Pain lecture part 1

Question 1

Common chronic pain conditions include

Answer 1

lumbar radiculopathy
facet arthropathy
SI joint dysfunction
occipital neuritis

Question 2

The following material is released after trauma and is thought to enhance afferent transmission

Answer 2

potassium 
plasma
red and white blood cells
clotting factors
peptides 
prostaglandins
inflammatory cells

Question 3

Release of substance P & calcitonin gene related peptide causes

Answer 3

vascular leaking leading to swelling

Question 4

Release of materials enhance activation of

Answer 4

membrane channels (Na+, Ca++)

Question 5

Pain response without tissue injury includes

Answer 5

“escape” response consistent with intensity of stimulation

removal of stimulation terminates the sensation & response

Question 6

The sensation of a pain response without tissue injury is specific to

Answer 6

a site of potential injury

Question 7

The initial sensation to pain response without tissue injury is

Answer 7

sharp, followed by dull sensation

Question 8

Pain response with tissue injury includes

Answer 8

pain persists after removal of stimulus

stimulating injured tissue cause an intense response (hyperalgesia)

Question 9

Pain response with tissue injury has both

Answer 9

localized sensation and referred sensation

Question 10

______ of stimulation is required to elicit an adverse response in pain response with tissue injury

Answer 10

lower threshold

Question 11

Allodynia is defined as

Answer 11

increased pain sensation with light touch

-pain that should not be

Question 12

Pain response with nerve injury is an ongoing unpleasant pain sensation usually referred to

Answer 12

the dermatome innervated by the injured nerve (hyperalgesia)

-pain greater than expected)

Question 13

The evolution of chronic pain is

Answer 13

associated with nerve injury response
failure to treat nerve & tissue injury effectively 
occult inflammation 
failure of tissue healing 
persistent inflammation

Question 14

Windup is defined as

Answer 14

when normal pain responses become abnormal

Question 15

Chronic pain results in

Answer 15

despair, poverty, homelessness, divorce, suicide

Question 16

The pathway to windup includes

Answer 16

repetitive stimulation releases glutamate, neurokinin, substance P** overwhelming the Mg block
channels are opened, proteins couple with receptors producing long lasting Ca++ release
glial cell dysfunction (dorsal horn)
loss of central inhibition mechanisms

Question 17

Loss of central inhibition mechanisms include

Answer 17

increased intracellular Ca++
release of arachidonic acid (irritant)
creation of cylooxygenase (Cox)
Cox synthesizes prostaglandins
which reduce glycine and GABA mediated inhibition 
negative impact on NMDA receptors 
promote dorsal horn excitability

Question 18

Goals of pain treatment include

Answer 18

improve mobility and activities of daily living
ensure compliance with treatment plan
address emotional/social components
decrease pain sensation

Question 19

Nonsteroidal anti-inflammatory drugs have the following activities:

Answer 19

antipyretic
anti-inflammatory
analgesia
acetaminophen has little anti-inflammatory activity

Question 20

MOA of NSAIDS include

Answer 20

inhibits prostaglandin production from arachidonic acid by acetylation of COX

Question 21

COX1 is responsible for

Answer 21

contributes to hemostasis & platelet aggregation

protects the gastric mucosa via prostacyclin production

Question 22

Cox2 is responsible for

Answer 22

producing inflammation
contribute to fever
stimulates pain sensation
supports prostacyclin anti-coagulation activity
both are present peripherally and in the CNS

Question 23

Absorption of NSAIDs includes

Answer 23

orally in the stomach and small intestines
peak concentration in 1-4 hours
food delays absorption
IV admin may not reduce negative gastric effects
topical absorption has advantages of local targeted effect

Question 24

Distribution of NSAIDs include

Answer 24

weakly acidic
highly plasma bound
liphophilic
only unbound portion is effective

Question 25

Elimination of NSAIDs include

Answer 25

hepatic oxidation & conjugation less than 10% renal elimination some active metabolites

Question 26

Examples of propionic acid include

Answer 26

Naproxen (aleve)- non-selective COX | ibuprofen- non-selective COX

Question 27

Anthranilic acid includes

Answer 27

meloxicam (Mobic)- cox 2 | -cox 2 selective at lower doses <15 mg

Question 28

Acetic acid drugs include

Answer 28

diclofenic indomethacin- non-selective- high GI side effects toradol- non-selective- can impair renal function, limit doses to 3-5 days

Question 29

Describe issues with diclofenic.

Answer 29

hepatic toxicity transdermal use is effective without systemic toxicity increased risk of thrombotic event

Question 30

Pure cox 2 inhibitor includes

Answer 30

celecoxib (celebrex)

Question 31

Celebrex may be used in treatment of

Answer 31

colon polyps, cancer, mental illness

Question 32

IV tylenol may be used to

Answer 32

reduce post-operative narcotic consumption

Question 33

Tylenol works by

Answer 33

inhibiting central prostaglandin synthesis poor cox inhibition no effect on platelet function or gastric mucosa

Question 34

Salicylates include

Answer 34

aspirin -nonselective cox inhibitor long term antipyretic and anti-inflammatory properties

Question 35

Long term effects of aspirin include

Answer 35

bleeding ulcers Reye's syndrome (children)

Question 36

NSAID side effects include

Answer 36

gastric mucosa dyspepsia decreased renal function hepatic side effects acetaminophen hepatotoxicity increased platelet aggregation at high doses decreased platelet aggregation at low doses (ASA)

Question 37

Opioid receptors include

Answer 37

Mu, Kappa, & Delta

Question 38

Effects of stimulating the Mu receptors include

Answer 38

``` analgesia respiratory depression euphoria sedation decreased GI motility dependence ```

Question 39

Effects of stimulating the kappa receptors include

Answer 39

``` spinal analgesia sedation dyspnea dependence dysphoria respiratory depression ```

Question 40

Effects of stimulating the delta receptors include

Answer 40

psychomimetic effects** dysphoria increased release of dopamine stimulating pleasure centers insignificant analgesic effects

Question 41

Most effects and side effects of opioids can be traced to

Answer 41

metabolites | higher metabolite activity usually means more side effects

Question 42

Metabolites can produce

Answer 42

hyperalgesia

Question 43

Opioid side effects include

Answer 43

constipation - does not resolve over time nausea pruritus sedation- transient respiratory depression- long term use leads to sleap apnea endocrine- low testosterone, amenorrha, immunologic, inhibition of cellular response

Question 44

The solution to opioid side effects is to

Answer 44

reduce opioid use

Question 45

The primary action of oxycodone is

Answer 45

kappa (dysphoria) | metabolites have anti-sedative effects