Pain Lecture 3 and 4

Question 1

What is pain?

Answer 1

An experience based on complex interactions of physical and psychological processes.

Question 2

3 goals of pain control

Answer 2

1st- relieving the pain source

2nd- modify patients perception of discomfort

3rd- maximize function within the limitations of the pain perception

Question 3

What are the three types of pain?

Answer 3

Nocioceptive
Neuropathic
Psychogenic

Question 4

Where does pain enter and leave?

Answer 4

Enters through dorsal horn and exits through spinothalamic tract

Question 5

What is an opioid?

Answer 5

any substance, whether endogenous or synthetic, that produces morphine-like effects that are blocked by the morphine antagonist naloxone

Question 6

List the 9 opioids

Answer 6

• Codeine
• Hydrocodone
• Hydrocodone with acetaminophen (Vicodin)
• Morphine (MS Contin)
• Oxycodone (Oxycontin)
• Oxycodone with acetaminophen (Percocet)
• Fentanyl (Duragesic)
• Hydromorphone (Dilaudid)
• Meperidine (Demerol)

Question 7

What are the indications for opioids?

Answer 7

analgesia, antitussive (codeine)

Question 8

Opioid MOA

Answer 8

bind opioid receptors in the CNS to inhibit ascending pain pathways

Question 9

Opioid routes

Answer 9

PO, rectal, IM, IV, topical, subcut infusion, epidural, intrathecal, intranasal, transmucosal
(everything)

Question 10

Opioids most common AE

Answer 10

CNS- sedation, nausea

Peripheral- constipation

Question 11

Which opioid side effect do you not gain a tolerance to?

Answer 11

Constipation, miosis

Question 12

PT specific considerations regarding opioids

Answer 12

Respiratory depression even at usual doses-contributes to accidental OD

Cognitive Impairement

Question 13

What is oxycodone often combined with for additive effects

Answer 13

acetaminophen or aspirin

Question 14

Only mild-moderate opioid

Answer 14

codeine

Question 15

What is special about codeine

Answer 15

It is a prodrug meaning that it is inactive until it is converted into morphine via metabolization

Question 16

What does Tramadol increase the risk of?

Answer 16

Seizures

Question 17

What schedule drug is tramadol?

Answer 17

IV

Question 18

Difference between induction therapy and maintanence therapy?

Answer 18

Induction- inpatient to titrate drug out

Maintanence- outpatient for observation

Question 19

Naloxone routes

Answer 19

IV, IM, subcut, intranasal

Question 20

Opioid therapeutic concerns

Answer 20

• Drowsiness and decreased cognition
• Pateints pain perception is altered
• Avoid heat on patches

Question 21

List the 8 NSAIDs

Answer 21

• Ibuprofen (Mortin, Advil)
• Naproxen (Aleve)
• Indomethacin
• Aspirin
• Celecoxib (Celebrex)
• Meloxicam
• Diclofenac (Voltaren gel, Flector patch)
• Trolamine salicylate (Aspercreme)

Question 22

Aspirin AE

Answer 22

GI
Rare skin rash
Rayes Syndrome

Question 23

Why would you need to increase your aspirin dose?

Answer 23

In order to be selective for cox-2 as well as cox 1.

Cox-2 for analgesia and anti inflammatory effects

Question 24

NSAID general risks

Answer 24

Renal
GI
Cardiovascular

Question 25

Which drug should be avoided if you have a CV risk?

Answer 25

Celecoxib Take naproxen

Question 26

If you have a GI risk you should take which NSAIDs?

Answer 26

Ibuprofen or Celecoxib

Question 27

Acetaminophen route

Answer 27

PO, IV, rectal

Question 28

Acetaminophen indication

Answer 28

Analgesia and Anti-pyretic | Combo with NSAIDs to reduce risk

Question 29

Acetaminophen AE

Answer 29

Hepatotoxicity Metabolized in 3 ways (3rd is hepatotoxic)

Question 30

Acetaminophen MOA

Answer 30

inhibits prostoglandin synthesis in CNS

Question 31

What population is this the safest?

