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PM Review > Pain > Flashcards

Pain Flashcards

1
Q

Define pain

A

Unpleasant sensory or emotional experience associated with actual or potential tissue damage, and described in terms of such damage

(Intl. association for study of pain)

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2
Q

What is dysesthesia

A

decrease or exaggeration of spontaneous or provoked sensitivity

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3
Q

Compare allodynia and hyperalgesia

A

Allodynia - pain caused by usually non-painful stimuli
Hyperalgesia - heightened pain response to normally painful stimuli

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4
Q

What is hyperpathia

A

painful syndrome characterized by abnormal pain reaction to a stimulus, especially repeated stimulus

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5
Q

What are the nociceptive nerve fibres that carry information about pain?

A

A-delta fibres - thinly myelinated
C-fibres - unmyelinated

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6
Q

Describe key characteristics of the A-delta fibres

A
  • Poorly myelinated
  • Transmit “quick” pain signals
  • Acute, highly localized pain
  • Carry signals to the dorsal horn
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7
Q

Describe the key features of the C fibres

A
  • Unmyelinated
  • Slow impulse conduction
  • “polymodal” pain signals (mechanical, thermal, and chemical)
  • “secondary pain” (radiating, shooting, burning, piercing following the acute pain signal)
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8
Q

Which 2 neurotransmitters carry pain signals between peripheral and central nociceptive fibres?
What are their corresponding receptors?

A

1) substance P (neurokinin receptor)
2) glutamate (AMPA - alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic-acid receptor)

(Activation of NMDA occurs much later, induced by “floods” of glutamate)

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9
Q

3 enzymes for methadone metabolism

A

cyp 3a4, 2d6, 2b6, 1a2

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10
Q

3 inhibitors of cyp 3a4

A

antibiotics (cipro, erythro, metronidazole)
antifungal (fluconazole, ketoconazole)
CCB (dilt, verapamil)
benzo (alprazolam, diazepam)

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11
Q

cyp3a4 inducers

A

antiepileptic - phenytoin, phenobarb, carbamaz
antibiotic - rifampin
steroid - dex high dose over 16mg /d
tca - ami/nortryp

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12
Q

list opioids in phenanthrene class

A

morphine, oxy, hydro, codeine

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13
Q

list opioid in phenylpiperidine class

A

fent, sufent, meperidine

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14
Q

what class of opioid (structurally) is methadone?

A

diphenylheptane

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15
Q

2 types of opioid allergy (immune mediated reactions)

A
  • allergic dermatitis (type IV)
  • anaphylaxis / anaphylactoid
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16
Q

define chronic pain

A

pain that persists beyond usual course of healing
OR
associated with a chronic pathological illness that causes continuous or recurrent pain over months/years

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17
Q

2 neuropathic pain screening tools

A

leeds assessment
neuropathic pain questionnaire

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18
Q

most common cause of pain in cancer

A

bone mets

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19
Q

ion channel involved in peripheral sensitization

A

sodium

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20
Q

ion channel involved in central sensitization

A

calcium

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21
Q

receptor responsible for wind up
what blocks the receptor under normal activity?

A

NMDA
magnesium ion

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22
Q

3 key mechanisms of bone pain

A
  • osteoclast activation and acidity increases nociceptor activity
  • inflammatory factors (cytokines, IL’s, chemokines etc.)
  • structural damage
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23
Q

most common neuropathic pain syndrome in HIV patients (from disease not NRTI’s)

A

distal polyneuropathy

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24
Q

gabapentin / pregabalin target

A

alpha-2-delta subunit voltage gated ca-channels

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25
Q

2 ion channels that upregulate after a nerve injury

A

Na
Ca

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26
Q

proposed mechanism for opioid headache

A

histamine

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27
Q

describe spinal opioid hyperalgesia syndrome

A

intrathecal / epidural opioid (HIGH DOSE) complicated by:
- segmental myoclonus
- hyperalgesia
- piloerection
- priapism
- pain (perineal/leg/butt)

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28
Q

cause of spinal injection pain

A

compression of adjacent nerve root

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29
Q

what are 4 IV chemo infusion pain syndromes?

