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PR3136 > Pain Management > Flashcards

Pain Management Flashcards

1
Q

Definition of pain (3)

A
  • an unpleasant sensory & emotional experience associated with actual or potential tissue damage
  • a physiological & psychological response that vary from person to person & day to day
  • pain is anything the patient tells you
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2
Q

Classification of pain (2)

- duration

A
  1. Acute

2. Chronic

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3
Q

Acute pain (2)

A
  • associated with invasive procedures, trauma & disease

- resolves over days to weeks

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4
Q

Chronic pain (3)

A
  • persists past normal tissue healing
  • 4-6 weeks or 3 months
  • can be malignant or non-malignant (eg headache, migraine)
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5
Q

Types of pain (4)

- location

A
  1. Nociceptive pain
  2. Neuropathic pain
  3. Referred pain
  4. Ischemic pain
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6
Q
  1. Nociceptive pain & their receptors
A
  • arises due to tissue damage from noxious stimuli (chemical, thermal & mechanical)
  1. Visceral (organ)
    - often refer pain to a distant cutaneous site
    eg appendicitis, cholecystitis
    - stretch receptors
  2. Somatic (skin, muscles, bones)
    - localised pain
    - A-delta fibres & C-fibres
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7
Q
  1. Neuropathic pain (3)

& description

A
  1. Central
  2. Peripheral
  • no area of tenderness
  • no area of allydonia (decreased pain threshold)
  • resistance to opioids
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8
Q
  1. Referred pain (2)
A
  • pain located away from its point of origin

- occurs because signals from different part of the body travel along the same pathways

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9
Q
  1. Ischemic pain
A
  • loss of blood flow
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10
Q

Somatic pain sensation (nociceptive) (4)

A
  • aching
  • stabbing
  • throbbing
  • pressure
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11
Q

Visceral pain sensation (nociceptive) (4)

A
  • gnawing
  • cramping
  • aching
  • sharp pain
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12
Q

Neuropathic pain sensation (4)

A
  • burning
  • tingling
  • shooting
  • electric / shocking pain
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13
Q

How to do pain assessment (4+1)

A
  1. Believe the patient’s report of pain
  2. Use open-ended questions
  3. Take history of each pain
  4. Any psychological distress
(( SOCRATES ))
Site
Onset
Character
Radiation
Associations (any other symptoms)
Time course
Exacerbating / relieving factors
Severity
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14
Q

Steps to developing pain management treatment (6)

A
  1. Characterise & quantify pain
    - using scales
  2. Identify pain syndrome
    - acute or chronic
    - malignant or non-malignant
  3. Infer pathophysiology
    - nociceptive, neuropathic or mixed
  4. Evaluate physical & psychological comorbidities
  5. Assess degree & nature of disability
  6. Develop a therapeutic strategy
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15
Q

WHO Ladder (Pharmacological treatment for pain)

  • mild
  • moderate
  • severe
A

Mild pain : non-opioids +/- adjuvants
eg paracetamol, NSAIDs
- avoid aspirin due to irreversible anti-platelet effects

Moderate pain : weak opioids +/- adjuvants
eg tramadol, codeine

Severe pain : strong opioids +/- adjuvants 
eg morphine (q4h), fentanyl, oxycodone (q6), methadone
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16
Q

WHO treatment guides for cancer pain (5)

A
  1. Oral dosage form preferred
  2. Regular dosing
  3. Detailed dosing instructions
  4. Initiate dose according to patient’s pain intensity/scale
  5. Titrate to adequate pain relief & tolerable side effects
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17
Q

Titration of analgesics

A

Mild pain : even slower titration
Moderate pain : slow titration
Severe pain : rapid titration

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18
Q

Dosing of Paracetamol / Acetaminophen

A

Dose (normal) : 0.5-1g every 6-8h (max 4g/24h)

Dose (hepatic impairment) : 1g every 12h (max 2g/24h)

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19
Q

Advantages of Paracetamol / Acetaminophen (3)

A
  • low incidence of ADR
  • PO/PR available
  • multi-preparations & combinations
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20
Q

Disadvantages of Paracetamol / Acetaminophen (3)

A
  • lack anti-inflammatory properties
  • hepatotoxicity with large doses (avoid >4g/24h)
  • risk of overdose as many combination preparations contains paracetamol
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21
Q

NSAIDs (3)

A
  • use any NSAIDs effective for the patient, otherwise use ibuprofen
  • failure to improve even after trial of 2 NSAIDs require another approach to analgesia (weak opioids)
  • COX-2 selective NSAIDs have lower GI side effects & anti-platelet activities
    eg diclofenac, celecoxib, etoricoxib
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22
Q

