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-Palliative Care & Hospice Pharmacology > Pain > Flashcards

Pain Flashcards

1
Q

People at risk for under treatment of pain.

A 
Elderly
Children
Minorities
Underinsured
Women
Those with a history of drug abuse.
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2
Q

Patient related barriers to pain relief

A

Reluctant to report pain due to:

Fear of opioids and their side effects such as constipation, sedation, addiction, cognitive impairment

Wanting to be a good patient

Fear of loss of effectiveness

Fear that morphine means death

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3
Q

Nociceptive Pain

A

Activation of nociceptors which are pain sensitive structures.

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4
Q

Types of nociceptive pain

A

Somatic and viceral pain

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5
Q

Somatic pain

A

Cutaneous and deep MSK

Well localized

Ex: Bone metastasis, incisional pain, spasm, muscle inflammation.

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6
Q

Visceral Pain

A

Infiltration, compression, distention or stretching of thoracic or abdominal viscera.

Ex: cirrhosis, pancreatic ca.

Poorly localized, deep, squeezing or pressure, cramping.

Associated with nausea, vomiting or diaphoresis.

May be referred to cutaneous sites that can be remote from lesion.

Shoulder pain associated with diaphragmatic lesio .

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7
Q

Neuropathic Pain

A

Injury to CNS or PNS

Plexopathies, cord compression, neuralgia, chemo induced neuropathies.

Sharp, shooting, electric shock, pressure.

Difficult to control.

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8
Q

Chronic pain

A

Longer than 3 months.

Adaptation of autonomic system means no increased HR or BP.

Poorly controlled may lead to depression, fatigue, anxiety, insomnia.

Limits interactions with others.

Limits goal achievement.

Contributed to desire of death.

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9
Q

Breakthrough Pain

A

Transient increase in pain to greater than moderate intensity occurring in the presence of a baseline pain of moderate intensity or less.

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10
Q

Incident Pain

A

Marked by a particular movement or activity.

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11
Q

NSAIDS

A

Inhibit cyclooxygenase leading to analgesia and decreased production of prostaglandins that protect the gastric mucosa and renal parenchyma increasing risk of GI symptoms and bleeding.

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12
Q

Step one on the WHO Pain ladder

A

Mild pain - 1-3

Non opioids plus coanalgesics if needed.

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13
Q

Step two on who Pain ladder

A

Moderate pain - 4-6

Low dose opioid and nonopioid or coanalgesic

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14
Q

Step 3 on the WHO Pain ladder

A

Severe pain - 7-10

Opioids titrated to pain relief plus nonopioids plus coanalgesics

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15
Q

Those at risk for NSAID renal failure

A

CHF, renal disease, cirrhosis with ascites, atherosclerotic HD, multiple myeloma.

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16
Q

Side effects of NSAIDS

A

Hypertension, sodium retention, edema, cardiovascular event risk,

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17
Q

What happens when partial agonists are given to patient who use full opioid agonists?

A

Withdrawal syndrome.

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18
Q

Why are partial agonists not recommended for chronic pain or progressing pain.

A

They have a ceiling dose and can cause withdrawal syndrome.

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19
Q

Why is methadone dangerous?

A

Long and variable half-life, plasma concentration rises slowly requiring a week or longer to reach steady state,, QT prolongation requiring EKG before use.

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20
Q

Equianalgesic dose when switching from another opioid to methadone.

A

Dose reduction by as much as 90 percent.

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21
Q

Methadone dosing in older adults or renal failure/hepatic failure

A

less frequent dosing, more conservative dose titrations.

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22
Q

Causes contributing to methadone induced cardiac arrhythmia or QT prolongation

A

Cardiac disease, other medications use with it that are QT prolongers, drugs that interact with methadone.

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23
Q

Types of pain that methadone is good for

A

Nociceptive pain and neuropathic pain that is unresponsive to other therapy.

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24
Q

Gastrointestinal side effects of opioids

A

Nausea, constipation, vomiting

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25
Q

Autonomic effects of opioids

A

postural hypotension, urinary retention, xerostomia

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26
Q

Cutaneous effects of opioids

A

Itching, sweating

27
Q

CNS effects of opioids

A

Cognitive impairment, delirium, drowsiness, hyperalgesia, myoclonus, respiratory depression, seizures.

28
Q

What is the most common opioid side effect

A

Constipation, and people do not gain tolerance.

29
Q

Bowel regimen for opioid use

A

Stool softener and a bowel stimulant

30
Q

What is used for refractory constipation

A

methylnaltrexone

31
Q

What does methylnaltrexone do?

