Pain Management Flashcards
Define Pain
Nociceptive: catergories
Neuropathic
Pain
- unpleasant sensory and/or emotional experience associated with actual or potential tissue damage
- subjective: difficutl to qualitfy and understand what pt. feels
- most common reason for medical attention
Nociceptive Pain
- somatic: from tissue, bone, skin, joint or connective tissue sharp, localized and throbbing pain
- visceral: from the organs themselves (internally); felt as referred or poorly localized pain thats deep and achy
Neuropathic Pain
- pain due to damange of teh nervous system
- felt like buring, sharp, electric-shock like pain that is shooting
- can be associted with paresthesias: pins and enedles
Definitions of alterations in pain sensitivity
hyperalgesia
allodynia
paresthesias
analgeisas
Hyperalgesias: an increased sensitivtiy to pain
- opioids can cause this, disease stattes and even just an exacerbated pain (rolled ankle, will hurt more to move)
Allodyina
- things which arent normally painful elict a painful response
- socks on feet = painful!
Paresthesias
- the pins and needles feeling
Analgesia
- pain relief
Pain Classifications
acute
chronic
breakthrough
Acute Pain
- pain which is brief
- lasting for the duration of an injury
- not a specific time frame, but like weeks
commonly acute pain is…..
- from an injury
- self limited
- gets better over time
- have autonomic symptoms
Chronic Pain
- pain which remains lasting longer than anticiapted
- usually > 3 months
commonly chronic pain is…
- sudden or gradually developing
- surrfering increases over time
- interventions help to make pain more bearable, not complete resolution
- can have anxiety/depression concurrently
Breakthrough
- pain flare which is on top of a chronic pain at baseline
step-wise guidelines for treatment of pain and medications
Pain is 3/10 = use what
Pain is 4-7/10 = use what
Pain is 7-10/10 = use what
Step 1: Pain is 3/10
- use Non-opiod pain relief = NSAID/acetaminophen + adjunt
Step 2: Pain is 4-7/10 (or remaisn after step 1)
- use opioid for mild to moderate pain
- + adjunct non-opioid
Step 3: Pain is 7-10/10 (or remains after Step 2)
- opioid for moderate to severe pain
- + non-opioid adjuct
Guidance on how to manage pain : Acute Pain Control
- acute (IR) v (ER) pain control and when to use
for Acute Pain
for Initial Stages: short acting agents = dose finders
- these are meds to fingure out what dose is alievating the pain
- can be given around the clock or just when needed
- key here = short acting on/off
for Intermittent
- giving these short acting meds (IR) around the clock; schedule to GET AHEAD of the pain
- not waiting for the pain wave, but given to prevent the wave
- start with IR formulation PRN => then if pain progresses chagne to around the clock dosing
Guidance on how to manage pain : Chronic Pain Control
ATC and breakthrough
Chronic Pain
Around the Clock Dosing: ATC
- these is when you decide if youre going to ATC dose IR or give long acting agents to control chronic pain
- ATC: helps you get ahead of the pain and prevent the wave
- start with short acting and convert to long
Breakthrough Pain
- use short acting agents to help
- can use long actin, but we use IR
key pearls (2) of all pain management dosing
- maximize the dose of first pain medication using before you add on another pain med
- consider adjuvant (OT,PT, etc.) whenever able
Acetaminophen
- use for what type of pain
- 2 MOA
- ADR
- max dose
Acetaminophen
- pain: nociceptive pain (muscle, skin, joints, connective tissue)
MOA
- anti-pyretic
- analgesic
- therefore: no anti-inflamm. properties
ADR
- well tolerated
- hepatotoxic: max dose is 4g/day under medical advice, 3g/day for everyone (keep pt. at 3g/day)
- watch combo drugs!
NSAIDS
names & key pearls about Naproxen, celcoxib and meloxicam
NSAIDS
- ibuprofen
- dicolfenac
- meloxicam : prefers COX II > COX I
- Naproxen: good for those with CVD (aleve)
- Celecoxib: watch if sulfa allergy; COXII inhibitor - good for GI issues, not good for CVD
NSAIDS
- type of pain used for
- MOA
- ADR
- elderly?
- councel
NSAIDS
- use for nociceptive pain
- analgesic
- anti inflammaotry
ADR
- GI irritation and ulceration
- RENAL IMPAIRMENT: do not use NSAIDS in the elderly; they have bad kidneys
- HTN pt. : increased sodium retetion, can make it worse
- caution use in CHF, HTN, PUD and GERD
- increased risk of bleeding: caution in those with concominant anticoag. use (if on a DOAC or heparin, cannot use
councel
- take with food!!
