Pain Management

Question 1

Mechanisms of pain: nociceptive pain

Answer 1

Stimulation, transmission, perception, modulation

Question 2

What is nociceptive pain caused by?

Answer 2

Injury to body tissues

Question 3

Common descriptors of nociceptive pain

Answer 3

Aching, sharp, throbbing

Question 4

Mechanisms of pain: neuropathic

Answer 4

Spontaneous transmission: nerves firing without stimulation

Question 5

Common descriptors of neuropathic pain

Answer 5

Burning, tingling, hypersensitivity to touch or cold

Question 6

Hyperalgesia definition

Answer 6

exaggerated pain

Question 7

Allodynia definition

Answer 7

feeling pain from a stimuli that normally doesn’t cause pain

Question 8

Acute pain causes

Answer 8

Trauma, surgery

Question 9

Chronic musculoskeletal pain causes

Answer 9

Arthritis, OA, LBP, crystal-induced arthropathy

Question 10

Chronic neuropathy pain causes

Answer 10

DM, post-herpetic, trigeminal, phantom

Question 11

Chronic vascular pain causes

Answer 11

PVD, ulcers

Question 12

Other cause of chronic pain

Answer 12

Cancer

Question 13

Patient interview about pain: PQRSTU

Answer 13

Palliative/provocative
Quality
Radiation
Severity
Temporal
U (QoL)

Question 14

Other ways to assess patient’s pain

Answer 14

Pain scales, pain diaries, ongoing function

Question 15

Nonpharm management of pain

Answer 15

Physical activity: reverse deconditioning (increasing mobility to decrease pain)
Patient education for the caregiver/family
Cognitive-behavioral therapies for anxiety/depression
Adjuncts: heat, cold, massage, liniments, acupuncture, spirituality

Question 16

Step 1 to managing pain (think of that step chart thing)

Answer 16

Nonopioid +/- adjuvant

Question 17

Step 2 to managing pain

Answer 17

Opioid for mild-moderate pain +/- nonopioid +/- adjuvant

Question 18

Step 3 to managing pain

Answer 18

Opioid for mod-severe pain +/- nonopioid +/- adjuvant

Question 19

General principles for prescribing pain-control meds

Answer 19

Administer meds routinely, not PRN
Use least invasive route of administration first
Begin with a low dose, titrate carefully until comfort achieved
Reassess and adjust dose frequently to optimize pain relief while monitoring and managing ADEs

Question 20

2016 CDC guidelines in prescribing opioids in patients with chronic pain: initiating or continuing opioids for CNCP

Answer 20

Recommend nonpharm and non-opioid treatments prior to opioids; if opioids are used, combine with non-opioids if possible

Establish treatment goals

Weigh risks vs. benefits

Question 21

2016 CDC guidelines in prescribing opioids in patients with chronic pain: opioid selection, dosage, follow-up, D/C

Answer 21

IR formulations preferred initially, but can switch to XR for chronic pain

Administer the lowest effective dose and titrate slowly

Don’t prescribe them for any longer than necessary (≤3 days good)

Evaluate patients in 1-4 weeks, evaluate risks vs. benefits

Question 22

2016 CDC guidelines in prescribing opioids in patients with chronic pain: assessing risk and harms of opioid use

Answer 22

Screen patients for risk factors for opioid-related harms before starting and periodically during therapy

Urine drug screens should be conducted when starting, then annually at minimum

Review controlled substance Rx Hx in PMP

Don’t use BZDs and opioids together

Provide resources for addiction help

Question 23

Analgesic agents used for chronic pain

Answer 23

APAP, NSAIDs (COX-II), opioids

Question 24

Pros of APAP

Answer 24

useful for mild-moderate pain, elder “safe,” adjunctive, “starting point” for initial and ongoing pharmacotherapy, no side effect profile

Question 25

Cons of APAP

Answer 25

very few: hepatic failure, ethanol use, hepatic insufficiency, drug interaction with warfarin, MDD=4gm/day (be careful when using opioid/APAP combos), patient perception that it might not work because it’s an OTC, failure to complete an adequate trial

