Pain Flashcards
2 Subtypes of Nociceptive Pain ?
Somatic and visceral
Somatic pain involves what? (4)
-Pain is usually ___
-Described as __,__ or __
-Pain is usually ___
-Increases with ___
Patient can point to ___
Skin, bone, joint, soft tissue
-well localized
-sharp, aching, throbbing
constant
movement
site of pain
Visceral Pain
-Arises ___ damage of the __ or ___
-Described as ___ (3)
-Poorly ___ , hard to ___, “deep or __”, “____ or coming in waves”
afferent nerves, soft tissue, viscera (heart, lung, GI or GU tract)
-stretching, cramping, distention
localized, describe, aching, colicky
Neuropathic pain can be both __ or __
-Described as ? (5)
peripheral, central
burning, shooting, pricking, paresthesias or dyesthesias
Acute Pain
-Time period?
-Sx’s?
-Temporary ___?
-May require __ then ___ or just ___ for a short time
<1-3 months
pain, bruising, swelling
loss of function
scheduled therapy, prn therapy, prn therapy
Chronic Pain
-Time period
-Sx/s?
-___ impairement
-___ pain
-___ of sx’s
-Requires __ and ___
> 1-3 months to life long
just pain
functional
neuropathic
progression
scheduled ,prn therapy
Opioids : Tx of ___ to ___ pain that doesnt respond to ___
Role in Therapy?
(4)
moderate, severe, non opioids alone.
acute (trauma or postop), cancer , chronic non cancer, Visceral and somatic pain > neuro pain
Phenanthrenes ? (5)
Phenylpiperidines? (1)
Diphenylhepatnes? (1)
Atypical opioids? (1)
Morphine, hydromorphone, hydrocodone, oxycodone, buprenorphine
fentanyl
methadone
tramadol
Common AE of Opioids : Constipation
Gets better over time?
Tx?
Schedule meds ___ not __
Can u use osmotic agents?
Docusate?
Fiber?
No
Stim laxatives like Senna
around the clock, prn
yes can be added on
not helpful
can make it worse
Common AE of Opioids : Nausea
MOA?
__ over time
TX? (5)
- Dopamine agonist
- Subsides
- Prochlorperazine
-Metoclopramide (D2 antag and prokinetic which helps with constip)
-Promethazine (D2 antag and antichol)
-Haloperidol ??
-Olanzapine ??
What secret side effects does zofran have?
- HA and constipation
Sedation : COMMON AE
-__ over time
TX?
Pruritis UNCOMMON
-Gets better over time?
-TX?
Subsides
-Education to pt and caregiver to watch out for extreme sleepiness
NO
CHange to diff opioid also called opioid rotation
-non sedating antihistamine
Uncommon AE : Respir Depression
Defined as ?
TX?
Respiratory rate of < 8 breaths per min
-oxygen saturation of <90%
-decrease of more than 5% from baseline in pt’s with baseline oxygen saturation of <90%
-NALOXONE
For acute pain , use __ pain meds usually given as __
What drug?
short acting, prn
oxycodone 5mg PO q4 hrs prn pain
Chronic Pain , use ___ and ___
What drugs?
LA scheduled meds , Short acting prn meds
Oxycodone 20 mg CR PO q12hrs
Oxy 5 mg IR PO q 4 hrs prn
If patient has true morphine allergy what do u use?
methadone, fentanyl, tramadol
Renal Impaired/Hemodialysis
CI? (2)
Caution with?
Better choices? (3)
Start with low doses, immed release formulations, and prn dosing
Best choice for LA meds ? (2)
Codeine and Meperidine
morphine
oxycodone, hydromorph, fentanyl IV only
Methadone + fent patch for chronic pain
Hepatic Dysfunction
CI? (2)
Caution ? (2)
Better choices? (3)
-Start with low dose, IR forms, and prn dosing
Best choice for LA?
Codeine + Meperidine
Morphine + methadone
Oxy, hydromorph, fentanyl IV
Fent PATCH
Chronic Pain Dosing Regimen :
2 options
-Short acting med should be ___ of total daily dose of LA med
LA Med + IR
Titrate up to the next dose after?
For breathrough or intermittent acute pain, dose IR opioid once____
Med reaches steady state concentrations
every time to Cmax as needed
Steps to Opioid Conversion For LA and SA opioids
1. Calculate ?
2. For LA, how do u dose based on pt pain scale?
- Whats dosing frequency?
- What about short acting?
- total amount of opioid in 24 hrs
- Severe pain (7-10) Include 90-100% of calculated dose in LA
Mod pain (4-6) include 75% of calc dose in LA
Mild pain score of 1-3 : Include 50% of the calculated dose in LA
- Scheduled around the clock!
-Divide LA dose/day by 2 and dose q12 - 10% of Long acting dose/day (Dosed as PRN q2-4 hrs)
FDA definition of Opioid Tolerant?
On at least 60 mg/day of morphine or equiv opioid for at least 7 days
Tramadol pros and cons ?
Pro : nociceptive and neuro pain.
Cons : Schedule 4, risk of seizures and serotonin syndrome . Hypoglycemia, need to adjust dose for renal and hepatic impairment
Tapentadol pros and cons?
Pros : Nocicpetive and neuro pain . NO risk of seizures and serotonin syndrome.
Cons : Only used in opioid toelrant pt’s
Schedule 2
Need to adj for renal ad hepatic impairment
Name 4 1st line agents for neuropathic pain
- TCAs
2.Gabapentin or pregabalin - SNRI’s
- Lidocaine patch (Lidoderm)
Tertiary Amines Name 4
Secondary Amines name 2
Effective to treat neuro pain at __ doses and ___ at higher doses
Amitriptyline, imipramine, doxepin, clomipramine
Nortriptyline, desipramine
lower, depression
TCA’s and their AE’s
Sedation , dry mouth, blurred vision, weight gain , urinary retention
DDI’s with MAOis, SSRI’s , anticholinergic agents , agents that prolong QTc
START TCA dose low for pain . Whats the dose?
10-25 mg QHS .
Gabapentin and Pregabalin AE’s ?
-Requires?
well tolerated!
Dose dependent dizziness, ataxia, sedation and diplopia
Weight gain and periph edema
-renal dose adjustment !
Gabapentin : Titrate dose to pain relief!
-Start with?
-if partial relief achieved at 1800 mg/day, titrate up to?
100-300 mg QHS
Titrate dose every 2-3 days
3600 mg/day
Pregabalin begin dosing at?
Increase to ? within a week
-requires?
150 mg per day
-300 mg/day
renal dosing
