Epigastric distress
Tremor, agitation
Headache, insomnia
Tachycardia
Postural hypotension
Facial flushing
82
Q

The Soma metabolite name & significance

A

metabolite = MEPROBAMATE = active as an anxiolytic - the degree to which it contributes to the efficacy of carisoprodol is unknown

83
Q

CONTRAINDICATIONS TO CARISOPRODOL

84
Q

PRECAUTIONS WITH CARISOPRODOL

85
Q

MOST COMMON SE WITH CYCLOBENZAPRINE (FLEXERIL)

A

DRY MOUTH ( anticholinergic SE)

  • drowsiness
  • fatigue
  • headache
86
Q
  • Centrally acting skeletal muscle relaxant that does not directly relax tense skeletal muscles (which relaxant)
A

CARISOPRODOL (SOMA)

87
Q

relieves skeletal muscle spasm of local origin without interfering with muscle function

A

CYCLOBENAPRINE (FLEXERIL)

88
Q

BIGGEST SE OF CONCERN WITH CARISOPRODOL

A

DIZZINESS, DROWSINESS

89
Q

cyclobenzaprine (flexeril) is contraindicated with

A

CV issues

  • arrhythmias
  • heart block
  • acute phase of MI

and also with concurrent use of MAOIs

90
Q

contraindicated with MAOIs and CV issues (acute phase of MI, arrhythmias, heart block)

A

cyclobenzaprine (flexeril)

91
Q

anticholinergic SE

A

cyclobenzaprine (flexeril)

92
Q

most common cyclobenzaprine (flexeril) SE

A

⦁ DROWSINESS
⦁ DRY MOUTH
⦁ FATIGUE
⦁ HEADACHE

93
Q

least common cyclobenzaprine (flexeril) SE

A
⦁	constipation
⦁	abdominal pain
⦁	acid regurgitation
⦁	dizziness
⦁	nausea
94
Q

depresses muscle excitability indirectly by potentiating the effects of synaptic inhibition medication by GABA

A

DIAZEPAM (VALIUM)

95
Q

**Out of all the benzos, ________ = only agent to be approved for treatment of muscle spasms or MSK disorders

A

DIAZEPAM (valium)

96
Q

which muscle relaxant is a better choice for elderly patients

A

METHOCARBAMOL (ROBAXIN)

better choice for elderly pts and pts with cognitive dysfunction / dementia

97
Q

other muscle relaxants

A

⦁ Metaxalone (Skelaxin)
⦁ Tizanidine (Zanaflex)
⦁ Baclofen (Lioresal)

98
Q

treating orthopedic pain

A
  • NSAIDS, muscle relaxants, narcotics, steroids, TCAs, GABA analogues (gabapentin/neurontin, valproic acid, pregabalin/lyrica)
  • OTC = glucosamine / chondroitin, Omega 3s
99
Q

seizures are a precaution in which muscle relaxant

A

SOMA (CARISOPRODOL)

100
Q

this class of NSAIDS is effective for management of arthritis associated pain

A

ACETIC ACID GROUP OF NSAIDS

  • indomethacin
  • ketorolac
  • diclofenac, etc
101
Q

most common ankle sprain & grades

A
  • Lateral is the most common
  • Anterior Talofibular Ligament = most commonly sprained ankle ligament

⦁ Grade I = stretching or slight tear
⦁ Grade II = larger but incomplete tear
⦁ Grade III = complete tear

102
Q

what should be given for grade I sprain

grade II or III sprain?

A

Naproxen or Ibuprofen

o for Grade II or III = give NSAIDS (can give acetic acid or propionic acid NSAIDS), or may even consider a short dose of narcotics in conjunction with anti-inflammatories, especially to be able to sleep at night

⦁ Vicodin 5/325: 1-2 po every evening prn pain, #10 (hydrocodone + APAP)

⦁ Percocets are probably a little too strong, but can consider (oxycodone + APAP)

103
Q
  • Man presents with lower back pain after lifting a heavy object; had a sudden sharp, non-radiating LBP
  • no bowel or bladder incontinence, no saddle paresthesias (cauda equina)
  • no fever, DTRs 2+, no CVA tenderness
A

Start with an NSAID (Ibuprofen TID or Naproxen BID)
- can combine with a muscle relaxant (Flexeril TID or Robaxin qid)

LBP PEARLS: for acute lower back pain, the combination of an NSAID and a muscle relaxant = provided most effective symptom relief in 1 week
⦁ try no to use opioids - consider Tramadol
⦁ no bedrest - do gentle ROM exercises and PT

104
Q

low back pain management

A

NSAID + MUSCLE RELAXANT (combo provides the best symptom relief)

105
Q

risk factors for fibromyalgia

A

⦁ genetics
⦁ rheumatic diseases
⦁ hx of physical or emotional trauma

106
Q

what is fibromyalgia

A
  • widespread MSK pain accompanied by
    ⦁ fatigue
    ⦁ sleep
    ⦁ memory and mood issues
  • Researchers believe that fibromyalgia amplifies painful sensations (substance P)
  • Cause unknown and/or multifactorial
  • Trigger points (have diffuse pain in at least 11/18 trigger points > 3 months
  • muscle biopsy shows “moth eaten” appearance of type I muscle fibers, and muscle damage
  • have diffuse pain, especially in the morning, extreme fatigue, stiffness/tender joints, sleep disturbances, haziness. symptoms may worsen with stress

