Pain - Block 2 Flashcards
What is pain?
Unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
- Overall, pain is very subjective
What are the factors that affect pain?
- Biological
- Psychological
- Social
What are the duration classification of pain?
What are the classifications of the type of pain?
What is adaptive pain?
Physiologic: Stimulated by temperature extremes, mechanical trauma, or chemical irritation
Protective: Designed to protect the body from actual or potential tissue injury
What is the physiological process of adaptive pain?
What are the types of somatic pain?
Superficial: skin, SC, mucous membranes (localized, sharp, pricking, throbbing, burning)
Deep: muscles, tendons, joints, bones (dull, aching, less well localized)
What is visceral pain?
Due to a disease process or abnormal function involving an internal organ or its covering
What are the types of visceral pain?
- True localized visceral pain
- Localized parietal pain
- Referred visceral pain
- Referred parietal pain
What are the presentation of visceral pain?
Dull, diffuse, and usually midline; frequently associated with abnormal autonomic activity causing nausea, vomiting, sweating, and changes in blood pressure and heart rate
What are the presentations of parietal pain?
Sharp and often described as a stabbing sensation that is either localized to the area around the organ or referred to a distant site
What is and the presentation of maladaptive pain?
Pathophysiologic & harmful: episodic or conituous pain, (burning, tingling, shock-like, or shooting), hyperalgesia, allodynia
What are the types of maladaptive pain?
Neuropathic
CNS
Central
What is neuropathic pain?
Damage or abnormal functioning of the peripheral nervous system (PNS)
Ex: Postherpetic neuralgia, painful diabetic neuropathy, trigeminal neuralgia, phantom limb, or chemotherapy-induced neuropathy
What is CNS pain?
Damage or abnormal functioning of the CNS
Ex: Ischemic stroke, spinal cord injury, or multiple sclerosis (MS)
What is central pain?
No nerve injury or inflammation exists, but a centrally mediated disturbance in pain processing within the CNS
Ex: Fibromyalgia, irritable bowel syndrome (IBS), temporomandibular joint disorder, and myofascial pain syndrome
What are the screening tools for PAIN?
- SCHOLAR-MAC
- OLD-CARTS
- SOCRATES
- PQRST
What is used to assess the full body for pain?
Melzack Pain Questionaire
What are the types of severity indices?
- Verbal Pain INtensity Scale
- Visual analogue scale
- 0-10 numeric pain intensity scale
- Wong-baker faces pain rating scale
What are examples of non-verbal screeening tools?
FLACC scale (Face, Legs, Activity, Cry, Consolability)
- Guarding
- Increased vitals
- Increased respiratory rate
- Facial expressions
- Movement/activity
What is the difference between acute and chronic pain?
What are the tx goals for acute pain?
Pain relief to help patients attain functional goal
What is the tx goals for chronic pain?
- Improve functioning
- Decrease pain
- Reduced med use
- Improve QoL
What are the components of multimodal pain managment?
- Medications (Opioid and Non-opioid)
- Restorative tx
- Interventional procedures
- Behavioral health approaches
- Complementary and intregrative health
What are the requirements for selecting non-pharm?
What are types of restorative therapies?
Therapeutic exercise (PT/OT)
Transcutaneous electric nerve stimulation (TENS)
Massage therapy
Traction
Cold and heat
Therapeutic ultrasound
Bracing
What is the difference between PT and OT
PT: focuses on an area of dysfunction
OT: Improves ADL functioning
What are the types of behavioral health approaches?
What are the types of Complementary & Integrative Health?
What are the pharmacologic approaches to pain?
COnsiderations for selecting a pain med?
1.Severity and duration
2.Frequency
3. Comorbidity
4. Frequency
5. Concomitatn med
6. Allergies
Classes of pain meds?
- NSAIDs
- APAP
- Opioid
- ANticonvulsants
- Antidepressants
- Musculoskeletal Agents
- Topical
- Emerging
Acetaminophen
MOA, Dosing, Considerations
MOA: antipyretic and analgesic
Dosing:
* Adult: 325-1000 mg Q4-6H PRN (Max: 3 g)
* Children: 10-15 mg/kg Q4-6H PRN (Max: 75mg/kg/d)
Consideration: hepatic metabolism, alcohol
What is the antidote for APAP?
NAC: to shift pathway to non-hepato tox
NSAIDs
MOA, PK, ADR, COnsideration
MOA: Antipyretic, analgesic, anti-inflammatory
PK: High F, High PPB, absorption as active drugs (except sulindac and nabumetone -> hepatic conversion)
ADR: CV thrombotic events (except aspirin), GI bleeding, ulcerations, and perforations
Considerations: CV hx, kidney function, preganancy status
How do you reduce GI risk from NSAIDs?
- Take the lowest dose possible and only when needed
- Misoprostol QID (reduce ulcer rate and GI complications)
- PPI or full dose H2RA QD
- COX2 selective
Who are CI from taking NSAIDs?
Active ischemic HD, cerebrovascular dx, mod-severe heart failure
What NSAID has the less of a CV risk?
Naproxen
What are the renal effects of NSAIDs?
- Acute renal insufficiency
- Sodium retention
- Acute interstitial nephritis
- Renal papillary necrosis
- Accelerated chronic kidney disease
NSAIDs inhibt compensatory vasodilation
What are the DDI fo NSAIDs?
Lithium, warfarin, agents that increase bleeding risk, AntiHTN, diuretics, ACEI, b-blockers
What are the coxib DDI?
