Pain and QOL Flashcards
4 medications to deprescribe of the following and why (GFR 30):
Tylenol 500 BID
Celecoxib 500 mg BID
Morphine 5 mg QID
Amitriptyline 25 mg
Pregabalin 150 mg BID
Repaglinide 0.5 BID
Docusate
Senna
Warfarin
- Celecoxib - renal impairment avoid <30, avoid in elderly
- Amitriptyline - TCA, anticholinergic, sedating, orthostasis
- Pregabalin - avoid when <30, CNS adverse effects
- Morphine - not good in renal impairment, avoid if recurrent falls, bad combo with pregabalin
Equivalent dose for morphine 20 mg daily for hydromorphone and oxycodone
Morphine:HM 5:1
20 mg daily / 5 = 4 mg total daily dose
Morphine:OC 3:2
20 mg / 1.5 = 20X2 = 40/3 = 13.3 mg
Non Pharmacologic strategies to help with chronic spinal stenosis pain
- Exercise
- Yoga
- Multidisciplinary rehab
- Acupuncture
- Tai chi
- Mindfulness based stress reduction
- Motor control exercise
- Progressive relaxation
- EMG feedback
- Low level laser therapy
- Spinal manipulation
Non pharm strategies for acute lower back pain
- Heat
- Massage
- Acupuncture
- Spinal manipulation
Choosing wisely recommendations re:opioids
Don’t initiate opioids long term for chronic pain unless trial of available non-pharm tx and adequate trials of non-opioid medications
10 risk factors for post stroke pain
- Female
- Older age at time of stroke
Pre stroke - Alcohol use
- Statin use
- Depression
- PVD
Stroke - Ischemic stroke
Post Stroke - Spasticity
- Reduced UE movement
- Sensory deficits
Types of post stroke pain
- Central - 3-6 mos post stroke, constant pain from injured nerve, burning or aching or shooting
- Change in sensation, skin temp/colour/swelling, skin texture
- HA
- Spasticity
- Contractures - Shoulder pain - subluxation, frozen shoulder
Patient with functional decline, spinal stenosis, chronic pain and falls. 3 areas of assessment for OT, PT and SW.
PT
- Strengthening
- Balance
- Flexibility
OT
- Ability to perform BADLs (dressing, bathing)
- Gait aid use
- Home safety/equipment
- Cognitive assessment
SW
- PSW support
- Meal services
- Counselling for chronic pain/CBT
4 validated ways to identify pain in patient with severe dementia
PAINAD Tool
1. Breathing - laboured, hyperventilation
2. Negative vocalization - moan, groan, crying, calling out
3. Facial expression - grimace
4. Body language - rigid, clenched, knees up, striking out
5. Consolability - unable to console, distract or reassure
Cochrane review on peripheral nerve blocks in hip fractures
- Reduce pain on movement within 30 mins
- Reduce risk of acute confusional state
- Probably reduces risk of chest infection
- Probably reduces time to first mobilization
- May be small reduction in cost of analgesic drugs
No difference
MI
Mortality
3 common AEs for pregabalin
3 common AEs for gabapentin
Pregabalin
1. Peripheral edema
2. Dizziness
3. Drowsiness
Gabapentin
1. Ataxia
2. Dizziness
3. Drowsiness
OA = 5 drug therapies and 1 sfx of each, 3 interventions
Drugs
1. Topical NSAID - skin irritation
2. Oral NSAID - GIB, PUD
3. Duloxetine - dizziness
4. Tylenol - liver toxicity
5. Opioids - falls, delirium
Intervention
1. Intra articular steroid injections
2. TENS
3. Joint replacement surgery
Clinical findings of lumbar spinal stenosis
- No pain while seated
- Bending forward improves symptoms
- Bilateral buttock/leg pain
- Neurogenic claudication
- Wide based gait
- Abnormal Romberg
6 causes and 6 treatments for leg cramping
- Medications - CHEI, diuretics, statins
- Metabolic - CKD, DM, hypothyroid, liver failure
- Fluid/lytes - hypo/perK, hypoCa, hypoNa, volume depletion
- Neurologic - neuropathy, Parkinson’s, MS
- Vitamin deficiency
- Peripheral vascular disease
Treatment - Quinine
- Magnesium
- Vit B complex
- Diltiazem
- Stretching affected muscle
- Change in footwear
Patient on long acting morphine with increasing nocturnal pain, constricted pupils, myoclonus. How would you optimize med management?
Signs of opioid induced neurotoxicity
- Reduced dose of drug
- Change to another opioid
- Addition of adjuvant analgesic (Tylenol, NSAID, topical, bisphosphonate, radiation)
- Hydration
- Correct underlying factors (renal impairment)