TX = exercise (swimming preferred - relaxing effect of water); TCAs*, SNRIs or SSRIs, Neurontinn. Pregabalin (Lyrica) = FDA approved for fibromyalgia (schedule V)

107
Q

MEDICATIONS FOR FIBROMYALGIA

A
  • pain relievers
  • anti-depressants
  • anti-seizure drugs

PAIN RELIEVERS
⦁ - OTC: Acetaminophen (tylenol), Ibuprofen (motrin / advil), Naproxen (aleve)
⦁ - RX: Tramadol (Ultram)
⦁ - Narcotics NOT advised

ANTI-DEPRESSANTS
⦁ - Amitriptyline (TCA) - start at 10mg qhs, may increase to up to 150mg
⦁ - Duloxetine (Cymbalta) - SNRI - 30mg qd x 1 week, then increase to 60 qd as tolerated
***must taper off antidepressant before d/c use - do not abruptly discontinue!

Alternative to Amitriptyline (TCA) = Cyclobenzaprine (Flexeril) - does NOT treat depression

ANTI-CONVULSANTS
⦁ - Gabapentin (Neurontin) - starting dose 300mg
⦁ - Pregabalin (Lyrica) - 75mg bid, may increase to 150 after 1 week

COMBO TREATMENT
- if unresponsive to monotherapy, get BH, PT, physical medicine involved - directed at reducing major symptoms of: chronic widespread pain, fatigue, insomnia, and cognitive dysfunction

108
Q

related tricyclic antidepressants…..can be used as an alternative to amitriptyline, but does NOT treat depression

A

Cyclobenzaprine (Flexeril)

109
Q

SUMMARY OF TREATMENT FOR FIBROMYALGIA

A
PAIN RELIEF 
o NSAIDS (ibuprofen or naproxen)
o can use tramadol, but not narcotics!

ANTIDEPRESSANTS
o amitriptyline (TCA)
o duloxetine/Cymbalta (SSRI)

  • can use cyclobenzaprine (flexeril) as alternative to amitriptyline, but doesn’t help with depression
ANTI-CONVULSANTS
o gabapentin (Neurontin)
o pregabalin (lyrica)
110
Q

what is Reflex Sympathetic Dystrophy

(now known as Complex Regional Pain Syndrome

A
  • disorder of a body region - usually the extremities
  • characterized by severe pain, swelling, limited ROM, and skin changes
  • unknown etiology
  • autonomic dysfunction following bone or soft tissue injuries (wrist fracture or post-surgery)
  • MC affects upper extremities

⦁ stage I = pain out of proportion to injury. Symptoms of swelling, extremity color changes, increased nail and hair growth

⦁ stage II = waxy, pale skin, brittle nails, loss of hair
⦁ stage III = joint atrophy and contractures

***Vitamin C prophylaxis after fractures may reduce incidence of CRPS

  • initial tx = NSAIDS. can do anesthetic blocks, PT, steroids, TCAs, nerve stimulation, etc.
111
Q

most common inciting event prior to reflex sympathetic dystrophy =

A

soft tissue injury (40%)

then fracture (25%)

INCITING EVENT
⦁	soft tissue injury (40%)
⦁	fractures (25%)
⦁	MI (12%)
⦁	CVA (3%) - cerebrovascular accident
112
Q

treatment for reflex sympathetic dystrophy (complex regional pain syndrome)

A

MEDS
⦁ Capsaicin cream
⦁ Prednisone may be effective (corticosteroids)
⦁ NSAIDS (ibuprofen, naproxen)
⦁ Propranolol (sympathetic blocker) - beta blocker
⦁ Terazosin or Prazosin (alpha 1 blocker)
⦁ opioids may be needed for severe pain

NSAIDS = initial treatment (pance prep)

vitamin C prophylaxis after fractures may help reduce incidence of CRPS

113
Q

DRUG SEEKING BEHAVIOR

A
characteristics of patients
⦁	Requests for early refills 
⦁	Multisourcing
⦁	Intoxicated behaviors
⦁	Pressuring behaviors
Requests for early refills
“I took too many”
“Lost the prescription”
“Washed it with the laundry”
“Spilled it in the toilet”
“The pharmacist shorted the count”
“My sorry ass brother-in-law stole them”

Multisourcing:
Visiting multiple physicians (“doctor shopping”)
Recruiting surrogates to obtain the medication
Purchasing drugs from illicit drug dealers or over the internet

Intoxicated behaviors:
Slurred or disinhibited calls to the office
Presenting to pharmacy under the influence
Emergency department visits for:
⦁ repeated falls
⦁ other traumatic injuries
⦁ accidental overdose

Pressuring behaviors:
Begging or pleading
Excessive compliments
Breaching boundaries
Threats of harm to:
⦁	 self
⦁	 others
⦁	 the provider
114
Q

***THE MOST COMMON REASON THAT PROVIDERS GET IN TROUBLE WITH OPIOIDS =

A

inadequate documentation