Metabolized by CYP2C9
- Inducers: rifampin, carbamazepine, and phenytoin
- Inhibitors: fluconazole, fenofibrate, Bactrim
Inhibits CYP2D6
Celebrex is a sulfonamide -> allergies
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What are the meds used for maladaptive pain?
Anticonvulsants:
1. Carbamazepine, Oxcarbazepine
2. Gabapentin, Pregabalin
3. Lamotrigine
4. Topiramate
Why are antidepressants used for pain?
Decrease 5-HT and NE
What are the meds used for neuropathic pain?
TCA:
* Amitriptyline
* Imipramine
* Nortriptyline (less anticholinergic effects)
* Desipramine (less anticholinergic effects)
SSRI:
* Duloxetine
* Milnacipran
* Venlafaxine
What is the difference between spasm and spasticity?
Spasm: Involuntary contractions of the muscle
Spasticity: upper motor neuron disorder
What are the sx and causes of spasms?
Sx: jerks, twitches, cramps
Causes: musculoskeletal pain, fibromyalgia, sciatica (peripharl conditions)
What are the sx and causes of spasticity?
Sx: stiffness, hypertonicity, and hyperreflexia
Causes: MS, CP, spinal cord or brain injury, post-stroke syndrome (central conditions)
What are you antispasmodics?
- Carisoprodol
- Chlorzoxazone
- Cyclobenzaprine
- Methocarbamol
- Metaxalone
- Orphenadrine
What are you antispasticity?
Baclofen
Dantrolene
Types of topical NSAIDs?
Diclofenac
Types of local anesthetics? What has the longest DOA?
Lidocaine, benzocaine, and pramocaine; bupivacaine (liposomal)
* Decrease discharges in superficial somatic nerves and cause numbness on the skin surface
ADRs of local anesthetics?
LAST:
* CNS: excitation and depression
* Cardiac effects
MOA of rubefacients? Types?
Produce redness; methyl salicylate
Counterirritants that produce cooling effects?
Camphor, menthol
Counterirritants that cause vasodilation?
Methyl nicotinate
Counterirritants that irritate without redness?
Capsaicin
What counterirritant is used for chronic pain?
Capsacin -> ↓ Substance P
Types of opioids?
Common ADRs of opioids?
N/V (transient)
Constipation
Dependence
Tolerance
Pruritus
What is the standard opioids are compared to?
Morphine
What are common full mu agonists?
- Morphine
- Hydromorphone
- Codeine
- Oxycodone
- Hydrocodone
- Fentanyl
- Metadone
What is the CI with morphine?
CrCl <30 mL/min
Does fentanyl require dosing adjustments?
Renal and hepatic adj with patch
How is methadone unique compared to other full µ agonists?
Can be used for neuropathic pain because it is an NMDA receptor antagonist, kappa/delta opioid receptor agonist, seratonin/NE reuptake inhibitor
ADR: QTc prolongation
Requires titration in 5-7 day increments cause of long t1/2
Opioid conversion
What the counseling points for topical fentanyl?
- Apply to flat surface (chest, back - cognitive impaired, flank, upper arm)
- Excess hair may be clipped but not shaved
- Don’t cut
- Change Q72H and rotate site
- May tape edges, but don’t wrap
- Don’t expose to excessive heat
- Fold and flush after use
- Wash hands thoroughly
What are the types of opiod antagonists?
- Butorphanol and nalbuphine (psychomimetic responses)
- Buprenorphine
- Buprenorphine/Naloxone
What is Nalbuphine used for?
MOR agonist-associated pruritis
What is suboxone used for?
Opioid use disorder
What are examples of central acting opiods?
Tramadol
Tepentadol
ADR of central acting opioids?
Sz, hyponatremia, hypoglycemia with tramadol
Types of opioid antagonists?
- Naloxone (Narcan), nalmefene (Opvee) - reversal agents
- Naltrexone (Vivitrol) -> w/ buproprion for weight loss
- Naloxegol (Movantik), naldemedine (Symproic), methylnatrexone (Relistor), Linaclotide (Linzess) - Peripheral acting used for opioid induced constipation
What is opioid tolerance?
Reduction of med effect over time as a result of exposure to the agent
What is hyperalgesia?
Increased sensitivity to pain
What is physical dependence?
An abstinence syndrome following admin of an antagonist med or abrupt dose reduction or discontinuation
What are the types of emerging therapies?
Ketamine
Cannabis
What are neurosurgical procedures for pain management?
What is the treatment for acute pain?
Nonopioid therapies are just as effective as opioids
3-7 days supply of opioids is recommends with close follow-up
What is PCA?
Patient controlled analgesia: IV opioids utilized with basal-bolus conceptr
* Button should only be pushed by the patient
What the guideline to prescribing opioids for chrronic pain?
What do we use to determine if patients should recieve chronic opioid alalgesia?
DIRE score
* 7-13: not suitable
* 14-21: suitable
What are the steps to develop an opioid regimen?
What should opioid tapering look like?
Taper slow enough to minimize sx and signs of withdrawal
Short duration: Decrease of 10% of the original dose per week or slower -> 30% of the original dose is reached -> weekly decrease of approximately 10% of the remaining dose
Long duration: Longer durations (e.g., for ≥1 year) of opioid use -> tapers of 10% per month or slower -> approximately 30% of the original dose is reached -> weekly decrease of approximately 10% of the remaining dose