NSAIDs precautions (7)

A
  1. Elderly >65y/o
  2. Bleeding disorder
  3. Anti-coagulants
  4. GI disease (ulcer, bleeding, perforation)
  5. Cardiovascular disease
  6. Asthma & bronchospasm
  7. Renal/hepatic disease
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23
Q

Types of Adjuvants (5)

A
  1. Gabapentin, pregabalin, antidepressants, anti-epileptics & topical lidocaine
  2. Corticosteroids
  3. Muscle relaxants
  4. Hyoscine
  5. NSAIDs & bisphosphonates
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24
Q

Classifications of opioids by pain intensity (2,1,5)

A

Weak opioids (2)

  • codeine
  • tramadol
Moderate opioids (1)
- tapentadol (between tramadol & morphine)

Strong opioids (5)

  • morphine
  • fentanyl
  • methadone
  • oxycodone
  • pethidine (not used)
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25
Q

Codeine metabolism (2)

A
  • CYP2D6 metabolism to active morphine metabolite
  • hence CYP2D6 inhibitors/hepatic insufficiency decrease efficacy of codeine
  • use tramadol
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26
Q

Dosing of codeine

A

Normal dose

  • 15-60mg up to 6 times daily
  • max 400mg/day

Renal impairment

  • CrCl 10-50mL (75%)
  • CrCl <10mL/min (50%)

Hepatic impairment

  • necessary if hepatic insufficiency
  • use tramadol
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27
Q

Tramadol (5)

A
  • onset 1h
  • duration 9h
  • also SSRI (good for neuropathic pain)
  • CYP2D6 metabolism to active metabolites BUT extensively glucuronidation, demethylation & sulfation
    Hence preferred > codeine if hepatic disease
  • high doses lowers seizure threshold
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28
Q

Dosing of tramadol

A

Normal dose
- 50-100mg every 4-6h (max 400mg/24h)

Renal impairment

  • CrCl <30mL/min (50-100mg every 12h) (max 200mg/day)
  • do not use ER if CrCl <30mL/min

Hepatic impairment

  • Cirrhosis (25-50mg every 12h)
  • do not use ER if severe hepatic dysfunction
29
Q

Dosing of morphine

A

Normal dose

  • if previously on weak opioid : 10mg every 4h OR MR 20-30mg every 12h
  • if opioid-naive : 5mg every 4h
  • if elderly & frail & renal impairment : 5mg every 4h

Renal impairment

  • CrCl 10-30mL/min (75%)
  • CrCl <10mL/min (50%)

Hepatic impairment

  • mild (unchanged)
  • severe (excessive sedation)
30
Q

Fentanyl (2)

A
  • 100x more potent than morphine
    Hence dose is in mcg NOT mg
  • CYP3A4 metabolism
31
Q

Dosing of fentanyl

A

Normal dose

  • 50-100mcg/kg
  • MICROgrams

No dose adjustments for renal/hepatic impairment
- monitor

32
Q

Indications for fentanyl (4)

A
  1. Intolerable side effects from morphine
  2. Renal failure
  3. Dysphagia
  4. “tablet phobia” or poor oral compliance
    - cos transdermal patch
33
Q

Methadone (3)

  • metabolism
  • MOA
A
  • hepatic metabolism by CYP3A4
  • complex dosing hence only for experienced physicians
  • MOA :
    1. Opioid receptor antagonists
    2. NMDA antagonists
    3. Serotonin re-uptake inhibitor
34
Q

Dosing of methadone (renal & hepatic)

A

Renal impairment
- CrCl <10mL/min (50-75%)

Hepatic impairment
- avoid in severe hepatic disease

35
Q

Oxycodone metabolism (2)

A
  • CYP2D6 (inhibitors decrease oxycodone efficacy)

- CYP3A4

36
Q

Dosing of oxycodone

A

Normal dose

  • immediate release (5mg every 6h)
  • controlled release (10mg every 12h for opioid naive)

No dose adjustment for renal impairment

Hepatic impairment
- reduce dose if severe hepatic disease

37
Q

Tapentadol (2)

A
  • only for acute pain

- between tramadol & morphine

38
Q

Pethidine (1)

A
  • for acute pain only, not for chronic pain due to fast onset & short acting
39
Q

Can use pethidine for palliative care?

