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Palliative > Pain and Symptom Management > Flashcards

Pain and Symptom Management Flashcards

1
Q

Define Opiates

A

a group of naturally occurring compounds derived from the juice of the poppy Papaver somniferum
-morphine is the classic opiate in clinical use

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2
Q

Define Opioids

A

Semisynthetic (hydromorphone) and synthetic (fentanyl, methadone) drugs that act on opioid receptors

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3
Q

What are the primary uses of opioids in palliative care?

A

management of pain and dyspnea

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4
Q

What are the overarching principles of opioid adminstration?

A

1) doses proportionate to the degree of distress are safe
2) anticipate and preempt predictable (incident) pain
3) dose increases 10-100% depending on the context should be done after 5 half-lives (reaches a steady state) before increasing dose
4) IV, subcut administration bypass first-pass metabolism in the liver, and doses usually 1/2 po dose
5) short-acting opioids (morphine, hydromorphone) should be used during dose titration when pain is unstable

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5
Q

Why is constipation a side effect of opioids?

A

because the opioid receptors are in the gut and when the opioid attaches to the receptor it stops peristalsis

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6
Q

Which opioids are safe to give for a codeine allergy?

A

for a true anaphylactic allergy they can’t receive any natural or semi-synthetic opioids. They can receive the synthetic ones: fentanyl, sufentanil, methadone, and meperidine

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7
Q

When would you use short-acting opioid formulations?

A

for opioid-naive patients or during a pain crisis

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8
Q

When should long-acting opioid formulations be used?

A

during reserve for stable situations

-can add short-acting opioids for breakthrough pain

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9
Q

What are the two gold standards for pain in palliative?

A

-morphine
-hydromorphone

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10
Q

Which opioids are preferred for patients with a history of renal disease?

A

fentanyl and methadone because they don’t have any active metabolites

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11
Q

Describe intranasal drug delivery

A
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12
Q

What is breakthrough pain?

A

a transitory flare of pain of moderate to severe intensity occurring on a background of otherwise controlled pain

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13
Q

Should you administer ER or IR for breakthrough pain?

A

ALWAYS give immediate release for breakthrough pain

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14
Q

Who is Transdermal Fentanyl not used for?

A

-opioid-naive patients
-unstable pain
-cachexic patients (insufficient fat layer for absorption)

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15
Q

Who is Transdermal Fentanyl good for?

A

-pain control is stable
-oral route is compromised or vulnerable (bowel obstruction, etc)
-simplifying a medication regimen in a non-compliant or confused patient (may need to put out of sight)
-simplify a medication regimen for other reasons– traveling, etc.

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16
Q

How much more potent is Transdermal Fentanyl than morphine?

A

about 100x more potent

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17
Q

How often should you change a Transdermal Fentanyl patch?

A

-titrate no more often than q3d unless otherwise stated due to patient having an increased amount of breakthrough pain by the third day

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18
Q

What are the side effects of opioids?

A

-constipation
-nausea/vomiting
-urinary retention
-itch/rash
-dry mouth
-respiratory depression
-drug interactions
-neurotoxicity

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19
Q

How can you manage nausea/vomiting due to opioids?

A

-treat with dopamine antagonists and/or prokinetics
-metoclopramide is the first choice
-can also use domperidone, haloperidol, prochloperazine

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20
Q

How are adverse effects of opioids treated?

A

-reduce opioid dose–> won’t do this in palliative
-symptomatic management of adverse effects
-opioid rotation (switching)
-switching route of administration–>less likely to occur

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21
Q

What are the signs of a true morphine allergy?

A

-swelling of the face and throat (angioedema)
-red welts

anaphylactic reaction!

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22
Q

What is the definition of constipation?

A

-passage of small, hard stool
-painful passage (straining)
-prolonged interval

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23
Q

Why should bulk laxatives not be used for advanced cancer patients?

A

bulk laxatives are contraindicated for advanced cancer patients because they don’t have enough fluid intake to work properly (need an extra 1-1.5L per day) and can turn the stool into basically bricks that can perforate the bowels

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24
Q

What are the 2 common laxatives on a palliative unit?