A

1) venous spasm
2) chemical phlebitis
3) vesicant extravasation
4) anthracycline related flare - flare with urticaria

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30
Q

most common agents causing chemo mucositis

A
  • 5FU and capecitabine
  • doxorubicin
  • cytarabine
  • etoposide
  • methotrexate
  • everolimus (mTOR inhib)
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31
Q

most common agents causing chemo induced peripheral neuropathy

A
  • vinka alkaloids (vincristine/vinblastine/vinorelbine)
  • platinums (cisplatin/oxaliplatin)
  • taxanes (paclitaxel)
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32
Q

1 unique pain syndrome with fluorouracils

A

anginal chest pain (coronary vasospasm)

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33
Q

unique pain syndrome with vinka alkaloids

A

neuropathic acute pain (trigeminal and glossopharyngeal nerves common)

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34
Q

agents associated with hand foot syndrome
treatment

A

5fu, doxorubicin, paclitaxel
some TKI’s (nibs)
MTX
everolimus (mTOR)

pyridoxine treatment

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35
Q

common s/e of g-csf

A

bone pain and constitutional symptoms

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36
Q

most common symptoms of acute RT brachial plexopathy

A

paresthesia

pain and weakness less common

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37
Q

most common manifestation / location of RT related subacute myelopathy

A

L’hermittes sign (cervical cord)

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38
Q

what is the incidence of RT induced bony pain flare
what is the timeline

A

30-40%

timeline 1-2d, resolves by 3-5days

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39
Q

how does acute herpetic neuralgia manifest in patients with malignancy

A

more common in areas associated with tumor, and areas previously irradiated

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40
Q

cancers with highest thrombosis risk

A

bone
brain
pancreas
ovary

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41
Q

what is phegmasia cerulea dolens

A

tissue ischemia +/- gangrene in context of DVT, without arterial occlusion

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42
Q

cancers most likely to metastasize to bone

A

lung
prostate
breast
myeloma

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43
Q

most common site of bone mets

A

vertebra (most commonly thoracic)

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44
Q

list 3 ddx other than bone mets for bony pain in cancer

A
  • OP fracture
  • focal osteonecrosis
  • ## paraneoplastic osteomalacia
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45
Q

describe malignant piriformis syndrome

A

buttock / leg pain exacerbated by internal rotation of hip

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46
Q

describe hypertrophic pulmonary osteoarthropathy
- associated with which ca.
- features
- management

A

NSCLC

clubbing, periostitis of long bones, rheumatoid like polyarthritis
pain, tenderness, swelling in knees, ankles, wrists

cancer therapy
bisphosphonates

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47
Q

which cancers are most likely to cause leptomeningeal disease

A

hematologic - non-hodgkins, ALL
solid tumor - breast, SCLC

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48
Q

2 key diagnostic tests for leptomeningeal ca., and their pros/cons

A

MRI (gad enhanced) - sensitive, not as specific

CSF cytology - more specific, sensitive only with numerous samples (55% after one, 90% after three)

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49
Q

describe the pain patterns of cervical plexopathy (direct and referred)
what are 2 associated features?
which nerve roots are involved?

A

direct pain - periauricular, anterior neck
referred - face and shoulder

associated - horner’s and hemidiaphragmatic paralysis

roots - C1-4

50
Q

differentiate early vs. late RT brachial plexopathy

A

1) early onset - transient,

2) delayed onset - progressive (6mo.-20yrs)

weakness and sensory changes dominate

51
Q

describe paraneoplastic painful sensory neuropathy
features
cause

A

injury to dorsal root ganglion or peripheral nerve
pain (paresthesia), sensory loss, severe sensory ataxia

