Pain Flashcards
1
Q
Which gender experiences more chronic pain?
A
females especially >65 years old
2
Q
What ethnicity has the highest rate of chronic pain in Canada?
A
FN
3
Q
What time frame is acute pain?
A
<3 months
4
Q
What is nociceptive pain?
A
sharp aching or throbbing pain,
5
Q
What is somatic pain?
A
Skin bone joint
6
Q
What is visceral pain?
A
internal organ- more dull cramping pain
7
Q
What is neuroplastic pain?
A
damage to nervous system, burning or shooting pain
8
Q
What is nociplastic pain?
A
sensitization of pain to nervous, chronic
9
Q
What are the steps of nociceptive pain?
A
Transduction-stimulus found
conduction-action potential
transmission- up spine
perception-becomes conscious
modulation- if needing to heighten pain
10
Q
What is difference between noxious and innocuous?
A
noxious= harmful
11
Q
What nerve fiber is fast conduction? What is slow?
A
Fast- A gamma
Slow- C fiber
12
Q
What type of pain is felt by each fiber?
A
A- sharp localized
C- achy
13
Q
What neurotransmitters are released when in spine?
A
glutamate and substance P
14
Q
What neurotransmitters are needed to inhibit pain?
A
endorphins, GABA, NorE, Serotonin
15
Q
What tool can we use to assess pain?
A
Wong baker faces
PQRSTU
16
Q
What are red flags for back pain?
A
bladder dysfunction, lax anal sphincter, motor weakness in lower body
17
Q
What is some nonpharm for pain?
A
cold if less than 48 hours
heat after 48 hours
move!!!
18
Q
How does acetaminophen work?
A
stop prostaglandins and stop pain impulse generation
19
Q
What is dosing for acet?
A
1000mg q4-6 max of 4 grams
20
Q
How does NSAIDs work?
A
stop COx1+2
21
Q
When is NSAIDs contraindicated?
A
under 40 ml/min, HF, MI
22
Q
Which COX is good for heart and which is good for stomach?
A
Heart-CoX 2
GI- Cox 1
23
Q
Which options are more cox 2 selective? Which are COX 1?
A
2- Diclofenac, ketorolac
1-Ketoprofen and aspirin
24
Q
What is dose for ASA?
A
max 4 grams a day
25
What is ibuprofen dose?
max 2400 mg a day
26
What is most neutral NSAID?
naproxen
27
When will you have Gi risk for NSAIDs?
2 risk factors= high risk
greater than 60, history of bleed, on anticoag
28
What can we do if risk of gi from NSAIDs?
misoprostol or PPI
29
What factors make you at risk of renal issues with NSAIDs?
greater than 70
renal disease,
HF
diuretics
30
What is pros of Celecoxib?
selective for COX 2= less gi risk and minimal platelet interactions
31
What are issues with Celecoxib?
CYP 2C9 and renal issues
32
What is dosing for celecoxib?
400 mg on first day then 200 the next 5 days
33
IN regards to pregnancy, what is process for NSAIDs?
dont recommend
ASA low dose maybe
Issues with ductus arteriosus
34
How long can you use muscle relaxants for?
1-2 weeks
35
S/e of relaxants
drowsy, falls,
36
What are the muscle relaxants?
methocarbamol
baclofen
cyclobenzaprine
37
What do muscle relaxants actually do?
sedation then maybe relax?
38
True or false Acet has anti inflam?
False
39
When should you refer after using NSAIDS or acet?
exceeding 10 days in adult
40
Why does cyclobenzaprine so anticholinergic?
similar structure to TCA
41
What is chronic secondary pain?
pain originates as a symptoms from a different condition
42
What is chronic primary pain?
persist longer than 3 months, not caused by another condition
43
What is a tuning fork used for in pain?
for neuropathic pain
44
What is. first line for pain?
non-pharm
45
What is first line DRUG for low back pain?
NSAIDs
46
What are some back up meds for low back pain?
Duloxetine= FOR CHRONIC
TCA= not alot of evidence
47
How good is placebo generally in pain studies?
40% improvement
48
How often should NSAID trial be reassessed?
every 6-12 months
49
For neuropathic pain what is our go to drugs?
Duloxetine
Pregab
Gabapentin
50
WHat is the recommended dosing for duloxetine for Low back pain?
60 mg/day
51
What is the recommended dosing for duloxetine for neuropathic pain?
40-120mg/day
52
What is recommended dosing of pregabalin for neuropathic pain?
usually 300 mg/day
divided BID-TID
53
What is recommended dosing of gabapentin for neuropathic pain?
1800mg/day divided TID-QID
54
What are back up drugs for neuropathic pain?
TCA
55
What is the drug given for trigeminal neuralgia?
CBZ-200 QID
56
What is dosing for TCA for neuropathic pain?
Amitriptyline= 25-100mg/day
Nortriptyline= 25-100 mg/day
57
What is stepwise approach for neuropathic pain?
Gabapentins, SNRI,
TCA
Tramadol/Opiods
Cannabinoids
58
What is the main issue with cannabinoids for neuropathic pain?