A

sennokot and PEG

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25
What does senokot do?
helps to move the stool through the tract
26
What does PEG do?
it is an osmotic laxative that "gush"
27
What is Selective Opioid Receptor Blocker?
-for refractory opioid induced constipation -given subcut -for when other methods aren't working -expensive
28
How does an anxiolytic treat dyspnea?
-breaks the anxiety-dyspnea-anxiety cycle -does NOT reduce dyspnea directly -decreases anxiety accompanied by dyspnea Benzodiazepines
29
How do corticosteroids help to treat dyspnea?
-decreases inflammation
30
What is an adjuvant?
-serves to help or contribute -the drug is not primarily indicated but has been shown to help
31
What are some general adjuvants used in palliative care for pain?
-corticosteroids -cannabinoids (not commonly used)
32
What adjuvants are used in palliative care for neuropathic pain?
-Gabapentin -Antidepressants -Topiramate -Methadone and Ketamine -Clonidine
33
What are some adjuvants used in palliative care for bone pain?
-Bisphosphonates-- Pamidronate, Zoledronate, Clodronate -Calcitonin
34
What anticonvulsants can be used for neuropathic pain?
Gabapentin Pregabalin Topiramate Lamotrigine Carbamazepine
35
What are some of the uses of Corticosteroids in advanced illness?
-inflammatory neuropathic pain from peripheral nerve injuries -bone pain -pain from bowel obstruction -pain from headache associated with increased intracranial pressure -stimulation of appetite -weakness -nausea and vomiting -fatigue -general affect
36
What is hyperalgesia?
abnormally increased sensitivity to pain
37
What are NMDA antagonists?
-dextromethorphan -memantine -methadone -amantadine -ketamine
38
Who is an appropriate methadone candidate?
-true morphine allergy -significant renal impairment -neuropathic pain -opioid-induced adverse effects -pain refractory to other opioids or uncontrolled pain -cost is an issue -long-acting opioid preferred
39
What are the on-label indications of cannabinoids?
-nausea and vomiting from chemotherapy -chronic pain (neuropathic) -anorexia associated with HIV/AIDS
40
What are the off-label indications of cannabinoids?
PTSD anxiety depression insomnia bladder symptoms of MS dementia-related symptoms cancer neuropathic/mixed pain chronic daily headache fibromyalgia anorexia/cachexia neurodegenerative diseases epilepsy inflammatory bowel disease
41
What is Capsaicin?
a topical cream that is made with the active ingredient in hot chili peppers -inhibits peripheral nociceptive transmission which reduces pathologic pain responses
42
What is Topical Lidocaine
topical patch for neuropathic pain -most common AE is localized skin reaction, but can also cause cardiac arrhythmia, somnolence, GI upset -up to 3 patches; approved for 12 hour on and 12 hours off
43
What are some causes of chronic nausea?
gastroparesis constipation opioid therapy bowel obstruction gastric/duodenal ulcer other drugs radiation therapy/chemotherapy metabolic abnormalities increased intracranial pressure dehydration
44
Why do we do opioid rotation?
-inadequate analgesia despite appropriate escalation -intractable/intolerable side effects -altered renal/hepatic function -drug shortages
45
What is Equi-analgesic dosing?
refers to different doses of two agents that provide approximate pain relief
46
Explain the process of opioid rotation
1) calculate the total daily dose 2) convert using equi-analgesic dose tables 3) compensate for incomplete cross tolerance (decrease by 25%) 4) switching to transdermal fentanyl, do NOT reduce equi-analgesic dose 5) calculate PRN dose 6) assess
47
Define pain
whatever the experiencing person says it is, existing whenever the experiencing person says it does -unrelieved pain is one of the most frequent reasons for palliative consultations
48
What is visceral pain?
organs and tissues from endoderm (stomach, bowel, liver, etc) -often felt on the body surfance -referred pain, diffuse and ill-defined -dull and aching (constant, cramping) in nature
49
What is deep somatic pain?
-mesodermal (bone, muscle, ligaments, fascia) -most common for cancer patients -site specific and described as dull and aching
50
What is cutaneous pain?
Ectodermal (nervous tissue) -clearly localized and described as sharp or burning -dermatome charts are useful to map out this pain
51
What are the two main types of pain and how are they further divided?
Nociceptive pain: divided into somatic and visceral Neuropathic pain: peripheral and central
52
What is acute pain?
-caused by an identified event, resolves within days to weeks -usually nociceptive
53
What is chronic pain?
-cause often not easily identified, multifactorial -indeterminate duration -nociceptive and/or neuropathic
54
Define breakthrough pain
transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable trigger, despite relatively stable and adequately controlled background pain
55
Define incident pain
a type of breakthrough pain that is precipitated by a movement or a voluntary action, and is predictable or expected
56
Define spontaneous pain
a type of breakthrough pain that is not related to an identifiable precipitant, and so is unpredictable in nature
57
Define end-of-dose failure
a type of breakthrough pain that is described an exacerbation of pain that occurs prior to the next dose of the background analgesic, and reflects declining levels of the background analgesic
58
What would occur if the patient was given enough opioid to treat the peaks of incident pain at all times?
-the dose would result in excessive dosing for the periods between incidents -can make them groggy, etc.
59