SCLC associated

52
Q

sensorimotor peripheral neuropathy
most common ca. association

A

hodgkin’s disease and paraproteinemia (5-15% MM patients)

53
Q

2 causes of aseptic avascular necrosis of femoral head in cancer patients

A

prolonged steroids
high dose chemo with BMT

54
Q

diagnosis of avascular necrosis
- presentation
- diagnostic imaging

A
  • pain precedes radiological change by weeks to months
  • bone scan and MRI are both sensitive (MRI superior)
55
Q

common pain s/e of aromatase inhibitors

A

MSK pain and stiffness (arthralgias, bone pain, joint stiffness)

56
Q

list symptom 3 s/e of IV bisphosphonates

A
  • flu like (fevers, arthralgias, myalgias)
  • osteonecrosis of the jaw
  • chronic diffuse pain (unknown etiology, FDA warning 2008)
57
Q

list risk factors for phantom limb pain after surgery

A
  • tumor-related surgery > trauma-related surgery
  • prolonged pain pre-amputation
  • post-operative chemotherapy
58
Q

describe the pathophysiology of stump pain

A

neuroma development at site of nerve transection

59
Q

differentiate the presentation of chronic RT myelopathy from plexopathy

A

myelopathy - sensory symptoms predate motor and autonomic, burning dysesthesia’s typically, brown-sequard pattern

plexopathy - pain is rare and weakness / sensory manifestation predominates

60
Q

what is the difference b/w efficacy and effectiveness

A

efficacy - performance of an intervention under controlled circumstances (clinical trials with strict control standards, exclusionary criteria etc.)

effectiveness - performance of an intervention on population level (real-world circumstances)

61
Q

factors that influence pharmacokinetics

A

age
organ function (hepatic and renal)
body mass (obesity increases Vd)
hypotension
hypovolemia
hypo/hyperthermia

62
Q

4 aspects of pharmacokinetics

A

Absorption
Distribution
Metabolism
Excretion

63
Q

What is bioavailability

A

amount of drug that gains unchanged access to systemic circulation

64
Q

how is bioavailability impacted in liver disease

A

blood shunting away from liver increases effect of oral medication (in relation to parenteral)

65
Q

2 phases of metabolism in the liver and the processes:

A

Phase 1 - oxidation, reduction, hydrolysis (CYP450 enzymes)
Phase 2 - conjugation, glucuronidation

66
Q

define potency

A

dose-response relationship
intensity of a specified effect at a specified dose

67
Q

5 poor prognostic factors for pain

A

delirium
neuropathic
severe incidental pain
somatization / total pain
chemical coping / substance abuse history

68
Q

why are opioids considered first line for cancer neuropathic pain management

A

non cancer neuropathic pain - >60% response to non-opioid

cancer neuropathic pain - <30% response to non-opioid (>60% response to opioid)

69
Q

outline the cellular mechanism of opioids

A
  • binds to g protein coupled receptors and inhibits adenyl cyclase (decreases cAMP)
  • inhibits voltage gated Ca channels
  • causes K efflux (hyperpolarization)
  • decreases neurotransmitter release (substance p, neurokinin a + b, glutamate)
70
Q

what is the receptor effect of buprenorphine

A

mu partial agonist
kappa and delta antagonist

71
Q

what is the receptor action of nalbuphine

A

mu agonist (moderate affinity)
kappa agonist (strong affinity)
no affinity for delta

72
Q

which opioids undergo phase 1 metabolism

A

codeine
oxycodone
fentanyl
methadone

73
Q

which opioids undergo phase 2 metabolism

A

morphine
hydromorphone

oxymorphonne

74
Q

morphine metabolites and actions

A

m3g - neuroexcitatory (not a mu agonist)
m6g - analgesic (mu activity)

75
Q

oxycodone metabolites

A

oxymorphone - active, analgesic with 6h half life
noroxycodone - weak, inactive

76
Q

codeine metabolites

A

phase 1 -> morphine, norcodeine
phase 2 -> codeine6g

77
Q

HM metabolites

A

HM3G - neuroexcitatory

78
Q

3 adverse effects of tramadol

A

serotonin syndrome
hypoglycemia
seizures

79
Q

which CYP enzymes play a role in methadone metabolism

A

cyp2d6
cyp2b6
cyp3a4
cyp1a2

80
Q

methadone mechanisms of action

A

mu agonist
nmda antagonist

weak snri effect

weak a2 agonist?

