Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

PHRM 845 final > Pain > Flashcards

Pain Flashcards

1
Q

Types of pain fibers

A

Aβ
- non-noxious – touch, pressure
- innervate the skin
- very fast
Aδ
- pain, cold
- fast
- first pain reflex (sharp, prickly)
C
- pain, temp, touch, pressure, itch
- slow
- 2nd pain (dull, aching)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Quality of Pain ( inflammatory, neuropathic, visceral, referred)

A
  • inflammatory: throbbing, pulsating
  • neuropathic: stabbing, shooting, burning, tingling
  • visceral: squeezing
  • referred: usual distribution of pain with myocardial ischemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Pain Transmission (MOA)

A
  • pain starts in PERIPHERY, when there is a peripheral stimulus and this signal is conducted to the spinal cord
  • once the signal gets to the spinal cord, it is processed and that info is sent up through the ascending input up to the brain for processing effect(central effect)
  • then the info gets sent back down through descending modulation, and the idea of this process is to help control the action of the afferent neuron that’s bringing info into spinal cord
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Peripheral Receptors (Temperature Sensitive)

A
  • Transient receptor potential cation channel (TRP)
  • TRPV (vanniloid) = heat
  • TRPM (melastatin) = cold
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Peripheral Receptors (Acid Sensitive)

A
  • activated by protons
  • acid sensing ion channel (activated by H+, conduct Na+)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Peripheral Receptors (Chemical irritant sensitive)

A
  • Histamine
  • bradykinin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Importance of glutamate with nerve transmission

A
  • once the signal gets to the spinal cord, a neurotransmitter gets released, glutamate acts on AMPA, mGluR, NMDAR and they get released and go to the brain or work by reflex
  • glutamate plays a huge role in conduction of pain in spinal cord
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Repeated stimuli reduces firing threshold

A

becomes easier for pain conducting neuron to fire and conduct a painful stimuli

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Substance P role in heightening pain responding

A
  • when there’s a stimulus, substance P is released, which stimulates the blood vessels
  • vasodilation, release of degranulate mast cells, histamine release, and inflammation occur
  • these events lead to an increase in signal receiving receptors in the periphery — AMOA and NMDA
    (which can then send more signals to the spinal cord and thus to the brain)
  • this is known as peripheral sensitization
    – an example of this is a sunburn
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Phenanthrenes

A

morphine
codeine
thebaine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Benzylisoquinolines

A

noscapine
papaverine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Types of opioid receptors

A
  • G protein-coupled receptor
  • Mu
  • Kappa
  • Delta
  • Nociceptin
  • Sigma – not an opioid receptor
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

GPCR (opioid receptor)

A
  • family A - peptide receptors
  • Gi/o coupled (inhibit cAMP production)
  • open GIRK potassium channels
  • close calcium channels
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Mu (opioid receptor)

A
  • M - morphine
  • endogenous opioid = endorphin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Kappa (opioid receptor)

A
  • K - ketocyclazocine
  • endogenous opioid = dynorphin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Delta (opioid receptor)

A
  • D - deferens -> where identified
  • endogenous opioid = enkephalin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Nociceptin, orphaniin FQ receptor

A

endogenous opioid = nociceptin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Opioid receptor signal transduction (presynaptic)

A

Presynaptic = inhibit calcium channel (Gi), results in decrease in neurotransmitter release
- decreases conduction ( of primary neuron bringing info to spinal cord)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Opioid receptor signal transduction (postsynaptic)

A

Postsynaptic = activate GIRK channel (Gbetagamma), efflux of K+ which causes hyperpolarization
- causes an increased difficulty for action potential to reach threshold, thus reduction of neurotransmitter release of painful stimuli

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Mu opioid receptor

A
  • most drugs work here
  • beta-endorphins (endogenous morphine) – runner’s high
  • therapeutic use for analgesic (acute)
  • not as effective for chronic pain
  • also used for sedation and antitussive
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

opioid induced SE at Mu receptor

A
  • respiratory depression
  • constipation
  • pruritus (itch) - SE not allergic response
  • addiction
  • urinary retention
  • N/V
  • miosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Kappa opioid receptor

A
  • dynorphins natural ligand (though that drug therapy is less addictive)
  • activation is dysphoric, aversive
  • use in treatment of addiction because it results in reduction of dopamine release (decreases abuse potential)
  • counterbalance mu opioid receptor effects
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Delta opioid receptor

A
  • no FDA approved opioid receptor agonists for delta receptor
  • therapy - reduce anxiety, depression, treat alcoholism, relief hyperalgesia
    SE: seuzures!!
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Opioid site of action

A
  • inhibit gabanergic neuron which increases dopamine and increases reward pathway
  • Ventral Tegmental Area –> Nucleus Accumbens
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

dopamine release

A
  • opioid binds at Mu receptor
  • Gi signaling inhibits neurotransmitter release
  • less GABA to activate GABAa
  • less inhibition of dopamine neuron activity
  • increase dopamine release
  • increase activation of dopamine receptors
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Morphine PK

