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PHM 704- Geriatrics > Pain Management > Flashcards

Pain Management Flashcards

1
Q

Mechanisms of pain: nociceptive pain

A

Stimulation, transmission, perception, modulation

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2
Q

What is nociceptive pain caused by?

A

Injury to body tissues

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3
Q

Common descriptors of nociceptive pain

A

Aching, sharp, throbbing

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4
Q

Mechanisms of pain: neuropathic

A

Spontaneous transmission: nerves firing without stimulation

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5
Q

Common descriptors of neuropathic pain

A

Burning, tingling, hypersensitivity to touch or cold

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6
Q

Hyperalgesia definition

A

exaggerated pain

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7
Q

Allodynia definition

A

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

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8
Q

Acute pain causes

A

Trauma, surgery

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9
Q

Chronic musculoskeletal pain causes

A

Arthritis, OA, LBP, crystal-induced arthropathy

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10
Q

Chronic neuropathy pain causes

A

DM, post-herpetic, trigeminal, phantom

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11
Q

Chronic vascular pain causes

A

PVD, ulcers

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12
Q

Other cause of chronic pain

A

Cancer

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13
Q

Patient interview about pain: PQRSTU

A

Palliative/provocative
Quality
Radiation
Severity
Temporal
U (QoL)

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14
Q

Other ways to assess patient’s pain

A

Pain scales, pain diaries, ongoing function

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15
Q

Nonpharm management of pain

A

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

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16
Q

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

A

Nonopioid +/- adjuvant

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17
Q

Step 2 to managing pain

A

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

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18
Q

Step 3 to managing pain

A

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

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19
Q

General principles for prescribing pain-control meds

A

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

20
Q

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

A

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

21
Q

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

A

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

22
Q

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

A

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

23
Q

Analgesic agents used for chronic pain

A

APAP, NSAIDs (COX-II), opioids

24
Q

Pros of APAP

A

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

25
Q

Cons of APAP

A

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

26
Q

Pros of NSAIDs

A

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

27
Q

Cons of NSAIDs

A

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

28
Q

NSAID CIs

A

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

29
Q

Pros of opioids

A

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

30
Q

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

A

Non-opioids are preferred over opioids

31
Q

Preferred opioids in the elderly

A

morphine, hydrocodone, oxycodone, hydromorphone, fentanyl

32
Q

ADEs of opioids: pulmonary

A

respiratory depression, apnea

Diseases like asthma, COPD, sleep apnea may be CI’ed

33
Q

ADEs of opioids: CNS

A

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

34
Q

ADEs of opioids: ocular

A

mitosis (pinpoint pupils)

35
Q

ADEs of opioids: GI

A

N/V, constipation

36
Q

Management of N/V in opioid use

A

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

37
Q

Management of constipation in opioid use

A

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

38
Q

Who qualifies for adjuvant therapy?

A

All patients with neuropathic pain

39
Q

First-line adjuvant agents

A

Lyrica, gabapentin, SNRIs (duloxetine)

Caution with TCAs because they’re anticholinergic

40
Q

Second-line adjuvant agents

A

Lidocaine, capsaicin

41
Q

When to consider topical analgesics

A

If pain is focal or regional

42
Q

Steroids as adjuvant therapy

A

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

43
Q

Practice pointers for adjuvant therapies

A

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

44
Q

Minimizing risk of adjuvant analgesics

A

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

45
Q

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

A

No

46
Q

Are adjuvant agents primary interventions?

A

No

PHM 704- Geriatrics (15 decks)

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