Answer 31

Elderly

Question 32

What are the two types of neuropathic pain?

Answer 32

Stimulus independent and stimulus dependent (If I don't know the meaning, its stimulus-dependent)

Question 33

What is the first line of treatment for neuropathic pain

Answer 33

Gabapentin

Question 34

What are the AE of gabapentin

Answer 34

dizziness and drowsiness

Question 35

What is intraarticular hyaluronate

Answer 35

Injection used to provide joint lubrication

Question 36

What is RA

Answer 36

Chronic, progressive, systemic inflammatory disease | autoimmune disease

Question 37

What are the 2 main drug groups to treat RA

Answer 37

Non-biologic and biologic (TNF inhibitor and non-TNF inhibitor) DMARD

Question 38

Drugs in each of these groups: 1. Non biologic DMARD 2. Biologic TNF inhibitor DMARD 3. Biologic non-TNF inhibitor DMARD

Answer 38

``` 1. Hydroxychloroquine Sulfasalazine Methotrexate (MTX) 2. Adalimumab Etanercept 3. Rituximab ```

Question 39

What is the gold standard for RA?

Answer 39

Methotrexate

Question 40

Combo of MTX+ another DMARD

Answer 40

Can improve efficacy but also toxicity

Question 41

What is the purpose of corticosteroids?

Answer 41

Short term treatment of RA

Question 42

Routes for corticosteroids?

Answer 42

PO and intraarticular

Question 43

Corticosteroid MOA?

Answer 43

decrease inflammation and suppresses immune system

Question 44

Corticosteroid long term vs short term AE

Answer 44

short term: increase blood glucose, mood changes, fluid retention long term: osteoporosis/↑fracture risk, thin skin, muscle wasting, poor wound healing, adrenal suppression, Cushing’s disease, ↑ risk of infection due to immunosuppression

Question 45

MTX MOA

Answer 45

unknown in RA, possibly by impacting IL-1 (interleukin), TNF-alpha and leukotriene levels

Question 46

MTX route

Answer 46

PO once weekly

Question 47

MTX common AE

Answer 47

N/V/D, alopecia, malaise

Question 48

MTX less common AE

Answer 48

↑ liver function tests (LFTs), hepatotoxicity, nephrotoxicity, thrombocytopenia, bone marrow suppression

Question 49

Hydroxychloroquine MOA

Answer 49

impacts mediators of inflammatory response

Question 50

Hydroxychloroquine route

Answer 50

PO

Question 51

Hydroxychloroquine common AE

Answer 51

GI and skin reactions

Question 52

Hydroxychloroquine rare AE

Answer 52

retinal toxicity

Question 53

Hydroxychloroquine indication

Answer 53

RA, Lupus, Malaria

Question 54

non-TNF and TNF inhibitor route

Answer 54

IV or subcut | serious infection risk

Question 55

What do both non-TNF and TNF inhibitor's MOA act on

Answer 55

inflammation process

Question 56

Rehab concerns with DMARDS

Answer 56

Awareness of drug toxicity - Skin rashes: inspect skin - Renal effects: toxic metabolites  keep patient hydrated! - Liver effects Other concerns - Immunosuppression - Bone marrow suppression - Easily bruised - Anemia - Fatigue

Question 57

What is SLE

Answer 57

Systemic Lupus Erythematosus Auto-antibody production (i.e. body produces antibodies against its own cells and causes tissue damage)

Question 58

SLE has what type of cell activity

Answer 58

A lot of B cell activity

Question 59

SLE treatment

Answer 59

mild-moderate (no major organ manifestations): - NSAIDs (arthritis, arthralgia, fever) - Steroids (inflammation) - Antimalarials - Hydroxychloroquine (Plaquenil) - Immunosuppressants severe (major organ manifestations): - High-dose steroids - Immunosuppressants

Question 60

Rehab concerns for SLE drugs

Answer 60

Immunosuppression Infection control!! Photosensitivity Bacterial infections