Usually women aged 20-50 - Chronic widespread musculoskeletal pain syndrome with multiple tender points - Fatigue, headaches, numbness - Inflammation absent , lab studies normal - easily written off! - look like have MDD

pain management Flashcards by Elizabeth DeGroot

pain def 1

an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

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pain def 2

A revised definition identifies pain as “a somatic perception containing: (1) a bodily sensation with qualities like those reported during tissue-damaging stimulation, (2) an experienced threat associated with this sensation, and (3) a feeling of unpleasantness or other negative emotion based on this experienced threat”

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hyperalgesia

Increased response to a stimulus that normally is painful

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hypoalgesia

Diminished response to a normally painful stimulus

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hyperesthesia

Increased sensitivity to stimulation, excluding the special senses

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hypesthesia

Diminished sensitivity to stimulation, excluding the special senses

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dysesthesia

An unpleasant abnormal sensation, whether spontaneous or evoked

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paresthesia

An abnormal sensation, whether spontaneous or evoked

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allodynia

Pain resulting from a stimulus (such as light touch) that does not normally elicit pain

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addiction

misuse of a substance for purposes other than one for which it was prescribed and despite negative consequences in health, employment, or legal/social spheres, demand for specific medications and doses, anger and irritability, poor cooperation, disturbed interpersonal reactions

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pseudo-addiction

exhibiting behaviors associated with addiction but only because their pain is inadequately treated
*undercontrolled*
figuring out difference is tough!*
-assess validity of pain
-multidisc. approach
-get a good hx
-tx pain

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avoid profiling in drug addiction

“white women” are the face of modern pill addiction

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Neuropathic pain

abnormal neural activity secondary to disease, injury, or dysfunction of the nervous system

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Sympathetically mediated pain (SMP) arises from ???
assoc. w/ ???
known as…
most common cause ??

a peripheral nerve lesion
associated with autonomic changes (complex regional pain syndrome I and II, formerly known as reflex sympathetic dystrophy and causalgia)
Diabetic neuropathy most common!

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Peripheral neuropathic pain

damage to a peripheral nerve without autonomic change (postherpetic neuralgia, neuroma formation)

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Central pain arises from ???

examples:

abnormal central nervous system (CNS) activity

phantom limb pain, pain from spinal cord injuries, and post-stroke pain
-hard to tx, tx CNS issue

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pain toxonomy axes (IASP)

Axis I: Anatomic regions
Axis II: Organ systems
Axis III: Temporal characteristics, pattern of occurrence
Axis IV: Intensity, time since onset of pain
Axis V: Etiology

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chronic pain dx

Chronic complaints of pain
Symptoms frequently exceed signs
Minimal relief with standard treatment
History of having seen many clinicians
Frequent use of several nonspecific medications

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visceral pain is very hard to ?

localize

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fibromyalgia dx

Usually women aged 20-50

Chronic widespread musculoskeletal pain syndrome with multiple tender points
Fatigue, headaches, numbness
Inflammation absent*, lab studies normal
easily written off!
look like have MDD

afferent pain tract

STT: spinothalamic tract

benzos for chronic pain

diazepam (valium)
lorazepam (ativan)
midazolam (versed)
clonazepam (klonopin)

opioid withdrawal stage I

opioid withdrawal stage II

8-24 hrs

insomnia, restlessness, anxiety, yawning, stomach cramps, lacrimation, rhinorrhea, diaphoresis, mydriasis

opioid withdrawal stage III

up to 3 days | vomiting, diarrhea, fever, chills, musc. spasms, tremor, tachycardia, piloerection, HTN, seizures (neonates)

muscle relaxants for chronic pain

``` cyclobenzaprine carisoprodol (soma) baclofen (lioresal) methocarbamol (robaxin) *loopiness-take before bed, used with ice packs ```

barriers

Physicians have poor training Fears of legality: FDA, DEA, controlled substance *document!* Fears of abuse: -Tolerance vs Dependence vs Addiction vs Pseudo-addiction -IPMP website, can see pts prescribed opioids to

pain1 slide 17: KNOW!!***

WHO analgesic ladder

mild pain

non-opioid: acetaminophen (paracetomol)(liv. tox, not v. strong), ASA, NSAID (GI, CV, renal SE) +/-adjuvant

mild-mod pain

opioid (codeine-not so much, tramadol*partial agonist) +/- non-opioid +/- adjuvant

mod-sev pain

opioid (morphine, fentanyl, dilaudid etc) +/-non-opioid +/-adjuvant

nociceptive pain: joints

patches, topical lidocaine

non-imflamm pain

tylenol

for chronic pain

adjuvants

neuropathic pain tx: 1st line agents

gabapentin SNRIS TCAs

neuropathic pain tx: 2nd line

opioids (tramadol) | antiepileptics

neuropathic pain tx: 3rd line

NMDA antagonists combo tizanidine baclofen

neuropathic pain tx: 4th line

consider botulinum toxin injection or | intrathecal ziconotide

spinal stimulator

for chronic lower lumbar pain, block pain | not first line tx, meds first

opioid manangement

document everything - avoid refills - printed out, NOT electronic prescription

benzos good for.. | but...

central, spasm, neuropathic pain, also tx anxiety rel. to pain tough to manage, can make pt "high" -Brown does not give often

tapering protocal

DEA have sp. protocol for opioids, give less and less with added behavioral therapy

palliative care focus

Focus on symptoms, quality of life, and goals of care

palliative care management

Pain Dyspnea Nausea,vomiting Constipation Agitation Emotional distress (depression, anxiety, relationships) Existential distress (spiritual distress)

opioid SEs

constipation- may need meds (docusate, colace, etc) | methalnaltrexone reverses constipation

OMM

medium effect on chronic low back pain

case 1: motorbike accident, 100 mph, road rash, stabilized

Need pain scale Probably in v. severe pain, potentially in shock (mental) Opioids are a good choice: don’t want to give so much stop breathing, or affect neural reflexes and cannot monitor -give morphine, "start low and go slow"(better for when you want to give a lot and worried about neuro) could use dilaudid, longer dosage schedule, not ideal -do everything when get to ER: head CT, CXR (ptx, broken clavicle etc.) -paramedics may call ahead to drs and give meds/prep for others/procedures -needle thoracotomy (fastest- relieves pressure, chest tube)

case 2: sharp stomach pain around lunch time, right of bb-radiates to right side no rebound tenderness no pmhx

- abdominal CT: appendicitis (take out), diverticulitis - visceral pain, not well localized - morphine, potentially stronger- dilaudid, fentanyl patch - control pain, prep for surgery

case 3: unresponsive old man, low RR, HTN, dying, end-stage lung ca

- family wanted comfort measures only (not IV) - palliative care, end of life care (not just, however-diff than hospice) - fentanyl patch: long-acting