Elderly
- do not use NSAIDS
- renal impairment : excretion issue
- Drug-Drug interactions
- Toxicities: CV, renal and GI
Ketoralac
when is it used for pain
contraindications
how often can it be used
Ketoralac: an IV formulation of NSAID
Indication for Use
- severe severe pain: considered to be equipotenet to a weak opioid
COntraindications
- PUD
- history of GI bleed
- renal disease
- prophlyaxis before surgery cannpt be used = bleeding risk
Use
- can only be given for 5 days or LESS & given 90 days apart
- cannot be used chronically = too high of a GI bleed risk
Opioids: REceptors Types and Concurrent actions
- abuse potential by receptor
Mu
Delta
Kappa
Receptors = mu, delta and kappa
Mu receptor: most common
the one that created analgesic properties = pain relief!
Side effects =
- respiratory depression
- bradycardia
- euphoria
- pruritis
- mitosis (constricted)
- nausea/vomiting
- inhibits gut motility (constipation)
HIGH abuse potential & Physical Dependnce
Delta Receptor
- low abuse potential
- analgesic properties
Kappa Receptor
- low abuse potential
- analgesic properties
side effects
- sedation
- psychomotor effects (delirum/dementia)
- dysphorisa
- diuresis
Opioids: what degree of pain is this indicated
oral formualtion & avalible dosing (IR v ER) & when used
Opioids: for moderate to severe pain
- class II highest abust potential drug
- patient specific responses to the doses and analgesic effects!
- for short term and chronic pain
Oral Formulation
Immediate Release (IR): Short Acting
- start with IR meds first to see how it controls the pain
- can be used for breakthrough ain
- can cause more sedation as it peaks
Extended Release (ER): Long Acting
- good for maitnence of pain management
- used after the dosage of IR has been stabilized
- this is consider standard/maitnence dosing
- less peaks: more steady release
Opioids
IV dosing pearls
Transdermal dosing pearls
Opioids
IV Dosing
- provides most rapid effect
- flexibile dosing
Transdermal (fetynal and bubrinorphine come as patches)
- not recommende for those with unstable pain = only used with those who are consistent, chronic pain
- always ensure these pt. are on a controlled regimen before transitioning to a patch : never really starting with a patch (NEVER strating with fetynal)
other administeration
- transbuccal
- intranasal
Morphine
onset of action & type of pain relief
metabolites
side effects
Morphine: usually the first opioid started when starting to use them
Onset of Action = quick (used for acute pain)
30 mins, 90 if ER, IV = minutes
Metabolites
- the metabolites will build up if renally impaired, need to watch your dosing
- M6G metabolite: is MORE POTENT than the parent drug; the reason for the respiratory depression side effect
- also has M3G but less clinically important
Side Effects
Histamine Release: pt. get itchy on this, hypotension and bronchospams
Respiratory Depression: at initial dose & every increased, increase risk (and the M6G metabolite)
Nausea/Vomiting
constipation: give them a stimulant laxitive
reduced Testoterone levels
Urinary retention
Codeine (Tylenol #3)
pain relief efficacy & indications
metabolites
side effects
Codeine: doesn’t work well for pain relief
- weak analgesic
- can be used for cough suppression
Metabolites
- metabolized to morphine!! via 2D6
- watch D-D interactions & slow/fast metabolizers
- nausea: lower dosing has higher risk of nasuea & more than other opioids
Hydrocodone (Vicodin)
avalibility in combo only with what
IR and ER
Hydrocodone
- only avalibel in combination pills with acetaminophen and ibuprofen
Metabolites
- 2D6 = into hydromorphone
IR: start dosing at Q4H
ER: avalible for 12-24H
Oxycodone
available in combo with what or alone
metabolizm
IR
ER
Oxycodone
- avaliable as its own
- avaliable as a combo: with acetaminophen
Metabolism: 2D6 = watch liver function
IR Formuation = Percocet
ER Formutaion = OxyContin
liuid too
Hydromorphone
prefered over what in who
metabolism
avalaible forms
Hydromorphone
preferred over morphine in pt. with renal failure : less renal accumulation than morphine
high first pass effect: lots will be lost at the liver
IR
ER formulation is 24H only
IV (for PCA)
SQ
Rectal
Methadone
what is is a combo of and why does this mattern
natural or synthetic
metabolism
Methadone
Racemic mix:
R form = potenet and gives pain relief
S form = NMDA antagonist, can be helpful in neuropathic pain but not what you strat with (inhibits SE and NE uptake)
methadone is a syntheic opioid; therefore for those who what true morphine allergies = this is ok to use
Metabolsim
- through the liver
- can auto-induce itself; ensure titration is slow in first week
- good for renal dysfunction
Methadone
- Uses
- side effects
- duration of action
Uses
- ** + good for heroin addicts and pain control
- most benifical opioid to treat neuropathic pain**
Side Effects
- QT-c Prolongation: check at baseline and staedy state (see in higher doses)
- NO effect on dysnpena: so therefre wont be helpful in someone who’s air hungery
- NO euphroic effects: no head high
Duration
- 3-6 hours = to 12H with repeated dosing
- conversion from person to person varies and from converting to otehr opioids varies (wont do these on exam)
Fentanyl
pearls about transdermal
how to apply patch & counceling points
metabolism through what
potency & synthetic or natural
Fentaynl
- can be given IV /intranasal
- can be given transdermal
- can be give transbuccal (for breakthrough severe cancer pain)
Transdermal
- transdermal can only ONLY be given to those pt. who are opioid toleratne = transitioning from an opioid to the patch : never an inital med choice
- can take a while to kick in, leave patch for 72 hours
Applying Patch
- clean dry skin, apply and stick
- AVOID HEAT: will increase abosrpbtion : this includes fever, will increase absorbtion
- in those with skinny arms/no body fat = decreased absorbtion
Metabolites
- 3A4: liver!!