Which medications are used for incident pain?
-fentanyl and sufentanil -more potent, rapid onset, short acting -sublingual or intranasal -q10-15 min PRN
60
What is the PPS?
Palliative performance scale -describes pt's current functional level -can help determine timeline for death
61
Describe delirium
-global cerebral dysfunction -"brain failure" -early signs often mistaken as anger, anxiety, depression, psychosis
62
What are some potentially reversible causes of delirium?
-infections -adverse med effects -metabolic abnormalities -pain -urinary retention -hypoxia
63
What are the types of delirium?
hypoactive hyperactive mixed
64
Describe hypoactive delirium
confusion, somnolence, decreased alertness
65
Describe hyperactive delirium
agitation, hallucinations, aggression
66
Describe mixed delirium
features of both hyperactive and hypoactive delirium
67
What are the characteristics of delirium?
-abrupt onset (VERY important to be able to differentiate from dementia) -disorientation, fluctuation of symptoms -hypoactive or hyperactive or mixed -changes in sleeping patterns -incoherent, rambling speech -fluctuating emotions -activity that is disorganized and without purpose
68
What are some things that we can do to prevent delirium?
-maintain sensorium-- hearing aids and glasses -orientation-- clocks, calendars, verbally reorient patient
69
What are the risk factors for dilerium?
-severe illness -sensory impairment -age (>65) -cognitive impairment (dementia) -dehydration -multiple meds -ETOH/substance use -previous delirium -infection -recovery from surgery -impairment of ADLs -pain
70
Which medications are first line therapy for dilerium?
First gen antipsychotics -haloperidol -methotrimeprazine
71
Define dyspnea
-an uncomfortable awareness/sensation of breathing -subjective and may not correlate with pulse oximetry, ABG, CXR, or pulmonary function tests
72
What is refractory dyspnea?
dyspnea that persists even when all identified reversible causes have been treated -persists at rest or with minimal activity despite optimal therapy of underlying condition
73
What is a dyspnea crisis?
sustained and severe resting breathing discomfort that occurs in patients with advanced, often life-limiting illness and overwhelms the pt and caregivers' ability to achieve symptom relief
74
What is incident dyspnea?
acute episode of breathlessness-- comes on as a result of an action or activity
75
What is the most reliable assessment of dyspnea?
the patient's subjective report
76
What is the first line medication therapy for dyspnea?
systemic opioids-- morphine and hydromorphone short-acting and regular low dose sustained release
77
What type of medication is provided for dyspnea accompanied by anxiety?
benzodiazepines -not used as routine management, only during a dyspneic episode
78
Define anorexia
involuntary loss of appetite or desire to eat that results in reduced caloric intake and often weight loss
79
Define cachexia
hypercatabolic state with accelerated loss of skeletal muscle in the context of a chronic inflammatory response
80
What is anorexia-cachexia syndrome?
a complex syndrome which is often defined in terms of its primary or secondary causes
81
What are the primary causes of anorexia-cachexia syndrome?
metabolic and neuroendocrine changes directly associated with underlying disease and an ongoing inflammatory state ie. cytokine production which stimulates chronic inflammation and resulting catabolism -body gets energy by breaking down its own muscle/fat rather than using food nutrients
82
What are secondary causes of anorexia-cachexia syndrome?
aggravating factors (fatigue, pain, dyspnea, dysphagia, infection, etc) that contribute to weight loss
83
What are the pharmacological interventions for decreased appetite?
1) Megestrol Acetate (MA)-- synthetic progesterone 2) Corticosteroids like Dexamethasone or Methylprednisolone 3) Metoclopramide
84
How does Megestrol Acetate work?
-synthetic progesterone -increases appetite and overall weight -no effect on QOL or lean body mass, and doesn't reverse cachexia
85
What is dexamethasone or methylprednisolone administered for?
-corticosteroids -increase appetite, nutritional intake, and well-being -effect lasts 3-4 weeks -possible modest weight gain but does not improve survival -most useful for life expectancy of <6-8 weeks
86
What is metoclopramide administered for?
treats early satiety in gastroparesis -increases gastric emptying and decreases nausea
87
What is mucositis or stomatitis?
inflammation, infection or ulceration of the mouth and throat leading to pain and sometimes bleeding
88
What are the common symptoms of mucositis/stomatitis?
redness pain swelling ulcers burning difficulty swallowing sensitivity to heat/cold, salty, or spicy
89
Define xerostomia
sensation of dry mouth-- sticky saliva
90
What causes xerostomia?
-dry mucosa-- mouth breathing, dehydration, N/V, cytotoxic agents, swallowing difficulties, etc -infection-- candidiasis, parotitis -decreased salivation-- drug therapy ie opioids, diuretics, anticholinergics, antidepressants (TCA), radiation to head and neck decreases salivation by 60%
91
Which laxatives are stimulant laxatives?
senna and bisacodyl
92
which laxatives are osmotic laxatives?
lactulose and PEG
93
What is Methylnaltraxone?
a selective opioid receptor blocker
94
What is docusate sodium?
stool softener
95
What are the indications for methadone?
-difficult to manage pain -neuropathic pain -allergies to standard opioids -neurotoxicity/hyperalgesia syndromes -patients on very high doses of opioids -use in renal failure

Palliative (8 decks)

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