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Spring 2022 > Pain Management > Flashcards

Pain Management Flashcards

1
Q

What is acute pain?

A

Nociceptive pain associated with specific somatosensory stimuli with an identifiable peripheral injury or lesion
<12 weeks duration

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2
Q

When does acute pain transition to chronic pain classification?

A

12 weeks

Shift from peripheral damage and tissue inflammation to more central sensitization and CNS mechanisms

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3
Q

Risks for transitioning from acute to chronic pain

A

Hx of chronic pain elsewhere
Stress
Comorbidities

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4
Q

What are the characteristics of centralized chronic pain?

A

Multifocal

Almost always associated with symptoms of energy, sleep, memory, mood disturbance

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5
Q

Define neuropathic pain origin

A

Pain caused by lesion or disease of the somatosensory nervous system

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6
Q

Define nociceptive pain

A

Pain that arises from actual or threatened damage to non-neural tissue and results d/t activation of nociceptors

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7
Q

Neuropathic Pain

Duration/Timing

A

Spontaneous, continuous, paroxysmal, evoked

Allodynia

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8
Q

Allodynia

A

Sensitive to touch

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9
Q

Neuropathic Pain

Descriptors/Qualities

A

Burning, electrical shock-like, dysesthesia, brush allodynia

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10
Q

Dysesthesia

A

Abnormal sensation

Pain-like quality: burning, tingling, prickling, aching

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11
Q

Identifying sources of neuropathic pain

A

PE

Evaluate for thermal and mechanical sensory deficits

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12
Q

Diagnostic testing for neuropathic pain

A

EMG
Quantitative sensory testing,
Brain/spinal cord imaging Nerve or skin biopsy

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13
Q

What is the DN4 Questionnaire?

A

Estimates probability of neuropathic pain
-Characteristics, associated symptoms, PE findings for hypoesthesia to touch and pinprick and ability to increase or illicit pain by brushing

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14
Q

History components for pain

A

Onset, location, duration, timing, characteristics, alleviating/aggravating factors, associated symptoms, impact on QOL

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15
Q

Psychosocial considerations for pain assessment/chronic pain

A

Psych hx, medical hx, r/f SUD

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16
Q

Biological Pain Factors

A

Etiology, dx, age, injury, neuro, genetic, hormones, obesity

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17
Q

Psychological Pain Factors

A

Mood, stress, coping, trauma, childhood

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18
Q

Social Pain Factors

A

Culture, economic, social support, spirituality, ethnicity, education, bio/stigma

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19
Q

Management of Refractory Neuropathic Pain

A

Interventional: Spinal cord stimulator, spinal medications, blocks, surgical

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20
Q

Management of Mild Pain

A

Non-opioids +/- adjuvant

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21
Q

Management of Moderate Pain

A

Weak opioid + non-opioid +/- adjuvant

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22
Q

Management of Severe Pain

A

Strong opioid + non-opioid +/- adjuvant

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23
Q

What are the 5 As of Pain Management?

A

Analgesia - pain relief
Activities - optimize ADLs, psychosocial functioning
Adverse effects - minimize AEs
Aberrant drug taking - Avoid d/t addiction-related outcomes
Affect - Relationship between pain and mood

Always document in clinical note

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24
Q

Non-opioid pain management medications

A

APAP, NSAIDs, anticonvulsants, antidepressants, musculoskeletal agents, anti-anxiety agents