Pearls
- fentanyl is 80 times more potent than morphine!!!!!
- can be used in those who are morphine allergic: this is syntehtic
Tramadol
type of pain and releif
caution in what pts.
IR and ER
other NT involvment
Tramadol : a weak mu agonist
- acts as a centrally acting analgesic: NOT for acute pain
- needs to be metabolized into active form
Caution
- seizure pt: this can lower thresehold
IR and Er dosing avalible
NT involvment
- has effect at SE and NE : watch serotonin syndrome and antidepressant use
Tapentadol
type of pain relieve
risk of what (side effect)
IR and ER
Tapentadol
- for moderate to severe acute pain
- centrally acting analgesic
- IR and ER avaliable
Risk
- respiratory depression
Buprenorphine & BUtorphanol
uses and how they work
Buprenorphine
- a partial opioid agonist: used for opioid withdrawal
- has a celing effect
- produces a submx. pain relief response but good for lower abuse potential
Butorphanol
- opiod agonist and anagonists
- antagonist at one receptor, agonist at other
- used for migraines: but addictive properties
Opioid Antagonists: Naloxone and Naltrexone
Opioid Antagonists
- reverse the effect of the opioid by binding, but not stimulating the receptor
- can cause and percipiate withdrawal if given with opioids
Naloxone
- the antidote!! = for overdoses
- mayneed multiple doses to get effect
- IV/IM gives 0.4-2mg = can give dose every 2-3 minutes
- if no repsonse afte 10 mg = consider other reason for respiratory depression
- intranasal: gives 4-8mg = give doses every 2-3 minutes alternating nostrils
Naltrexone
- used for chornic maitenence for reducing craving of opioid
Ketamine
MOA
ADR
MOA: NMDA receptor antagonist
- analgesic effect
- anesthetic effect
ADR
- CNS depression
- respiratory depression
- dependence
- emergency reactions: psychotic breaks
- increases HR and BP
Opioid: Considerations for choosing the drug
- pt age
- history of use and abuse
- renal function
- hepatic function
- allergy
Age: older age = more sensitive to opioids
History
- use: if SE to med previously, probably happen again
- abuse: know if they have ever and maye choose something else
Renal
- always check: active metabolites: morphne and meperidine
- best choices for bad kidneys:methadone, fentanyl
Liver
- all opioids cleared by liver : will accumulate if bad liver
ADR
- true allergy is rare:see if its just intoleratnce (itchy!! N?V)
- if TRUE morphine allergy: can use methadone or fentanyl
Opioid Considerations
N/V
Itchy
Sedation
Constipation
Respiratory Depression
AMS
N/V: can be transient
- highest risk and most intense is with codine
Ithcy
- with the naturals: morphine and codine
- due to histamine release
- less with fentanyl and methadone = synthetics
Sedation
- CANNOT LEADLLY DRIVE OR OPERATE MACHINERY
- tolerance can occur
Constipation
- WILL Occur: give them a stimulant lax.: sinner or bisacodol
- there will not be tolerance to this
- can give a stool softener: PEG (miralax)
Respiratory Depression
- tolerance within 1 week
- highest risk with higher doses
AMS
- can have delirum
Opioid Considerations
BP
HR
QT
tolerance
dependence
substance use disorder
BP
- risk of hypotension (IV mostly)
- watch orthostasis
HR
- Bradycardia
QT
- QT-c prolongation with methadone
- get baseline EKG and EKG during treatment
Physical Dependence
- after using, stopping drug will produce a withdrawal effect if not tapered
Tolerance
- overtime, there is a dimished effect
Substance use Disorder
- keep an eye out, using ONLY for pain!