Question 26

Pros of NSAIDs

Answer 26

useful for mild-moderate pain, musculoskeletal pain (inflammation, cancer) Topical diclofenac (Voltaren) for “localized non-neuropathic persistent pain”, may be considered rarely, and with extreme caution, in highly selected individuals, other (safer) therapies have failed

Question 27

Cons of NSAIDs

Answer 27

Ceiling effect: there is a maximum dose that will provide benefit; higher doses beyond that point won’t make it better or worse

Question 28

NSAID CIs

Answer 28

Absolute CIs: PUD (ongoing PUD?), CKD, HF Relative CIs: HTN, H. pylori infection, PUD history

Question 29

Pros of opioids

Answer 29

moderate-severe pain, no ceiling dose (due to tolerance), routes for administration are diverse, long-acting agents available

Question 30

Opioids vs. non-opioids for mod-severe chronic back pain, hip or knee OA pain

Answer 30

Non-opioids are preferred over opioids

Question 31

Preferred opioids in the elderly

Answer 31

morphine, hydrocodone, oxycodone, hydromorphone, fentanyl

Question 32

ADEs of opioids: pulmonary

Answer 32

respiratory depression, apnea Diseases like asthma, COPD, sleep apnea may be CI'ed

Question 33

ADEs of opioids: CNS

Answer 33

*lethargy/sedation*, pre-existing cognitive impairment, dysphoria, delirium, hallucinations

Question 34

ADEs of opioids: ocular

Answer 34

mitosis (pinpoint pupils)

Question 35

ADEs of opioids: GI

Answer 35

N/V, constipation

Question 36

Management of N/V in opioid use

Answer 36

Haloperidol, droperidol Chlorpromazine, prochlorperazine, thiethylperazine Cyclizine, diphenhydramine, hydroxyzine, meclizine, promethazine Hyoscine, scopolamine Dolasetron, granisetron, ondansetron Metoclopramide Lorazepam

Question 37

Management of constipation in opioid use

Answer 37

Docusate Bisacodyl, casanthranol, senna Glycerin suppositories, lactulose, mannitol, polyethylene glycol, sorbitol Magnesium citrate, magnesium hydroxide, magnesium sulfate, sodium phosphates Naloxegol, methylnaltrexone, nalmefene, naloxone Mineral oil

Question 38

Who qualifies for adjuvant therapy?

Answer 38

All patients with neuropathic pain

Question 39

First-line adjuvant agents

Answer 39

Lyrica, gabapentin, SNRIs (duloxetine) Caution with TCAs because they're anticholinergic

Question 40

Second-line adjuvant agents

Answer 40

Lidocaine, capsaicin

Question 41

When to consider topical analgesics

Answer 41

If pain is focal or regional

Question 42

Steroids as adjuvant therapy

Answer 42

Reserved only for patients with pain-associated inflammatory disorders or metastatic bone pain

Question 43

Practice pointers for adjuvant therapies

Answer 43

Start low and go slow, monitor response, D/C ineffective drugs Multipurpose adjuvant analgesics can be used for any type of chronic pain Neuropathic pain: preferred approach is treatment with an AD analgesic or a gabapentinoid, and concurrent use of a topical agent if appropriate Musculoskeletal pain disorders: addressed with multipurpose adjuvant analgesics like the ADs and tizanidine and topical agents

Question 44

Minimizing risk of adjuvant analgesics

Answer 44

Consider if non-pharm care can be used and avoid using drugs Consider if topical therapies can be tried and avoid systemic drugs If a systemic drug may be useful, review the current drug regimen and consider deprescribing drugs with unclear benefit Select a PO adjuvant analgesic for a trial based on type of pain, conventional practice, and risks associated with the potential for ADEs, including DDIs If giving adjuvant therapy, make sure the prescribing information applies to the indication the drug has for pain Modify conventional prescribing information to augment caution (start low and go slow, monitor!) Have clear endpoints for evaluating effectiveness (pain relief, side effects, functional outcomes) If the drug is ineffective, eliminate it, but be cognizant of the potential for discontinuation syndromes (ADs) Educate the patient and caregivers that the use of these drugs is a trial-and-error process that requires time and careful monitoring

Question 45

If you fail one adjuvant agent, is it predictive of failure of another?

Answer 45

No

Question 46

Are adjuvant agents primary interventions?

Answer 46

No