A
  • readily absorbed - 1st pass metabolism (bioavailability 25%)
  • CYP2D6 and CYP3A4
  • elimination t1/2 increased with liver disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

CYP3A4 makes opioids starting with ____

A

NOR

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

CYP2D6 Metabolizers

A
  • UM: ultra-rapid metabolizers will activate morphine at a quicker rate, so will have higher concentrations when given codeine
  • PM: poor metabolizers won’t be able to convert codeine to its active form of morphine so will have no effect from codeine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

tramadol

A
  • mild opiate analgesic
  • has SNRI properties
  • increases NE and 5HT which then influences descending pathways of pain and can regulate pain
30
Q

Meperidine

A
  • used to treat rigors (shivering)
  • has toxic metabolite (normeperidine)
  • renally excreted so dangerous in patients with decreased renal function
    not recommended without good justification
31
Q

Methadone

A
  • primarily used for opioid dependence
  • QTc prolongation
  • NMDA antagonist
  • used for chronic pain
32
Q

Methadone (full agonist)

A
  • full Mu opioid receptor agonist
  • relief from withdrawal
  • slow acting (reduced risk of ‘high’ to deter overall opioid use)
  • accumulates with repeated dose
  • NMDA antagonist
33
Q

Buprenorphine (partial agonist)

A
  • Mu opioid receptor partial agonist
  • blocks full agonist effect of drugs like heroine or oxycodone
  • provides some activation to help with withdrawal
  • abuse potential with Subutex
34
Q

Naltrexone (agonist)

A
  • IM injection monthly or PO daily
  • decent oral bioavailability
  • will cause withdrawal
  • used later in treatment when withdrawal is not a concern, patient should be drug free for 1 month
  • blocks high and reinforcement
35
Q

Naloxone

A
  • IV or intranasal
  • treat overdose (antidote)
  • short half-life, rapid onset
36
Q

classifying pain (acute, chronic, malignant)

A
  • acute: <3 months
  • chronic: >3 months
  • malignant: mixed tissue and nerve
37
Q

stepwise treatment approach for non-malignant pain

A

1- non opioid and adjunctive if needed
2- opioid for mild-moderate pain + non-opioid plus adjuvant analgesic if needed
3- opioid for moderate-severe pain + non-opioid plus adjuvant analgesic if needed

38
Q

Non-opioid analgesics

A

non-opioids: acetaminophen, NSAIDS

adjuvant therapies: gabapentinoids, SNRIs, TCAs, skeletal muscle relaxants, antiepileptics, topical agents

39
Q

acetaminophen (tylenol)

A
  • tablet, capsule, chewable, liquid, IV solution, suppository
  • 4g/day max
  • peds: 10-15 mg/kg q4h max is 75 mg in day
  • gold standard for osteoarthritis
40
Q

NSAIDS

A
  • analgesic, anti pyretic, anti-inflammatory
  • SE: GI bleed, nephrotoxicity, fluid retention, increase CV events
  • take with food, caution in geriatric pts, avoid systemic NSAIDs with cardiac history, avoid in liver disease and CKD
41
Q

aspirin

A
  • capsule, tablet, chewable, suppository
  • avoid in pediatrics bc Reye’s syndroms
  • avoid in blood thinners or antiplatelet use
42
Q

ibuprofen

A
  • capsule, tablet, chewable, suspension, IV solution
  • max is 3200 mg/day
  • pediatrics: 5-10mg/kg q4-6h, max is 2400mg/day
43
Q

diclofenac

A
  • capsule, tablet, IV, suppository, topical, opthalmic, patch
  • 50mg PO q8h or 2-4 g applied QID
44
Q

naproxen

A
  • capsule, tablet, suspension
  • 220-500 mg PO q6-12h
45
Q

ketorolac (toradol)

A
  • tablet, IV/IM, nasal spray, opthalmic solution
  • max duration is 5 days – increased risk of GI bleeding
46
Q

celecoxib

A
  • capsule, oral solution
  • 200mg PO BID
  • cox 2 selective, so less GI toxicity
47
Q

gabapentinoids: gabapentin (neurontin) and pregabalin (lyrica)

A
  • uses: fibromyalgia, neuropathies, post-op pain
  • tablet, capsule, liquid solutions
  • gabapentin dosing: 100-300 mg PO TID (max 3600mg/day)
  • pregabalin dosing: 75mg PO BID (max 600 mg/day)
  • SE: sedation, dizziness, peripheral edema
48
Q

SNRIs for adjunctive therapy for pain

A
  • venlafaxine & duloxetine
  • fibromyalgia and neuropathy
  • capsule and tablet
  • SE: headache, nausea, hypertension, sedation, weakness
  • start low dose and titrate up to minimize SE
  • renally dose adjust venlafaxine and if CrCL is <30 avoid duloxetine
49
Q

