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Preclerkship > Pain > Flashcards

Pain Flashcards

1
Q

What are “red” and “yellow” flags when it comes to pain

A

Red flag = sign of serious underlying organic etiology

Yellow flag= thoughts/behaviours that put a person at risk of developing chronic pain

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2
Q

Pain is considered chronic after…

A

3 months (sometimes 6?)

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3
Q

Broad categories of types of pain related to where in body the signals are coming from

A

Nociceptive: somatic, visceral
Neuropathic: central, peripheral
(often “mixed”)

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4
Q

shooting pain along the course of a nerve, often described as electrical or shocking in nature

A

Lancinating pain

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5
Q

Abnormal sensations, usually uncomfortable in a sensory field often described as “burning”

A

Dysesthesia

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6
Q

An abnormal sensation in the absence of a stimulus; often described in terms of “pins & Needles”

A

Parasthesia

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7
Q

When pain or discomfort is felt with a non noxious stimulus.

A

Allodynia

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8
Q

When a noxious or painful stimulus is experienced as pain more severe than would be ordinarily expected

A

Hyperalgesia

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9
Q

Main tract transporting pain signals afferently? When does it cross over?

A

Lateral spinothalamic tract

Decussates immediately

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10
Q

Name 4 different sensory nerve fibres from fastest/thickest to slowest/thinnest, & what kind of info they transport

A

A-alpha: proprioception
A-beta: touch
A-delta: pain (mechanical, temp)
C: pain (mechanical, thermal, chemical)

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11
Q

Define sensitization. Peripheral vs central?

A

Abnormal pain perception due to heightened neuronal sensitivity noxious and/or normal stimuli; happens in response to injury, inflamm, repetitive stim
Peripheral sensitization usually goes away when injury/inflamm resolves. If becomes chronic –> central (brain/dorsal SC; nonnocicieptive fibers recruited into nociceptive pathway)

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12
Q

3 tenets of the WHO analgesic ladder

A

“By the mouth” (preferably oral)
“By the clock” (preferably scheduled dosing)
“By the ladder” (symptom-oriented progression through steps)

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13
Q

Analgesics > ___ times per week –> MOH

A

3

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14
Q

3 steps of postop pain treatment

A

1) Nonopioid analgesic + local anesthetic infiltration
2) Step 1 + intermittent opioid doses
3) 1 + 2 + local anesthetic peripheral neural blockade + sustained release opioid analgesics

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15
Q

What opioid is not recommended in pts with epilepsy?

A

Tramadol (lowers seizure threshold)

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16
Q

Contraindications to oral opioid therapy

A

Asthma, resp depression
Head injury
Biliary colic (sphincter of oddi spasm)
Bowel obstruction

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17
Q

3 topical analgesics

A

Lidocaine
Capsaicin
Diclofenac

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18
Q

Name a “Selective” NSAID. What does that mean?

A

e.g. Celecoxib
Selective inhibition of COX-2 only (most inhibit COX-1 & COX-2)
COX-1 in constitutively expressed and involved in gastric mucosal integrity whereas COX-2 is induced during inflammation. So selective has less PUR disk

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19
Q

Name 6 non-selective NSAIDs

A 
Aspirin
Ibuprofen
Diclofenac
Naproxen
Indomethacin
Meloxicam
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20
Q

Out of naproxen, ibuprofen, and indomethacin, which non-selective NSAID is NOT preferred first line for pain?

A

Indomethacin (more side effects)

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21
Q

Why shouldn’t you give opioids to head injury pt?

A

Opioids may alter consciousness and pupillary responses, both of which are used to monitor head injury patients.

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22
Q

Consider ____ as an adjuvant drug in the management of postherpetic neuralgia

A

Gabapentin

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23
Q

Consider ___ as an adjuvant drug in the management of postherpetic neuralgia, diabetic neuropathy, spinal cord injury-induced neuropathy

A

Pregabalin (Lyrica)

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24
Q

Consider ____ for the management of trigeminal neuralgia

A

Carbamazepine

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25
Q

3 anticonvulsants that can be used for chronic neuropathic pain
Side effects?

A

Gabapentin, pregabalin, carbamazepine

Side effects: weight gain, CNS depression (decrease excitatory tramission)

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26
Q

3 muscle relaxants. What type of pain are they used for?

A

For pain associated w/ muscle spasticity

Cyclobenzaprine, methocarbamol, baclofen

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27
Q

Antidepressants for neuropathic/chronic pain + side effects

A

TCAs: amitriptyline, doxepin, clomipramine
- ADEs: weight gain, andicholinergic/drying
SNRIs: duloxetine, venlafaxine
- can cause GI upset

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28
Q

What types of drugs may need to be co-prescribed to control side effects of analgesics?

A

laxatives (opioids)
PPIs (NSAIDs) - somewhat controversial?
Anti-emetics

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29
Q

What is the only opioid that has shown efficacy for fibromyalgia?

A

Tramadol

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30
Q

Have opioids been shown to have efficacy for low back or neck pain?

A

Yes

31
Q

Name 3 neuropathies that opioids have been shown to have efficacy for

A

Postherpetic neuralgia
Diabetic neuropathy
Peripheral neuropathy

32
Q

Name 7 CNCP conditions for which there is currently not evidence that opioids are helpful

A 
Headaches/migraines (MOH risk!)
TMJ
Lyme disease
Whiplash
Non-cardiac chest pain
Pelvic pain
IBS
33
Q

The postop period for opioid use is usually no more than __ days

A

3 days

34
Q

Name 4 weak opioids

A

Codeine (metabolizes to morphine)
Tramadol
Tapentadol
Buprenorphine

35
Q

Name 5 strong opioids

A 
Morphine
Oxycodone
Hydromorphone
Fentanyl
Methadone
36
Q

1st and 2nd line opioids for mild to mod pain

A

1) Codeine/tramadol

2) Morphine, oxycodone, hydrophormone

37
Q

1st/2nd/3rd line for severe pain

A

1) Morphone, hydromorphone, oxycodone
2) Fentanyl
3) Methadone………….

