Pain Flashcards by E D

What are the four key points to remember about treating pain?

Function is the goal and the measure of success
Non-pharm modality first or concomitantly
Treatment agreements, esp with narcotics
“Pseudoaddiction” is not “addiction”, and “dependence” is not “addiction”

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What is the WHO’s recommendation for mild pain (1-3/10)?

Regularly scheduled non-opioids

Ex: APAP 1000mg q6h or Ibuprofen 600mg q6h

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What is the WHO’s recommendation for moderate pain (4-6/10)?

Regularly scheduled analgesic with an added opioid

Ex: APAP 325/Codeine 60mg q4h or APAP 325/Oxycodone 5mg q4h

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What is the WHO’s recommendation for severe pain (7-10/10)?

Regularly scheduled highly potent opioid

Ex: Morphine 10mg q4h or Hydromorphone 4mg q4h

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What are the 11 things to document regarding persistent pain syndrome management?

Pt’s functional level
Aberrant behaviors
Adverse drug reactions
Focus s/s for pain monitoring
Adequacy of analgesia
Pt affect
Pt adherence to pain management plan
Date/result of most recent drug screen testing
Date of most recent narcotic agreement
Pt misuse or diversion potential
Consultations

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ASA: MOA

Inhibits COX-1 and 2

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ASA: max daily dose

4g/24h

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Acetaminophen: MOA

Blocks peripheral transmission

Inhibits CNS COX-1 and 2

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Acetaminophen: max daily dose for healthy adult

4g/24h

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What are the two classes of opioids?

Pure agonists

2. Partial agonists/antagonists

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Pure agonists are further divided into 3 classes

Phenanthrenes (morphine, oxycodone, hydrocodone)
Phenylpiperdine (meperidine, fentanyl)
Diphenylheptane (methadone)

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Excess stimulation of peripheral and CNS serotonin receptors can lead to….

Serotonin syndrome

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What are some ways serotonin syndrome can occur?

Increased 5HT production
Inhibited 5HT reuptake
Inhibited 5HT metabolism
Increased 5HT release
Stimulation of 5HT receptors

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Name some opioid side effects

Sedation
Constipation
Nausea
Pruritis
Nausea
Resp depression
Convulsions
Cough suppression

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What enzyme metabolizes opioids?

CYP2D6

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Does everyone have the ability to metabolize opioids?

No. ~10% of Caucasians lack the CYP2D6 enzyme.

Tell them to suck it up and rub some dirt on it already.

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By itself, codeine is a ____ drug

Class II

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As a combo product, codeine is a _____ drug

Class III

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Codeine is a prodrug that gets metabolized into…

Morphine

One time, on “Trauma, Life in the ER,” a nurse gave this guy a dose of an IV med.

The guy looks at her and says, “that tastes like heroine.”

The nurse says, “yeah, I just gave you some Morphine.”

The guy says, “I’ve been clean for three years. Why did you do that?”

Don’t be like that nurse.

Hokay! Hydrocodone…Is Hydrocodone available as an individual drug or a combo?

Combo only (Lortab, Vicodin, Lorcet)

Hydrocodone + APAP =

Vicodin

Oxycodone - in what two forms is Oxycodone available?

Percocet - combo

Oxycontin - long acting monoproduct

In addition to 2D6, what enzyme metabolizes Oxycodone?

3A4

What is the "standard" high potency opioid analgesic?

Morhphine

Morphine is available in what two release formulas?

MSIR - immediate release | MSER - extended release

This set of cards is unlike my well organized pharm cards of the past. This pain med lecture doesn't follow the usual pattern...

And this type A, anal retentive student isn't having an easy time with it.

So, in general, what is the MOA for any given opioid?

They bind to mu receptors in the CNS, inhibit ascending pain pathways, and alter pain perception. +/- cough suppression.

Dilauded is more potent than Morphine. By how much?

PO 4x more | IV 5x more

Demerol...what are some of the absorption issues with Demerol?

There is very erratic absorption when given IM. Given PO, it takes 4x the IM dose to work. Don't be like Demerol.

Fentanyl...There are reservoir issues, leading to what issue?

Onset of action can take 12-24 hours to occur. | Drug clearance can take as long after you D/C the drug.

What effect does heat have on a Fentanyl patch?

It increases absorption.

Naloxone: class

Competitive opioid antagonist

Naloxone: MOA

Competes with and displaces narcotics at opiate receptors

Naloxone: indication

Complete reversal of opioid drug impacts

Naloxone: side effects

Withdrawal with catacholamine release (AMI, BP changes, agitation, dyspnea, diphoresis, etc)

Agitation...that's a way of saying it

Agitation...anger....fighting Titrate to effect is all I'm saying

Naloxone: monitor

RR, HR, BP, temp, LOC, SpO2

Naloxone: t1/2

30-120 minutes...not as long the narcotic. Will likely need more dosing.

One time I went to this house for an overdose, and I was placing an IV in this guys hand, and all of a sudden I realized my knee was wet...and that he was all wet....and then I smelled vanilla...

He shot up and decided to have some coffee. He went out while he was pouring vanilla creamer into his coffee.

I was only kneeling in his coffee.

Don't be like me. Look before you kneel. It might not be coffee the next time.

What are the steps in establishing a longer term, high potency opioid dose schedule?

1. Start with q4-6h dosing 2. Titrate to pain control 3. Calculate total 24h dose 4. Convert to 24 hour equianalgesic dose --> long acting preparation 5. Reduce total 24h dose by ~25% 6. Divide into 2 dosing intervals (q12h) 7. Add a lower does (10-20% of 24h total) for breakthrough pain

Let's look at an example of that...

1. MSIR 10mg q6h 2. Total 24h dose = 40mg MSIR 3. 24h equianalgesic dose = 40mg (morphine to morphine) 4. Reduce 40mg by 25% --> 30mg 5. Divide dose to q12h dosing --> 15mg MSER q12h (note the change from immediate to extended release) 6. 10-20% of 24h dose for breakthrough pain = 3-6mg....so give 5mg MSIR q4-6 hours PRN for breakthrough pain.

That was easy

Right? Easy? If I keep telling myself that this is easy, everything with be oooookkkkaaaayyyyyyy.

What are some adjunct drugs we can use for pain control?

``` TCA Clonidine Anti seizure meds like Gabapentin, Lyrica, Carbamazepine Cymbalta Transdermal lidocaine ```

So after all this fluff, what are the three points to remember about pain control?

1. Function is key and the measure of success 2. Non-drug modalities are very important and should be used fort or concomitantly 3. Treatment agreements are important for your Pt's wellness, and yours