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25
First line therapy for chronic neuropathic pain
Anticonvulsants - pregabalin, carbamazepine, oxcarbazepine, gabapentin SNRIs - duloxetine, venlafaxine TCAs - Nortriptyline, amitriptyline Topical analgesics - lidocaine, capsaicin
26
First line pharmacological management of neuropathic pain with strong evidence
Gabapentin 400 to 1200 mg TID Gabapentin 600 to 1800 mg BID Pregabalin 150 to 300 mg BID SNRIs: Duloxetine (Cymbalta) 60 to 120 mg daily Venlafaxine (Effexor) ER 150 to 225 mg daily TCAs (Nortriptyline/amitripyline) 25 to 150 mg daily or 12.5 to 75 mg BID
27
Second line pharmacological management of neuropathic pain with weak evidence
Capsaicin 8% patches One to four patches to painful area for 30-60 min q3m Lidocaine patches One to three patches to pain region daily 12h on/12h off Tramadol 200-400 mg in three divided doses; if ER in 2 divided doses
28
Third line pharmacological management of neuropathic pain with weak evidence
Botulinum toxin A 50-200 units SQ q3m Strong Opioids
29
Pharmacologic agents for neuropathic pain with inconclusive recommendations
``` Combination therapy Capsaicin cream Carbamazepine Clonidine topical Lacosamide Lamotrigine NMDA antagonists Oxcarbazepine SSRIs Tapentadol Topiramate Zonisamide ```
30
Pharmacologic agents for neuropathic pain with weak recommendations against use
Cannabinoids | Valproate
31
Pharmacologic agents for neuropathic pain with strong recommendations against use
Levetiracetam | Mexiletine (Anti-arrhythmic)
32
Management of non-neuropathic, non-cancer pain
First line - APAP, NSAIDs ``` Alternatives: Antispasmodics - tizanidine (Zanaflex), baclofen Topical preparations Multimodal approaches SNRIs TCAs ```
33
Opioids | Routes of Administration
oral, buccal, SL spray, IV, IM, intrathecal, suppository, transdermal, lozenges
34
When may the efficacy of opioids wane?
After 3 months
35
Side effects of opioid medications
Constipation, sedation, lethargy, nausea, vomiting, irritability, pruritus, respiratory depression
36
What is opioid induced hyperalgesia (OIH)?
Enhanced pain sensitization with prolonged opioid therapy Pain is generalized, diffuse, ill-defined despite increasing dosages Management options: wean opioid, opioid rotation, NMDA antagonist (ketamine)
37
Opioid therapy evaluation for risk of harm and misuse should include what two documents?
Opioid agreement | Informed consent
38
What are the frequency of reassessment intervals when initiating and continuing opioid therapy?
Reassess in 4 weeks then q3m
39
Current recommendation for MDD of opioids per morphine equivalency?
Less than 90 mg of morphine mg equivalent per day
40
Opioids interactions with hypothalmic-pituitary-adrenal and gonadal tracts
Decreased sex hormones/fertility Decreased cortisol Decreased growth hormone
41
Signs and symptoms of opioid induced endocrinopathies | Hypothalamic-pituitatry-gonadal
Female: amenorrhea, dysmenorrhea, menstrual cycle disturbance Male: ED, decreased libido, decreased sperm, loss of muscle mass Fatigue, weakness, osteoporosis, depression, anxiety, anemia
42
Signs and symptoms of opioid induced endocrinopathies | Hypothalamic-pituitatry-adrenal
Hypotension, n/v, hypoglycemia
43
Signs and symptoms of opioid induced endocrinopathies | Pituitary
Decreased growth hormone, s/s unknown
44
Components of opioid use informed consent
Discuss risk/benefit, potential for common opioid-related AEs, risk of chronic therapy, respiratory depression/death, risks of long-term or high-dose therapy
45
Objectives of obtaining an opioid agreement
Improve adherence with safe use of controlled substances and reducing aberrant behaviors Obtain informed consent Outline prescribing policy/procedure Mitigate provider's legal risk
46
Recommendations for monitoring opioid therapy
Document pain intensity and level of functioning Assess and document progress towards therapeutic goals Presence of AEs Adherence to therapy Evaluate q3m minimum
47
Alcohol use and opioids
No safe level of use | Increases r/f morbidity and mortality
48
Naloxone (Narcan)
?
49
Buprenorphine Uses
OUD, pain management
50
Buprenorphine | Class and mechanism of action
Opioid partial agonist of mu receptors
51
Restorative therapies for pain
PT, OT, physiotherapy, exercise, TENS, traction, cold/heart, therapeutic u/s, bracing
52
Interventional Procedures for Pain Management Examples
Trigger point injections, joint injections, peripheral nerve injections Nerve block, epidural, radio-frequency (RF) ablation, autologous stem cell therapy, cryoneuroablation, neuromodulation Spinal cord sitmulation, intrathecal pump, vertebral augmentation, percutaneous discectomy
53
Behavioral health approaches to managing pain
Behavioral therapy, CBT, acceptance and commitment therapy (ACT), mindfulness-based stress reduction (MBSR), emotional awareness and expression therapy (EAET), self-regulatory and psychophysiological approaches
54
Barriers to behavioral health interventions for pain management