HIGH NNH
59
What is a non RX measure for neuropathic pain?
capsaicin
60
Why do studies have issues coming up with quality evidence in pain studies?
pain is subjective= bias, confounding
some outcomes arent clinically significant
short trials so we dont know longterm benefit
61
Why arent other anticonvulsants (topiramate and oxcarbazepine) used more for neuropathic pain?
More D/C from side effects
62
Main S/e of gabapentinoids?
Sleepy, dizzy
63
Which gabapentinoid may have better tolerability?
Pregabalin
64
Why is CMZ such a shitty drug?
Lots of cyp interactions- 2C9, 3A4, 1A2
65
How long does it take to see benefits of medication for neuropathic pain?
weeks
66
WHat is MOA of gabapentinoids?
block release of excititory transmitters by binding to calcium channels
67
Where are gabapentinoids cleared?
renally only
68
Which TCA is a pro drug?
amitriptyline
69
WHen should you take TCA?
before bed
70
MOA of TCA?
stop reuptake of serotonin and Norepinephrine
71
What drug interaction are we worried about with TCA?
2D6
72
Which TCA is more tolerated?
Nortriptyline
73
What are symptoms of withdrawl?
Flu like
Insomnia
Nausea
Imbalance
Sensory distrubance
hyperactivity
74
What is fibromyalgia?
diffuse body pain for 3 months, nociplastic pain
75
Who usually gets fibromylagia?
early 20-30s
76
What is the most effective treatment for FM?
exercise= better than any drug
and CBT
77
What drugs for FM?
same as neuropathic
fluoxetine can be used as well
78
What are the opiates?
morphine, opium, codeine
79
What are the receptors opiods act on?
mu
delta
kappa
80
What does mu receptors do?
addiction, analgesia, resp depression, sedation, constipation, euphoria
81
What does delta receptors do?
analgesia, euphoria, addiction
82
What does kappa receptors do?
analgesia, sedation
83
Where do opiods act?
central and peripherally
84
For acute pain what is max dose and duration
no more than 50 MEQ and 5 days
85
Why are opioids shit?
Bad S/e
dependence
no good study evidence
no change in functional outcomes
pain intensity was worse for opoids
86
Should you start opioids if addiction?
NO
87
What should be max opioid dose?
<90 MEQ
88
WHat is duration of immediate release opioids?
4-6 hours
89
What are some immediate release opioids?
hydromorphone,
90
What indicates it is continuous release?
contin
91
How much more potent is IV opioids compared to oral?
2 times
92
Should you ever use a CR opioid for acute pain?
NEVER
93
Does morphine have active metabolites
yes
94
When is renal failure contraindicated for opioids?
<20-30 ml
95
What is Codeine's MEQ?
0.15
96
What is special about codeine?
pro drug, needs CYP 2D6
97
What are bad inhibitors of CYP 2 D6?
clarithromycin and ketoconazole
98
At what dose is codeine maybe antitussive?
>15 mg q4-6
99
What is MEQ of Oxycodone?
1.5 times
100
Which is better, adding naloxone or laxative for opioid constipation?
neither
101
What is MEQ of hydromorphone?
5 times
102
What is special about hydromorphone?
good in renal impairment
103
What is effects of morphines metabolites?
6= analgesic
3= CNS stim
104
WHat is codeine metabolized into?
Morphine
105
What is special about tramadol MOA?
not just mu, also serotonin and norepinephrine, PRODRUG
106
What are the cons of tramadol?
more seizures, Qt prolongation, serotonin syndrome, 2D6, dont know proper dose
107
What do you need to know about tapentadol?
same as tramadol but less nausea
108
What is MEQ of fentanyl?
100 x`
109
When is fentanyl used?
if cant take oral, it is a patch, and for renal impairment
110
Who is fentanyl not for?
obese, ascites, super sweaty
111
Counseling points for fentanyl patch?
every 3 days, different site, dispose dont touch sticky
112
How does methadone work?
on mu and NMDA=prevent tolerance and potentiate analgesic
113
How is methadone cleared?
hepatic
114
WHat are the risks of methadone?
long half life= potential for overdose
Qtc prolongation and serotonin syndrome
115
What exam should you do if giving methadone?
baseline ECG
116
How do you dose methadone?
chart to do it. the higher the dose you need for methadone the more morphine it 'counteracts'
117
How frequently should you increase dose of methadone?
every 5 days
118
Is it ok to abruptly stop methadone?
NO
119
Why is there a risk of resp depression with methadone?
slow onset so you dont know when it happens
120
For opioid naive patients, what should you start buprenorphine dose at?
5 mcg/hr q7 day patch up to 20
121
What opioids can you switch to buprenorphine for pain?
Only if under 90 MEQ because max dose is low
122
True or false: Oral naloxone is better than IM?
NO ORAL DOES NOTHING
123
MOA of naloxone?
mu partial agonist= saturate so cant overdose
delta and kappa antagonist
124
Is naloxone safe in renal or hepatic impairment?
YES
125
What is sx of a pseudo allergy of opioids?
flush, itch, hives because histamine release side effect
126
Do opioids or opiates have more pseudoallergies?