38
Q

If pt is getting increased pain on opioid therapy it may be that they are developing

A

Tolerance OR opioid-induced hyperalgesia

39
Q

Treatment for opioid-induced hyperalgesia

A

Must taper of meds

Supplementation w/ NMDA receptor modulators possible (e.g. ketamine)

40
Q

Red flags for back pain

A 
Trauma
Unexplained weight loss
Neurologic Sx
Age >50
Fever
IV drug use
Steroid use
Hx of cancer
41
Q

When evaluating back pain for red flags, what are 4 main diagnoses of concern?

A

Cauda equina syndrome
Fracture(s)
Infection
Cancer

42
Q

First line meds for chronic low back pain

A

Acetaminophen/NSAIDs

43
Q

Imagine for nonspecific low back pain with no red flags should be delayed how long?

A

at least 1-2 months

44
Q

Worker’s compensation is managed by _____

A

WSIB (workplace safety & insurance board)

45
Q

Can a patient file a WSIB claim if they are at fault for the workplace injury?

A

Yes

46
Q

Time limit for WSIB claim after injury

A

usually 6 mo

47
Q

Health professional’s report in a WSIB claim is called…

A

Form 8

48
Q

Fill out a form 8 if your patient

A

Has filed a WSIB claim

Has presented with an injury/illness related to work

49
Q

SAFE assessment screen

A

SAFE questions [23]:
● Stress/Safety – Do you feel safe in your relationship?
● Afraid/Abused – Have you ever been in a relationship where you were threatened, hurt, or afraid?
● Friend/Family – Are your friends aware you have been hurt?
● Emergency Plan – Do you have a safe place to go and the resources you need in an emergency?

50
Q

Rank ibuprofen, naproxen, and diclofenac in order of increasing potency?

A

Ibuprofen –> naproxen –> diclofenac

51
Q

“Watchful dose” or opioids

A

90 mg morphine equivalents daily

52
Q

Are opioids useful for neuropathic pain?

A

Less so, later line

53
Q

Opioid use can affect the hypothalamic pituitary axis & sex hormones how?

A

Less GnRH/CRH and more prolactin
Less testosterone, estradiol, DHEAS
(hypogonadism may result!)

54
Q

Is watchful dose based on safety or efficacy?

A

Safety

55
Q

1st, 2nd, and 3rd line meds for neuropathic pain

A 
1st/2nd = antidepressants/anticonvulsants
3rd = Cannabinoids
56
Q

Define pseudoaddiction

A

Pt taking more because they’re pain is inadequately controlled, behaviour stops if pain adequately treated

57
Q

Prognosis of whiplash associated disorders (WAD)

A

Unknown & unpredictable

58
Q

Cluster breathing AKA ___ can occur in opioid overdose, high ICP, brain damage/stroke

A

Biot respirations (irregular breathing w/ intermittent apnea)

59
Q

Opioid overdose (if not mixed substances) causes what sign in eyes?

A

Bilateral miosis (pinpoint pupils)

60
Q

Opioid withdrawal eye symptom

A

Mydriasis (pupil dilation)

61
Q

Name 2 opioid antagonists and duration of action

Which is NOT used for acute overdose?

A

Naloxone (rapid onset, lasts 1-2 hrs)
Naltrexone (longer duration, 24-48 hrs)
Naltrexone not used acutely because oral admin and can induce prolonged withdrawal

62
Q

What opioid is a partial agonist with strong receptor affinity?

A

Buprenorphine

63
Q

In context of opioid addiction (not acute intoxication) administer ____ or ____

A

Buprenorphine/naloxone (orally the naloxone is not absorbed)

Methadone

64
Q

Main priority in an opioid OD? procedure?

A

Ventilation!
- Apneic patients (or very low respiratory rate/shallow) –> bag-valve mask ventilation attached to supplemental oxygen prior to and during naloxone administration (reduces chance of ARDS)

65
Q

If you overdo the naloxone during an opioid overdose and cause acute withdrawal, what do you do?

A

Don’t give more opioids! Naloxone is short-acting so will increase toxicity
Provide supportive care

66
Q

Conus medullaris syndrome & cauda equina syndrome refer to which spinal levels respectively?

A 
CMS = T12-L2
CES = L3-S5
67
Q

What are some issues with codeine and tramadol?

A

Codeine is metabolized to morphine, can have issues with dosing because diff people metabolize differently, do NOT give to breastfeeding woman

Tramadol is difficult to dose-compare to other opioids

68
Q

How do you dose opioids for breakthrough pain?

A 
EITHER
10% of 24 hr dose every 2 hours
OR
Half the dose, in half the time (half normal q4h dose every 2 hrs)
(opioids usually taken Q4H)
69
Q

How do you convert opioid to another opioid

A

If PO –> parenteral (IV/subQ) half the dose
reduce by 30% when switching due to incomplete cross-tolerance
specific ratios between the drugs (e.g. hydromorphone = 0.2 MED)

70
Q

Oral:Parenteral relative strength of opioids

A

1:2

71
Q

Co-analgesics for MSK pain

A

Muscle relaxants, benzodiazepines

72
Q

Co-analgesics for bone pain (in cancer)

A

NSAIDS, steroids, bisphosphonates. Consider radiation therapy

73
Q

NEVER START A ____ ON A _______

A

NEVER START A FENTANYL PATCH ON AN OPIOID NAIVE PATIENT

Preclerkship (25 decks)

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