Pain Lecture 3 and 4 Flashcards
What is pain?
An experience based on complex interactions of physical and psychological processes.
3 goals of pain control
1st- relieving the pain source
2nd- modify patients perception of discomfort
3rd- maximize function within the limitations of the pain perception
What are the three types of pain?
Nocioceptive
Neuropathic
Psychogenic
Where does pain enter and leave?
Enters through dorsal horn and exits through spinothalamic tract
What is an opioid?
any substance, whether endogenous or synthetic, that produces morphine-like effects that are blocked by the morphine antagonist naloxone
List the 9 opioids
- Codeine
- Hydrocodone
- Hydrocodone with acetaminophen (Vicodin)
- Morphine (MS Contin)
- Oxycodone (Oxycontin)
- Oxycodone with acetaminophen (Percocet)
- Fentanyl (Duragesic)
- Hydromorphone (Dilaudid)
- Meperidine (Demerol)
What are the indications for opioids?
analgesia, antitussive (codeine)
Opioid MOA
bind opioid receptors in the CNS to inhibit ascending pain pathways
Opioid routes
PO, rectal, IM, IV, topical, subcut infusion, epidural, intrathecal, intranasal, transmucosal
(everything)
Opioids most common AE
CNS- sedation, nausea
Peripheral- constipation
Which opioid side effect do you not gain a tolerance to?
Constipation, miosis
PT specific considerations regarding opioids
Respiratory depression even at usual doses-contributes to accidental OD
Cognitive Impairement
What is oxycodone often combined with for additive effects
acetaminophen or aspirin
Only mild-moderate opioid
codeine
What is special about codeine
It is a prodrug meaning that it is inactive until it is converted into morphine via metabolization
What does Tramadol increase the risk of?
Seizures
What schedule drug is tramadol?
IV
Difference between induction therapy and maintanence therapy?
Induction- inpatient to titrate drug out
Maintanence- outpatient for observation
Naloxone routes
IV, IM, subcut, intranasal
Opioid therapeutic concerns
- Drowsiness and decreased cognition
- Pateints pain perception is altered
- Avoid heat on patches
List the 8 NSAIDs
- Ibuprofen (Mortin, Advil)
- Naproxen (Aleve)
- Indomethacin
- Aspirin
- Celecoxib (Celebrex)
- Meloxicam
- Diclofenac (Voltaren gel, Flector patch)
- Trolamine salicylate (Aspercreme)
Aspirin AE
GI
Rare skin rash
Rayes Syndrome
Why would you need to increase your aspirin dose?
In order to be selective for cox-2 as well as cox 1.
Cox-2 for analgesia and anti inflammatory effects
NSAID general risks
Renal
GI
Cardiovascular
Which drug should be avoided if you have a CV risk?
Celecoxib
Take naproxen
If you have a GI risk you should take which NSAIDs?
Ibuprofen or Celecoxib
Acetaminophen route
PO, IV, rectal
Acetaminophen indication
Analgesia and Anti-pyretic
Combo with NSAIDs to reduce risk
Acetaminophen AE
Hepatotoxicity
Metabolized in 3 ways (3rd is hepatotoxic)
Acetaminophen MOA
inhibits prostoglandin synthesis in CNS
What population is this the safest?
Elderly
What are the two types of neuropathic pain?
Stimulus independent and stimulus dependent (If I don’t know the meaning, its stimulus-dependent)
What is the first line of treatment for neuropathic pain
Gabapentin
What are the AE of gabapentin
dizziness and drowsiness
What is intraarticular hyaluronate
Injection used to provide joint lubrication
What is RA
Chronic, progressive, systemic inflammatory disease
autoimmune disease
What are the 2 main drug groups to treat RA
Non-biologic and biologic (TNF inhibitor and non-TNF inhibitor) DMARD
Drugs in each of these groups:
- Non biologic DMARD
- Biologic TNF inhibitor DMARD
- Biologic non-TNF inhibitor DMARD
1. Hydroxychloroquine Sulfasalazine Methotrexate (MTX) 2. Adalimumab Etanercept 3. Rituximab
What is the gold standard for RA?
Methotrexate
Combo of MTX+ another DMARD
Can improve efficacy but also toxicity
What is the purpose of corticosteroids?
Short term treatment of RA
Routes for corticosteroids?
PO and intraarticular
Corticosteroid MOA?
decrease inflammation and suppresses immune system
Corticosteroid long term vs short term AE
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
MTX MOA
unknown in RA, possibly by impacting IL-1 (interleukin), TNF-alpha and leukotriene levels
MTX route
PO once weekly
MTX common AE
N/V/D, alopecia, malaise
MTX less common AE
↑ liver function tests (LFTs), hepatotoxicity, nephrotoxicity, thrombocytopenia, bone marrow suppression
Hydroxychloroquine MOA
impacts mediators of inflammatory response
Hydroxychloroquine route
PO
Hydroxychloroquine common AE
GI and skin reactions
Hydroxychloroquine rare AE
retinal toxicity
Hydroxychloroquine indication
RA, Lupus, Malaria
non-TNF and TNF inhibitor route
IV or subcut
serious infection risk
What do both non-TNF and TNF inhibitor’s MOA act on
inflammation process
Rehab concerns with DMARDS
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
What is SLE
Systemic Lupus Erythematosus
Auto-antibody production (i.e. body produces antibodies against its own cells and causes tissue damage)
SLE has what type of cell activity
A lot of B cell activity
SLE treatment
mild-moderate (no major organ manifestations):
- NSAIDs (arthritis, arthralgia, fever)
- Steroids (inflammation)
- Antimalarials
- Hydroxychloroquine (Plaquenil)
- Immunosuppressants
severe (major organ manifestations):
- High-dose steroids
- Immunosuppressants
Rehab concerns for SLE drugs
Immunosuppression
Infection control!!
Photosensitivity
Bacterial infections