81
Q

methadone has biphasic distribution and elimination
outline the 2 phases and the clinical relevance

A

alpha phase - distribution and early elim.
- lasts 6-8h
- correlates with analgesic period

beta phase - elimination
- 15-60h
- prevents withdrawal for this period
- can accumulate and produce toxicity

82
Q

how to opioids cause constipation

A
  • decr gastric motility
  • decr intestinal propulsion
  • reduced pancreatic, biliary, intestinal secretions
  • incr. anal sphincter tone
  • incr. amplitude of non-propulsive segmental contractions
83
Q

stellate ganglion block
- nerves blocked
- indications
- adverse effects

A
  • nerves blocked - sympathetic nerves to arm or face
  • indications - CRPS, sympathetic maintained pain, shingles of head / face (most commonly)
  • adverse effects - horner’s syndrome, hoarseness (rec. laryngeal), hemidiaphragm paralysis (phrenic)
84
Q

gasserian ganglion block
- clinical significance
- indications

A
  • ganglion from which 3 branches of trigeminal originate
  • for secondary trigeminal neuralgia
85
Q

list 3 other nerve blocks of head and neck

A
  • occipital - headaches
  • glossopharyngeal - tongue and posterior pharynx
  • sphenopalatine ganglion - headaches?
86
Q

celiac plexus block
- innervation
- location (anatomical)
- indications
- complications

A
  • innervation - sympathetic outflow, and sensory innervation from:
  • stomach, liver, spleen, pancreas, intestine (to splenic flexure of colon), kidney
  • location (anatomical)
  • retroperitoneal, T12-L2 level anterior to aorta
  • indications
  • pain from abdominal malignancy (most commonly pancreatic)
  • complications
  • diarrhea
  • orthostatic hypotension
  • bleeding
  • organ injury
  • spinal cord injury (artery of adamkiewics)
87
Q

superior hypogastric plexus block
- innervation
- location (anatomical)
- indications

A
  • innervation
  • sensory - pelvic viscera (bladder, prostate, vagina, uterus, rectum)
  • sympathetic outflow (descending colon down)
  • location (anatomical)
  • anterior to L5-S1 - technically challenging
  • indications
  • lower abdominal and pelvic pain
88
Q

Ganglion impar block indications

A
  • perineal and rectal pain
  • distal 1/3 of vagina, vulvodynia
  • proctalgia fugax
  • prostatitis
  • distal urethra and scrotum
  • proctitis
  • coccygodynia
89
Q

difference between kyphoplasty and vertebroplasty

A

kyphoplasty - balloon expansion, cement injection
vertebroplasty -

90
Q

which patients are more likely to respond to kypho

A
  • recent fracture (<2mo)
  • single/few levels
  • pain correlates with edematous / fractured area on MR
  • no sclerosis
91
Q

baclofen mechanism

A

gaba-b agonist

92
Q

match the antiepileptic to the mechanism of action
- block na channel
- promote inhibitory GABA transmission
- block ca channels
- inhibit excitatory glutamate

A

carbamazepine, phenytoin
VPA, topiramate
gaba/pregabalin
lamotrigine

93
Q

main benefit of pregabalin over gabapentin

A

quicker time to onset and effect
more rapid ability to titrate

94
Q

max dose of gabapentin
AND
dose above which effect is questionable

A

max: 3600mg/d
questionable benefit beyond 2700mg/d

95
Q

benefit of oxcarbazepine over carbamazepine

A
  • no CYP induction
  • less toxicity (no aplastic anemia)
96
Q

5 categories of risk factors for opioid misuse

A

health related - complex pain (intense, frequent, generalized)
psychosocial - emotional distress, trauma, limited supports
drug-related - previous or current substance use d/o, cravings
genetic - family history of drug abuse
demographic - male, caucasian

97
Q

selective COX2 inhibitors protect against which 2 s/e of non-selective COX inhibitors?