A

Antagonizes peripherally located opioid receptors and spares CNS effects of opioids producing analgesia.

32
Q

How is methylnaltrexone given?

A

SC, resulting in BM within 90 min.

33
Q

What can be done about nausea and sedation.

A

Common among initiation and fast upward titration. Most people gain tolerance within a week. Opioid rotation may be effective or stimulants may be added.

34
Q

Why is respiratory depression rare?

A

Sedation precedes respiratory depression.

35
Q

How do you give naloxone? What is the half-life of naloxone

A

Dilute 0.4mg in 10mL NS and give at a rate of 0.2mg IVP q 2 minutes. Half-life is 30 min.

36
Q

Who is at increased risk from opioid induced respiratory depression

A

COPD, sleep apnea, sedating medications.

37
Q

What is myoclonus

A

Uncontrolled spasm of muscle groups that may vary in intensity and may be progressive. It is dose related. May be related to metabolic disturbance such as renal compromise.

38
Q

How do you treat myoclonus

A

Rotate to another opioid which may allow for dose reduction or give low dose benzo.

39
Q

What is opioid induced hyperalgesia

A

When a person reports increasingly severe pain after an opioid increase.

40
Q

How do you treat OIH

A

Taper the opioid, rotate the opioid, add an NDMA modulator and evaluate patient pain for next 24-48 hours.

41
Q

What are co-analgesics?

A

Drugs that have a primary indication other than pain but have analgesic effects under certain circumstances.

42
Q

Examples of coanalgesics

A

antidepressants, anticonvulsants, corticosteroids. Most common in treatment of neuropathic pain.

43
Q

First-line coanalgesics

A

TCAs, dual reuptake inhibitors of serotonin and norepinephrine, calcium channel ligands, topical lido.

44
Q

Ketamine

A

NMDA receptor activity. Narrow therapeutic window. Sub-analgesic doses.

45
Q

Side effects of ketamine

A

hallucinations, memory problems, potential for abuse and addition.

46
Q

Intravenous Lidocaine

A

Short isolated infusions, for long term pain relief in terminally ill patients.

47
Q

Tricyclic antidepressants

A

Neuropathic pain.
Nortriptyline 10-25mg/QHS
Desipramine 10-25mg/QD

48
Q

Side effects of TCAs

A

Anticholinergic

49
Q

SNRIs

A

Neuropathic Pain
Venlafaxine 37.5mg PO QD
Duloxetine 30 mg PO QD

50
Q

Side effects of SNRIs

A

Nausea, Dizziness

51
Q

Benzodiazepines

A

Neuropathic Pain

Clonazepam 0.5-1mg PO QHS BID or TID

52
Q

Side effects of Benzos as pain meds

A

Dizziness and lower extremity edema

53
Q

GABA

A

Gabapentin 100mg PO TID

Pregabalin 75mg PO BID

54
Q

Side effects of GABA as pain meds

A

Dizziness and LE Edema

55
Q

Corticosteroids

A

Cord compression, bone pain, neuropathic pain, visceral pain and pain crisis.
Dexamethasone 2-20mg PO/IV/SC daily
Prednisons 15-30mg PO TID or QID

56
Q

Side effects of Corticosteroids as pain meds

A

Steroid psychosis delirium, dyspepsia

57
Q

Local anesthetics

A 
Lidocaine patch 5% 12 hours on/off - may cause skin erythema
Lidocaine infusion (IV/SC) may cause cardiac changes or perioral numbness
58
Q

Biphosphenates

A

Pamidronate 60-90mg Q 2-4 weeks
Zolendronic acid 4mg Q3-4 weeks

May cause pain flair and osteonecrosis.

59
Q

Risks of neural blockage

A

sensory loss, altered bowel, bladder function, weakness, altered sexual function, intravascular injection, hematoma, fatigue, over sedation.

60
Q

How much is a rescue dose?

A

10-15% of the patients 24 hours ATC dose.

61
Q

When do you consider opioid rotation?

A

Two or MORE side effects excluding constipation.

62
Q

What are withdrawal side effects?

A

lacrimation, rhinorrhea, yawning, goosebumps, tremor, insomnia, diarrhea, irritability.

63
Q

How do you prevent acute withdrawal syndrome?

A

Taper medications if ATC for a week or more. Give 25 percent of the previous 24 hours opioid dose.

64
Q

Abberant drug behavior

A

Repeated episode of unsanctioned dose escalation, calling in early prescription renewals, lost medication.

-Palliative Care & Hospice Pharmacology (6 decks)

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