Why do we avoid pethidine in palliative care? (4)

A

No

  1. Quick onset but short duration of action
    - increased risk of dependence
  2. Norpethidine is a toxic metabolite
  3. Norpethidine decreases seizure threshold
  4. More emetogenic than morphine
40
Q

PO Morphine : IM/IV Morphine

A

3 : 1

41
Q

PO Codeine : PO Morphine

PO Tramadol : PO Morphine

A

PO Codeine : PO Morphine = 10 : 1

PO Tramadol : PO Morphine = 5 : 1 OR 10 : 1

42
Q

PO Oxycodone : PO Morphine

A

1:2

43
Q

Morphine : Fentanyl patch

A

30mg/24h : 12mcg/h

44
Q

Morphine : Methadone

A
  • complicated conversion

- stepwise over 3 days

45
Q

New breakthrough dose

A

1/6 of new total daily dose

46
Q

Stimuli for :

  • A-delta fibres
  • C-fibres
A

A-delta fibres
- mechanical & thermal stimuli

C fibres
- mechanical, thermal & chemical stimuli

47
Q

Steps of Nociception (4)

A
  1. Transduction
  2. Transmission
  3. Modulation
    - in spinal cord
  4. Perception
48
Q

Tools to assess pain scale if :

  • <3y/o
  • unable to communicate pain
A

FLACC

Face
Legs
Activity
Cry
Consolability
49
Q

What kind of pain to use

  • gabapentin
  • pregabalin
  • antidepressants
  • anti-epileptics
  • topical lidocaine for what kind of pain?

(1)

A

Neuropathic pain

50
Q

What kind of pain to use Corticosteroids? (4)

A
  • neuropathic pain
  • bone pain
  • raised intracranial pressure (reduce edema)
  • liver capsule stretch pain
51
Q

What kind of pain to use muscle relaxants? (2)

A

eg baclofen, benzodiazepines

  • cramps
  • muscle spasms
52
Q

What kind of pain to use Hyoscine? (1)

A
  • intestinal colic
53
Q

What kind of pain to use NSAIDs & bisphosphonates? (1)

A
  • bone pain
54
Q

First line opioid for severe pain

A

Morphine

55
Q

CYP2D6 inhibitors (3)

A
  • chlorpromazine
  • fluoxetine / paroxetine
  • quinidine & quinine
56
Q

Tramadol DDI (4)

A

Increase risk of seizures

  • SSRI
  • TCA
  • neuroleptic drugs
  • naloxone
57
Q

Fentanyl patch (3)

A
  • transdermal patch duration 48-72h
  • after patch removal, still got drug depot in body
  • reserve for patients (cannot morphine, renal failure, dysphagia or poor oral compliance)
58
Q

CYP2D6 inhibitors decrease efficacy of __ (2)

A
  1. Codeine

2. Oxycodone

59
Q

Situations to consider 25-50% dose reduction when converting between opioids (3)

A
  • elderly & frail
  • conversion to methadone
  • organ dysfunction (renal & hepatic impairment)
60
Q

Situations to NOT consider 25-50% dose reduction when converting between opioids (2)

A
  • severe pain (up titration of dose)

- conversion to fentanyl patch (maintain dose)

61
Q

When to up titrate total daily maintenance dose

A

> 4 breakthrough doses in a day

62
Q

Treatment for opioid overdose if :

  • Respiratory rate >= 8bpm
  • Arousable
  • Not cyanosed

(2)

A
  • wait & see only, do not use naloxone

- reduce or omit next dose of morphine

63
Q

Treatment for opioid overdose if :

  • Respiratory rate < 8bpm
  • barely arousable/unconscious
  • cyanosed

(1)

A
  • IV 20mcg Naloxone (=0.5mL) every 2min until patient RR is satisfactory
64
Q

ADR of opioids (common) (3)

A
  1. N/V
  2. Somnolence & mental clouding
  3. Constipation
    - req chronic use of laxatives

1-2 weeks tolerance development for 1&2

65
Q

ADR of opioids (less common) (5)

A
  1. Myoclonus / seizures
    - clonazepam
  2. Respiratory depression
  3. Postural hypotension
  4. Rash / itch
    - due to histamine release
    - antihistamine
  5. Urinary retention
66
Q

Management of opioids ADR (3)

A
  1. Change to another opioids
  2. Symptomatic treatment
  3. Dose reduction + adjuvants
67
Q

Monitoring outcomes for opioid therapy (4)

A
  1. Pain relief
  2. Side effects
  3. Recovery of function/activity
  4. Drug-related behaviours
    - addiction
    - but risk of addiction in cancer pain & acute pain unlikely
68
Q

PO Morphine : PO Codeine : PO Tramadol : PO Oxycodone

A

2 : 20 : 10/20 : 1

PR3136 (19 decks)

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