A
  • GI ulceration
  • Bleeding risk (platelet aggregation)
98
Q

list all s/e of NSAIDs

A
  • PUD and GIB
  • Hypertension
  • Edema
  • Renal failure
  • Bleed risk
99
Q

what negates the relative GI protection benefit of celecoxib vs. other NSAIDs?

A

concomitant ASA use

100
Q

Which NSAID has the lowest CV risk?

A

Naproxen

101
Q

What is unique about ASA?

A

Irreversible COX 1 and 2 blockade
Will inhibit COX enzyme for entire life of platelet

102
Q

mechanism of:
- bisphosphonate
- denosumab

A
  • osteoclast inhib.
  • RANKL inhib.
103
Q

3 evidence based strategies for behavioural pain management

A
  • pain coping skills training (CBT type interventions)
  • mindfulness based stress reduction (MBSR)
  • acceptance and commitment therapy (ACT)

other:
- hypnosis
- meaning centred psychotherapy

104
Q

Evidence for bisphosphonate and denosumab is strongest for bone pain mgmt. and prevention of SRE’s in which cancers?

A
  • prostate (castrate resistant, not castrate sensitive)
  • breast
  • multiple myeloma

other solid tumors:
- use case by case (not a first line intervention)

105
Q

4 topical agents that can be used for acute and chronic wound pain

A
  • opioids - morphine and methadone
  • ketamine
  • lidocaine and prilocaine
  • TCA - amitriptyline
106
Q

which patients might need to be considered for naloxone kit in the home

A
  • MEDD > 100mg/d
  • Methadone
  • Benzodiazepines in combination with opioids
  • History of overdose
  • History of substance use disorder
  • Chronic renal, hepatic, or pulmonary disease
107
Q

greatest concern about prescribing naloxone to patient with terminal illness

A

caregivers may administer when actively dying

108
Q

list opioids in order of protein binding
least to most

A

hydromorphone (8%)
morphine (20%)
oxycodone (45%)
methadone (70-80%)
fentanyl (85%)

109
Q

2 types of cannabinoid receptors and their locations / effects

A

CB1 - CNS - pain, nausea, appetite, memory
CB2 - immune system

110
Q

effects of THC and location of action

A

Psychoactive
CNS (CB1 receptor)

111
Q

effects of CBD

A

modulate psychoactive effect of THC
other therapeutic effects (anti-inflammatory)

112
Q

What is nabilone approved for?

A

CINV (adjunct)

113
Q

what is nabiximols?
what is it approved for?

A

1:1 THC:CBD formulation (?naturally derived)
spasticity - MS
cancer pain

very expensive

114
Q

optimal route for plant based cannabis?

A

buccal / sublingual
- predictable absorption / onset
- no smoking risks

115
Q

Greatest evidence for cannabis use in which 4 illnesses

A

chronic pain
spasticity in MS
seizures (dravet and lennox-gastaut)
CINV

116
Q

Which illnesses have moderate evidence for cannabis use

A

glaucoma
sleep disturbances

117
Q

key s/e of cannabis

A

dizziness
fatigue
increased appetite
dry mouth
psychoactive
cyclic vomiting
cognitive impairments

118
Q

main CBD related concern for those who are on immune therapy

A

immune suppression with high doses

119
Q

what is phenazopyridine used for?
how does it work?

A

dysuria and bladder spasms (irritative component)

local anaesthetic and analgesic effect on bladder

120
Q

3 receptors mediating opioid induced pruritis

A

mu-opioid
histamine
5ht3

PM Review (19 decks)

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