Clinical barriers: Accessibility, knowledge gaps, provider attitudes System barriers: cost and reimbursement Patient barriers: stigma, attitude
55
OUD DSM-5 Criteria
- Larger amounts over longer periods - Persistent desire to use, unsuccessful efforts to cut down - Time spent obtaining/recovering - Craving, strong desire - Use interfering with major role obligations - Continued use despite negative consequences - Giving up social, occupational, or recreational activities to use - Physically hazardous situations - Continued use despite psych/physical problem caused by or exacerbated by use - Tolerance - Withdrawal
56
OUD DSM-5 Criteria for Classification
Mild: 2-3 s/s Mod: 4-5 s/s Severe: 6+ s/s
57
OUD Risk Assessment Components
Biopsychosocial Approach - Patient hx - PE - Dx screening tools - Consult PDMP
58
PDMP Monitoring
State program to check for fill dates, refill patterns, prescribers, length of medication supply, meds in other states
59
Components of the Opioid Risk Tool (ORT)
Fam Hx of SUD ETOH 1pt Illegal drugs 2pt Rx 4pt Personal Hx of SUD ETOH 3pt Illegal drugs 4pt Rx 5pt Ages between 16-45yr 1pt Hx of preadolescent abuse 3pt Psych disorder ADD, OCD, bipolar, schizo 2pt depression, anxiety 1pt Low risk 0-3 Mod 4-7 High 7+
60
Urine toxicology for opioid treatment
Random | Assess for adherence/abuse
61
How is low back pain classified?
Symptom duration, potential cause, presence or absence of radicular pain symptoms, and corresponding anatomical or radiographic abnormalities
62
Duration of back pain | Acute/Subacute/Chronic
Acute - 4 weeks Subacute - 4-12 weeks Chronic - >12 weeks
63
Treatment recommendations for acute or subacute back pain
Non-pharmacologic methods are essential - heat, massage, acupuncture, spinal manipulation Pharmacological methods: NSAIDs, muscle relaxants
64
Non-pharmacologic treatment recommendations for chronic back pain First-line
Rehab, acupuncture, mindfulness-based stress reduction (MBSR), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, spinal manipulation, CBT, operant therapy, low-level laser therapy
65
Pharmacologic treatment recommendations for chronic back pain
First-line: NSAIDs | Second-line: Duloxetine (Cymbalta), tramadol
66
First line treatment for OA of hands
Exercise, self-efficacy and self-management programs, CMC orthoses, NSAIDs,
67
First-line treatment of OA of knees
Exercise, self-efficacy and self-management programs, NSAIDs, topical NSAIDs, IA steroids, weight loss, tai chi, cane, knee brace
68
First-line treatment of OA of hips
Exercise, self-efficacy and self-management programs, NSAIDs IA steroids, weight loss, tai chi, cane
69
Pharmacologic Treatments for OA
NSAIDs, intraarticular glucocorticoids, APAP, duloxetine, tramadol, topical capsaicin
70
Myofascial Pain Syndrome | Definition
Presence of trigger points within muscles or fascia Trigger point characteristics: - tender/hyperirritable - Taut - Palpable bands - Mediated twitch response
71
Myofascial Pain Syndrome | Risk Factors
``` Etiology unknown: overuse, disuse Ergonomic factors: posture, overuse Structural factors: OA, scoliosis Systemic factors: hypothyroid, vitamin d deficiency, iron deficiency Oral parafunctional behaviors, TMJ Insomnia Hx of Ca Psychological factors ```
72
Myofascial Pain Syndrom | Diagnosis
Trigger Points Manual Needs 5 major criteria and 3 minor criteria Major: localized spontaneous pain, altered sensations in the expected referred area for a given trigger point, taut palpable band, localized tenderness at precise point, reduced ROM Minor: reproduction of spontaneously perceived pain and altered sensations by pressure of trigger point, elicitation of a local twitch response of muscle fibers by transverse snapping palpation or by needle insertion into trigger point, pain relieved by muscle stretching or injection of trigger point
73
Referred pain patterns of the upper trapezius muscle in MPS
Neck behind ear, loops above ear to behind eye, TMJ/lower jaw
74
Referred pain patterns of the strernocleidomastoid muscle in MPS
Trigger points along muscle Upper occiput pain, radiated around eye, top of head, chin, under jaw, cheeks Clavicular division: Ear, Forehead
75
Myofascial Pain Syndrome treatment
Rehabilitate muscles: stretching, posture, strengthening, CV. fitness Topical anesthetic, injection Botulinum Toxin A Acupuncture, kinesiotaping, TENS, infrared ray, shockwave, laser
76
COVID-19 and Chronic Pain
Those with covid history especially in setting of inflammatory conditions Caregivers, burnout
77
Examples of 50 Morphine Milligram Equivalents (MME)/day
50 mg of hydrocodone 33 mg of oxycodone 12 mg of methadone
78
Examples of 90 MME/day
90 mg of hydrocodone 60 mg of oxycodone 20 mg of methadone
79
Conversion factors for opioids to MME
``` Codeine 0.15 Fentanyl transdermal 2.4 Hydrocodone 1 Hydromorphone 4 Methadone ***Varies by scale ranges Morphine 1 Oxycodone 1.5 Oxymorphone 3 ```
80
At which dose of MME/day should extra precautions be taken to minimize risk for AEs of opioid use
50 MME/day

Spring 2022 (14 decks)

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