Pain Flashcards
Somatic Pain
- Skin, bone, joint, soft tissue
- Well localized
- Sharp, aching or throbbing
- Constant
- Increases with movement
- Can point to the site of pain
Visceral Pain
- Afferent nerves damage of the soft tissue or viscera (heart, lung, GI tract, GU tract)
- Stretching, cramping, distention
- Poorly localized
- “hard to describe”
- “Deep, aching”
- “colicky” or coming in waves
Neuropathic Pain
Burning, shooting, pricking, paresthesias, dysesthesias
Acute Pain
- < 1-3 month
- Pain, bruising, swelling
- Temporary loss of function
- May require scheduled therapy then prn therapy or just prn therapy for a short term
Chronic Pain
- > 1-3 month to life-long
- Functional impairment
- Neuropathic pain
- Progression of sxs
-Requires scheduled AND prn therapy
PQRSTU
-Palliation
-Quality
-Region
-Severity
-Temporal
-How does it affect U
Opioid Adverse Effects: Common
-Constipation: use Senna/bisacodyl (miralax if hard stools)
-Nausea: use dop. anta. (prochlor/meto/prometh)
-Sedation
Opioid Adverse Effects: Uncommon
-Pruritus: change opioid, non-sed antihistamine
-Resp. Dep.: <8 breaths/min, ox <90
*start at low doses, titrate, monitor
*TX: Naloxone
IF true morphine allergy, rare:
Methadone, fentanyl, tramadol
Renal impairment/hemodialysis
- Contraindicated: codeine, meperidine
- Caution: morphine
- Better choices are oxycodone, hydromorphone, fentanyl (IVonly)
-Chronic pain: best are methadone, fentanyl patch
Hepatic dysfunction
- Contraindicated: codeine, meperidine
- Caution: Morphine, methadone (used by hepatology)
- Better choices are oxycodone, hydromorphone, fentanyl (IVonly)
-Chronic pain: best is fentanyl patch
Short-acting pain medication dose should be ___of the total daily dose of the long-acting medication.
10%
EX
* Long acting regimen is morphine 60 mg SR PO q12h
* Shorting acting dose should be morphine 15 mg IR q2h prn pain
Css is good to know WHEN to titrate up to the next dose
- Mean half-life of extended-release hydromorphone tablets (Exalgo) is 11 hours
- Steady state is 5 half-lives (3.3 half-lives)
- 11x 5= 55 hours ~2.5 days
Opioid tolerant
on at least 60 mg/day of morphine (or equivalent opioid) for at least 7 days
Tramadol, ultram VS Tapentadol, nucynta
Both for nocicpetive/neuro pain
Tramadol: C4, seizures/serotonin syn, hypoglycemia, renal/hepa dose adj
Tapentadol: only in opioid tolerant pts, C2, renal/hepa dose adj
Fentanyl Transdermal
-DOC in renal/hepatic dysf
-good for NPO
-Only for opioid tolerant pts
-long half life
Methadone
-GOOD for ESRF
-BAD for ESLF, cardiac arr
PCA Dosing
Opioid naive:
*Start with bolus doses
-Morphine 2, HM 0.2, Fen 20 mcg
-Lockout 10 min
Constant pain:
-If >20 bolus in 24hr OR >2 attempts times doses given = start basal
-Basal dose can be 2/3 of total opioid use in 24 hr (total opioid divided by 24 hr times 0.66)
Bolus dose can be one of 3 options based on clinical picture
- Half the basal dose (pain score of 1-3)
- The same as the basal dose (pain score of 4-6)
- OR double the basal dose (pain score of >7)
Neuro Pain: 1st Line
- Tricyclic Antidepressants (TCAs)
*amitriptyline, desipramine - Gabapentin/Pregabalin
- Serotonin norepinephrine reuptake inhibitors (SNRIs)
*duloxetine, venlafaxine - Lidocaine patch (Lidoderm)
TCAs
* Amitriptyline,imipramine
* Doxepin,clomipramine
* Nortriptyline,desipramine
AE: sedation, dry mouth, blurry vision, weight gain, urinary retention
DI: MAOI, SSRI, AC agents, antiarrhythmics, prolong QTc
Start at 10-25 mg, max is 150
Gabapentin, pregabalin
AE: dizzy, ataxia, sedation, diplopia, weight gain, edema (WE SADD)
DI: potential sedation if with opioids/alc/benzo
Lower dose in elderly, RENAL DOSE ADJ
-Gaba: start 100-300, max 3600 (not sched, cheaper), give in AM, titrate up 300 every 2-3 days, have to titrate down (seizure/withdrawal)
-Prega: start 150, incr to 300 within 1 wk, max 450-600
4% or 5% Lidocaine Patch (Lidoderm)
Well localized pain
-12 hour on, 12 hour off
-Up to 3 patches for simultaneous use
-Cut/shaped
-No burned/broken/inflamed skin
-Caution in hepatic disease
Fentanyl strengths
25, 50, 74, 100 mcg/hr
Hydromorphone strengths
2, 4, 8 mg ORAL IR
Methadone strengths
5, 10 mg
Morphine strengths
Oral: 15, 30, 60
Solution: 10mg/5ml, 20mg/5m
IR: 15, 30
Hydrocodone strengths
5/325, 7.5/325, 10/325
Oxycodone strengths
IR: 5, 10, 15
Solution: 20mg/ml, 5mg/5ml
Oral ER: 10, 15, 20, 30
Tramadol strengths
50 mg
STEPS FOR OPIOID CONV FOR LA AND SA
- Calc total amount of op in 24 hr
- LA dose per day:
-Pain 7-10: 90-100% if calc total
-Pain 4-6: 75% if calc total
-Pain 1-3: 50% of calc total
*LA dose is TWICE a day (divide into 2, q12h) - SA dose per day: 10% of LA dose
-PRN only, q2-4 hr
-If rounding up, use 4. Rounding down, use 2.
STEPS FOR PCA CONV/DOSING
- Basal
-After 24 hr (SS), if > 20 boluses or attempts >2 times doses given: add basal
-Basal dose is 2/3 (66%) of total opioid use in 24 hr = (total op / 24 hr * 0.66) - Bolus
-Pain 7-10: double basal
-Pain 4-6: same as basal
-Pain 1-3: half basal
STEPS FOR FENTANYL CONV
- Check if pt is opioid tolerant first
-60 mg morphine (equiv) - Evaluate pain score
-Same as LA/SA conversions
-High (100%), Mod (75%), Mild (50%) - Once converted…
-Morphine to fentanyl ratio is TWO TO ONE
-Morphine 50 ~ Fentanyl 25
SNRI, duloxetine, venlafaxine
Sexual dysfunction
BBW for suicidal thoughts
Good for pts who don’t want sedation/sleepy side effect
Take in AM - keeps you up