Opiates more
127
What are sx of true allergy to opioids?
severe hypotension, skin reaction other than flush, itch or hives, breathing issues and swelling of face
128
S/E of opioids?
Sedate
resp depression
constipation
nausea
miosis
itching
129
Which s/e of opioids will tolerance develop?
All except miosis and constipation
130
What is the issue with tolerance to resp depression with opioids?
quickly lost if increase dose or no opioids for a few days
131
How long to get tolerance to sedation?
3-10 days or NEVER
132
What are chronic s/e of opioids?
hypogonad
sleep apnea
pain
133
What are drug drug interactions with opioids?
CNS depressants
MAO
QT
CMZ
134
How does hypogonadism happen from opioids?
influence hypo and pit axis which can lower cortisol and increase prolactin and decrease other sex hormones
135
Is hypogonadism dose related or duration?
duration
136
Does methadone also cause hypogonadism?
YES
137
Regarding sleep apnea and opioids, what is important?
called central sleep apnea
more severe and longer in NREM
makes CPAP less effective
138
What is suggested MOA of hyperalgesia of opioids?
on NMDA sensitize= more glutamate released
139
What is a good option if opioid hyper algesia?
methadone and naloxone
140
Who is at risk of opioid use disorder?
if history of substances
>90 days or >120 MEQ
141
How can we screen for OUD before opioids and during?
before: ORT
During: POMI and COMM
142
What are signs of an overdose from opioids?
difficulty walking, talking or staying awake
blue lips
cold and calmmy
confused
drowsy
gurgling
no breathing
143
If someone is overdosing what should be done?
give naloxone and call 911
144
How does naloxone help with overdose?
binds more tightly than opioids to the same receptors
fix breathing in 2-5 min
effects wear off in 30-90 min
145
What to do if acute exacerbation of chronic pain?
use short acting opioids, may need higher doses cause tolerance, adjunctives
146
How does opioids effect sleep other than drowsy?
decrease mood and sleep quality
147
Is naloxone only for OUD?
NO
148
How long until tolerance to opioids will happen?
3 months
149
For opioid Naive how much opioid do you give and what kind to start with?
5-10 MEQ for a single dose and use IR for easier adjustment
150
When do harms of opioids (overdose/death) start to happen?
doses >50 MEQ
151
What patients should start at an even lower dose
really old
really small
sleep apnea
impaired clearance
gi obstruction
152
When is onset opioid analgesia?
15-30 minutes
153
How is optimal dose of opioids reached?
at least 30% pain reduction, plateau point
adverse effects
154
What is known about using opioids for breakthrough pain?
better to use other ways
leads to dose increases
155
How frequently should you reassess opioids?
q2-4 weeks
156
What can we do to limit OUD?
ask for a pill count, limit quantity
one opioid prescriber and one pharmacy
urine test q6 months
157
What is considered a failed opioid trial?
not enough pain relief after 2-3 dose increases, bad s/e, medical complications, OUD,
158
Which people should not enter taper of opioids?
Pregnant= withdrawal can induce labour/abortion
pysch unstable
OUD
159
When is it needed to taper opioids?
if > 1 week of regular use
160
What are symptoms of opioid withdrawal?
anxious, sweaty, pain, teary eyes, tremour, fever, nausea, irritable, low body temp
161
How can we help with withdrawal sx?
Clonidine helps with insomnia, nausea, sweaty, anxiety
NSAIDS= pain
Loperamide= bowels
Gravol= Gi
Hydroxyzine= anxiety
Trazodone= Insomnia
Oxybutinin= sweaty
162
What is MOA of clonidine?
alpha 2 agonist and has s/e that help with withdrawal
163
What is the usual course of a taper with opioids?
decrease of 5-10% weekly and go slower at last 1/3 of dose
164
What other strategies to taper opioids?
cross over rotation taper= go with a different opioid at 75% due to less tolerance
165
What should be done if pain from withdrawal?
may stop usually 2 weeks before continuing
166
Who would do a rapid taper of opioids?
done in 1-2 weeks
for people at high risk or highly motivated
167
When doing cross rotation tapering what must be done?
after rotation pause for a month then do it again
168
If the patient was on a dose of 250 mg total daily what should hes cross rotation dose be?
50% original because >200
169
Why is cross roation not done?
confusing risk of two opioids
170
Who should be on Opioid Agonist therapy?
if on for longer than 5 years, psych issues, OUD, hyperalgesia, pregnant
171
What are the effects of THC?
euphoria, appetite, BP and anxiety too
172
What are the effects of CBD?
potential antiinflammatory and anti anxiety
173
If using cannabis what route?
ORAL
174
Short term effects of cannabis?
anticholinergic
lower learning and memory, risk of MI 1 hour after smoking
175
Long term effects of cannabis?
cog impairment
anxiety
dependence
hyperemesis
176
DI with cannabis?
depressants, anticholinergic, CYP interactions
177
What are Rx cannabis?
nabilone, nabiximols
177
Is store bought cannabis okay?
NO use RX
177
What type of pain is cannabis good for?
refractory neuropathic pain