- dont be afraid to ask
Opioid Withdrawal
symptoms
withdrawal from opioids is awful, but not fatal
Symptoms
- nausea
- sweating
- anxiety
- agitation
- muscle cramping
- tachycardia
- HTN
- insomnia
- diarrhea
- yawn and sneeze
Perscribing Opioids Guidelines
acute pain = use what and do what
acute pain due to severe trauma
Acute Pain
- non-opioid meds are as effective as opioids for ACUTE PAIN
- maximize non-opioid medication and nonpharm first
- discuss all ADR and benefits with pt.
Acute Pain: Severe Trauma
- may consider using opioid: lowest dose and PRN
- always properly educate pt. on risks and ADR
- should be a trial use, not put on and never taken off
Prescribing Opioids Guidelines : subacute and chronic pain guideline
what to use
when to start opioids
Subacute and Chronic Pain
- maximize non-opioid medications first: these are preferrred!!!
if starting an opioid
- have exist stragety: “try 4 months, then stop if the pain does not respond at all”
Prescribing Opioids Guidelines
Starting Opioids: what type of dose first and pearls
Starting Opioids
IR
- always start with immerdiate release ALWAYS starts first
- never treat acute pain with long acting meds
- METHADONE IS NEVER A FIRST LINE or fentynal
Always start with the LOWEST EFFECTIVE DOSE
- espeically for naive pt. to opioids
- usually 5-10 MME mrphine milligram equ.
- at 50 MME: te risk of death from opioid ADR doubles
- there must always be a documented response/benefit
Prescribing Opioids Guidelines
alterating opioid doses (between doses)
for those on opioid therapy: always weight risk v benefit before changing doses
- if benefit > risk = continue
- if risk > benefit = d/c and taper
Prescribing Opioids Guidelines
quanitiy to Rx.
when to reevaluate for acute, subacute and chronic
tox screen
Rx.
- for acute pain = only rx. the quantity needed for expected amount of pain (usually a few days)
Acute Pain
- always reevaluate the need every 2 weeks
if continuing a dose > 1 month = this may need to consider the use of chronic opioids and transition from acute
for subacute-chronic
- reevalulate 1-4 weeks after starting
for those on chronic opioids
- need to reasses every 3 months
PERALS
offer naloxone as rx with opioid
mental health treatment
ask about drug and alcohol use
always revied info in PDMP: before every rx written
consider doing tox screening to asses for perscribed and non-rx. substances = test ANNUALLY
caution benzo and opioid co-rx. = increased respiratory drive
always help taper and assist in derx. process
PCA: pt. controlled analgesics
demand dosing: with lockout
continuous infucion with demand dosing
good for cognitively with it pr. and those post-op or with sickle cell
Opioid Converstion Tips
assess pain (scale 1-10) and controlled pain to help get idea about increase/decrease dosing
determine TDD by adding ER and IR together, dosing an damount taken per day (not what they’re rx. but what they take)
convert to same opioid: TDD divided by doses = new amt. and find closest strength dose that is comes in
conver to new opioid: TDD then equipotent dosing to find new (via chart)
- if changing to NEW opioid: need to decrease dose by 30% (so multiple by .75)
IR dosing is given Q4H
- this will be 10-20% of TT (so .1 -0.2 of TTD) then find the closes dosage form
- try to keep IR and ER same type of med
if using < 3 doses of rescue - pain is well controlled
if using > 3 doses of resuce - pain uncontrolled
always add HOURS to rx.
Neuropathic Pain
medications to use
first and second lines
SE of each
Neuropathic: nervous sytem pain
GAbapentin (First Line)
- start at bedtime
- SE: sedation, weight gain and edema
Pregabalin (if gabapentin not working)
- controlled substance
Second Lines
TCAs
- avoid in eldery
- start low and titrate up need 6-8wk.
Duloxeint/venlafaxine (SNRI)
- sexual dysfunction
risk of Serotinin syndrome with TCA and SNRI
Lidocaine Patch
- used for localized pain
- can be used in combo with other meds
- only 12 hours
- caution: class 1 antiarrythmic
BOne Pain
Bone Pain
NSAIDs = if tolerable
corticosteroids
bisphosphonates
use with other agents to get max. pain releif