TCAs for adjunctive therapy for pain

A
  • amitriptyline, nortriptyline
  • off label uses: fibromyalgia, neuropathy, migraine prophylaxis
  • tablet, capsule, oral solution
  • anti-cholinergic SE, sedation
  • last line option due to side effects
50
Q

carbamazepine (tegretol)

A
  • neuropathic pain
  • tablet, capsule, chewable, suspension
51
Q

Geriatrics

A
  • avoid chronic use of non cox 2 selective NSAIDs
  • indomethacin has most risk
  • avoid muscle relaxants (carisoprodol, cyclobenzaprine, methocarbamol)
  • use SNRIs, TCAs, and carbamazepine with caution
  • avoid opioids and benzos together
  • avoid opioids and gabapentin/pregabalin
  • avoid anticholinergics (TCA or muscle relaxant and another anticholinergic medication
  • avoid concurrent use of 3 or more CNS active agents
52
Q

pain medications that can be used in elderly to minimize side effects

A
  • acetaminophen
  • topical agents
  • SNRIs
  • gabapentinoids
53
Q

opioid overdose signs and symptoms

A
  • sedation
  • pinpoint pupils
  • bradycardia
  • decreased respiratory rate
  • hypotension
  • pale, clammy skin
54
Q

signs and symptoms of opioid withdrawal

A
  • insomnia/aggitation
  • dilated pupils
  • increased respiratory rate
  • tachycardia
  • hypertension
  • sweating
55
Q

opioid withdrawal treatment

A
  • clonidine - helps with symptoms of withdrawal such as HTN, sweating, vomiting, anxiety
  • buprenorphine
  • methadone
56
Q

opioid antagonist

A

naloxone

57
Q

opioid weak agonist

A
  • codeine
  • tramadol
58
Q

opioid full agonist

A
  • morphine
  • hydrocodone
  • hydromorphone
  • oxycodone
  • meperidine
  • fentanyl
  • methadone
59
Q

opioids

A
  • use: acute and chronic pain
  • SE: antitussive, constipation, N/V, itching, orthostatic hypotension, urinary retention, sedation, respiratory depression
  • consider starting stool softener or stimulant laxative
  • potential for tolerance, dependence, addiction
60
Q

codeine

A
  • tablet, cough syrup
  • metabolized by 2D6
  • poor metabolizers will get no effect from codeine
  • ultrarapid metabolizers can experience overdose
  • not recommended for breastfeeding mothers or children < 12
61
Q

tramadol

A
  • capsule, tablet, oral solution
  • one of the weaker opioids
  • risk of serotonin syndrome when used with other serotonergic meds
  • renally dose adjusted
  • 3A4 and 2D6
62
Q

morphine

A
  • capsule, tablet, oral solution, injection, suppository
  • itching more prominent compared to other opioids
  • avoid alcohol with ER capsules bc can overdose
63
Q

hydromorphone (dilaudid)

A
  • IR and ER tablets, oral solution, solution for injection, supposityry
64
Q

oxycodone and hydrocodone

A
  • tablet, capsule, oral solution
  • counsel abt APAP containing products
  • use with 3A4 inhibitors increase oxycodone concentrations
65
Q

fentanyl (duragesic)

A
  • buccal tablet, SL, lozenge, injectable, patch
  • 3A4 substrate
  • can use in renal impairment
  • less hypotension than morphine or hydromorphone at similar doses
  • patch only for later more stable pain
66
Q

methadone (methadose)

A
  • last line treatment for chronic pain
  • opioid detoxification
  • QTc prolongation
  • 3A4 substrate
67
Q

meperidine (demerol)

A
  • not really used bc SE
  • avoid in elderly
  • 3A4
  • do not use within 14 days of MAOi
68
Q

tramadol SE (bc serotonergic activity)

A
  • can lower seizure threshold
  • cause serotonin syndrome when used with other serotonergic agents
  • check if pt has history of seizures, and if so prob done use tramadol
69
Q

CDC recommendations

A
  1. maximize non-opioids first
  2. start with IR opioid when starting one
  3. lowest effective dose for opioid naive
  4. carefully weight risk/benefit and care when changing dosage
  5. prescribe no greater quantity than needed for expected duration of pain
  6. follow up and evaluate risk/benefit in 1-4 weeks
  7. offer naloxone and strategies to mitigate risk
  8. review if pt has other opioid scripts and risk for overdose
  9. consider toxicology testing
  10. caution when prescribing opioid with BZDs or other CNS depressants
  11. detoxification on its own is not recommended for opioid use disorder because increased risks
70
Q

reducing/tapering opioids

A
  • decrease by 10% per week if on opioid less than 1 year
  • decrease by 10% per month if greater than 1 year

PHRM 845 final (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions