Pain Management Flashcards by M Almasri

Classify pain by duration

Acute or Chronic

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Classify pain by nature

Nociceptive vs Non-Nociceptive

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What are the 2 types of nociceptive pain?

Somatic

Visceral

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Non-nociceptive pain, is broken down into ? (2)

Neuropathic

Sympathetic

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Neuropathic pain, involves a lesion in what?

Neural tissue

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Nociceptive pain is usually secondary to pain in what kind of tissue?

Non-neural tissue

Somatic or Visceral

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What is somatic pain broken down into?

Surface tissue (skin, nose, mouth mucosa)

Deep tissue (bone, joint, muscle, connective tissue)

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What structures are involved in visceral pain?

Thoracic, abdominal wall organs

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What kind of pain is it? Diffuse, dull, achy crampy, pressure, tight, associated with nausea and vomiting

Nociceptive, visceral

pneumonia, liver mets, gas pains

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What kind of pain is it? well localized, sharp, local burning or prickly sensation

Nociceptive - superficial somatic

incision, superficial burn

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Well localized pain, dull achy and throbbing?

Nociceptive - deep somatic

fx, bone mets, muscle cramps

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Poorly localized pain, follows nerve distribution, and is sharp/shooting/burning?

Neuropathic

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What is the risk with an epidural should a patient be on anti-coagulation (beyond usual prophylaxis)

Epidural hematoma

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What is acetaminophen’s mechanism of action?

Inhibits prostaglandin synthesis (weakly) via COX-1, COX-2 and COX-3 (likely) inhibition

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Besides PG inhibition, what else may acetaminophen inhibit

Inhibit serotonin re-uptake and act at NMDA receptors

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What is the maximum child dosage for acetaminophen?

75mg/kg/day

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What is one caution with Acetaminophen?

May cause hepatic necrosis (esp if combined with ETOH abuse)

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Two types of NSAIDS?

Non-selective (COX-1 and COX-2)
and Selective (for COX-2)

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What are the 5 non-selective (COX-1, COX-2) inhibitors?

Ketorolac, ibuprofen, naproxem, indomethacin, ASA

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What are the risks with non-selective NSADS? (name 3)

Gastric Ulcer
Platelet dysfunction
Impaired renal blood flow

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What is one COX-2 selective NSAID?

Celebrex

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Advantage of a selective over a non-selective NSAID?

No effect on platelet function or bleeding, nor gastric mucosa

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What are cons of a selective NSAID?

Increased risk of AKI in select populations
Cardiovascular events (MI/Stroke)

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What drugs are first line neuropathic pain?

Anti-convulsants (pregabalin, gabapentin)

TCAs

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Is there a difference in the analgesic efficacy between gabapentin and pregabalin?

How do pregabalin and gabapentin act?

On pre-synaptic calcium channels | Dorsal horn and brainstem/forebrain

Which of the two pregabalin and gabapentin is usually dosed BID?

Pregabalin, although you may see TID

What percent of patients experience drowsiness and dizziness with anti-convulsants

50% | Tend to resolve with prolonged administration

Anti-convulsants, hepatic or renally cleared?

Renal cleared (must adjust with impairment)

Starting dose for gabapentin?

100 mg qHs, titrate up to TID

How does tramadol act?

Weak opioid Acts on opioid receptors Inhibits re-uptake or norepinephrine and serotonin

Which medication tends to interfere with analgesia from tramadol?

Ondansetron

With what CrCl would you dose adjust Tramadol

Only if CrCl

What proportion of Caucasians wont get much analgesia from Tramadol?

7-10% who lack CYP 2D6

Tramadol can be useful in which 2 types of pain?

Neuropathic AND Nociceptive

3 advantages of Tramadol

Less dependence | Less constipation or resp depression

Two risks with Tramadol

Seizures | Serotonin syndrome

Which narcotic should you no longer use? Why (two reaons)?

Codeine (a pro-drug turned into morphine) 1- 40-50% lack CYP 2D6 activity and experience less analgesia 2- Constipates more than any

What are the strong opioids?

Morphine, hydromorphone, oxycodone Fentanyl (sufentanil, remifentanil, alfentanil)

What is the name for immediate release morphine?

Statex

What is the name for sustained release morphine?

MS contin

Time to peak for morphine PO? IV ? SC?

PO (IR tabs)

What organ metabolizes morphine?

Liver, reduce dose in severe liver failure Kindey clears active metabolites

In renal failure, how should you adjust morphine dosing?

Lengthen dosing interval (since metabolites renally cleared)

What is the synthetic analogue of morphine?

Hydromorphone | Same metabolism

What are the 3 oral formulations of oxycodone?

OxyIR OxyNEO Percocet

How did OxyNEO arise?

Tamper resistant replacement for Oxycontin (issue with abuse)

How is oxycodone metabolized?

Metab by liver, excreted by kidneys

Fentanyl's mechanism of action?

Weak serotonin re-uptake inhibitor

What metabolizes fentanyl?

CYP 3A4

Which drugs can increase plasma concentration of fentanyl?

Clarithromycin and fluconazole | inhibit CYP 3A4

Which opioid is safer in severe renal impairement?

Fenatyl, as its inactive metabolites are cleared by kidneys

What is a typical morphine PCA bolus dose? 4 hour limit?

``` 1 mg 30 mg (4 hr limit) ```

How do PCAs fair with regards to rates of resp depression?

``` Same rate as with PRN opioid use Negative feedback (drowsy patient wont press button as often) ```

In surgical patient, indication for PCA?

More invasive/larger surgery Pre-existing Hx of pain Surgeries with regional techniques were block wanes

Example of a non-surgical patient who can benefit from a PCA?

Sickle cell crisis patient

What are 2 less common opioid side effects?

Pruritis | Neurotoxicity

What are 2 rare opioid side effects?

Respiratory depression | Dependence

Delirium as an opioid side effect, is common initially or with ongoing dosing?

Initially

Patient on methadone awaiting surgery, continue or stop?

Almost always continue

What is Suboxone?

Combination of buprenorphine and naloxone

What is Buprenorphine?

It is an opioid agonist/antagonist

What is the role of naloxone within the Suboxone formulation?

- Deters crushing/injecting SL tabs - Inactive orally - But if injected causes WiTHDRAWAL by antagonizing opioid agonist of buprenorphine

How long does buprenorphine bind opioid receptors?

A long-time: 3-5 days | this means can be difficult to achieve pain relief in patients who haven't come off suboxone

If someone is not opioid naive, how do you start opioids in hospital?

Calculate their typical daily dose Continue their SR formulation INCREASE breakthrough dose and make it q1h (i.e. more frequent)

What is the opioid conversion from dilaudid?

Dilaudid:Morphine (1 : 5) Dilaudid:Oxycodone (1 : 2.5) Dilaudid:tramadol (1: 50)

In an opioid naive patient continually having pain on oral morphine, what would you add?

Q1h breakthrough dose that is 50-100% of the q4h dose

Define pain (4 key words)

Unpleasant SENSORY and EMOTIONAL experience | due to ACTUAL or POTENTIAL tissue damage