Pain Management Flashcards
What are the types of pain
Nociceptive pain
Inflammatory pain
Neuropathic pain
Functional pain
What is Nociceptive pain
Pain in response to noxious stimulus
- can be somatic or visceral
What is Inflammatory pain
when tissue damage occurs despite the nociceptive defense system..inflammatory pain ensues.
What is Neuropathic pain
Neuropathic pain results from damage to or dysfunction of the peripheral or central nervous system rather than stimulation of pain receptors.
- TRAMADOL
What is Functional Pain
Pain due to abnormal processing or function of the central nervous system in response to normal stimuli
which types of pain can be involved in Acute pain
Acute pain is usually nociceptive but can also be neuropathic.
which types of pain can be involved in Chronic Pain
may be: nociceptive inflammatory neuropathic or functional
Chronic malignant pain is associated with kind of diseases?
Associated with progressive disease like cancer of AIDs
Chronic Non-malignant pain is not associated with?
Pain not associated with a life threatening disease and lasting longer than 6 months beyond the healing period.
What medication should be given for mild to moderate pain
Acetamiophen and NSAIDs are effective for mild to moderate pain.
- Non-opioids do not cause physical dependence or tolerance.
What is the first line choice for lower back pain and osteoarthritis and is often selected as intial therapy for mild to moderate pain?
Acetaminophen
opioids for mild-moderate pain:
codeine hydrocodone oxycodon Meperidin Tramadol (neuropathic pain)
Opioids for mild to severe pain:
Morphine Hydromorphone Oxymorphone Levorphanol Fentanyl Sufentanil Methadone
Breakthrough pain
how is it alleviated?
what are the formulation for the analgesic?
Transitory severe acute pain that occura on a background of chronic pain that is adequately controlled by an opioid regimen
- targeted with a transmucosal Fentanyl formulation
6 formulation are available in the US:
- Oral transumucosal lozenge
- Immediate-release transmucosal tablet
- Effervescent buccal tablet
- Bucaal solubke film
- Nasal spray
- sublingual spray
Mixed agonist-antagonists all have what kind of effect?
are they a good for patients with severe pain?
Mixed agonist-antagonist: - Pentazocine - butorphanol - Nalbuphine and buprenorphine
all have Ceiling effect
Bad choice
Normeperidine (metabolite) AE:
t1/2=15-20hrs "No MSD" Dysphoria Myoclonus Seizures
Mixed agonist-antagonists adverse effects:
Pentazocine
nalbuphine
butorphanol
psychotomimetic adverse effects ( k agonists)
Most common opioid adverse effects:
Pruritis
Constipation
Nausea/Vomiting
Sedation
opioid induced Pruritis managed by
hydroxyzine or
diphenhydramine
opioid inuduced nausea and vomiting managed by
hydroxyzine
metoclopramide
prochlorperazine
Persisitent opioid SEDATION that limits activity should be managed by?
Methylphenidate
modafinil
if opioid use compromises respiration use:
Naloxone
Analgesic adjunctive agents (Coanalgesics)
Antidepressants
Anticonvulsants
Glucocorticoids
Tricyclic Antidepressants
tertiary amines: (TAI is a Turd)
Amitriptyline
Imipramine
Secondary amines: fewer side effects. Desired in elderly.
Desipramine
Nortriptyline
Tricyclic antidepressants: AE
constipation dry mouth blurred vision cognitive changes tachycardia urinary hesitation
rare AE: Sexual dysfunction orthostatic hypotension weight gain sedation
Tricyclic antidepressants should be administered cautiously in patients with:
Angle-closure glaucoma (due to blurry vision)
BPH
Urinary retention (because of urinary hesitation)
Constipation
CV disease (due to tachycardia)
impaired Liver function
TCA: Amitriptyline, Imipramine, Desipramine, Nortriptyline
should be avoided in patients with:
Second or third degree heart block Arrhythmias Prolonged QT Interval Severe Liver disease Recent acute MI
Serotonin and Norepinephrine Reuptake inhibitors (SNRIs)
Venflaxaxine and Duleoxetine:
- SNRIs selectively inhibit reuptake of serotonin and norepinephrine.
- SNRIs lack the antihistamine; a-adrenergic blocking and anticholinergic effects of TCAs (Amitriptyline, Imipramine, Desipramine, Nortriptyline).
What kind of pain are Venflafaxine and Duloxetine effective for:
Neuropathic pain
SNRIs AE:
which are better tolerated between SNRIs (Venlfafaxine and Duloxetine) and TCAs (Amitriptyline, Imipramine, Desipramine, Nortriptyline)?
Nausea
sexualdysfunction
somnolence
SNRIs are better tolerated than TCAs.
Anticonvulsants
Gabepentin and Pregabalin
Carbamazepine
Gabepentin and Pregabalin
MOA?
AE?
Block voltage gated calcium channels leading to reduction of the influx of calcium into neurons decreasing release of glutamate norepinephrine and substance P.
AE:
dizziness
solmnolence
peripheral edema
DOC for trigeminal Neuralgia
MOA?
Carbamazepine
- Voltage-gated sodium channels in sensory neurons play a crucial role in neuropathic pain
- Carbamazepine blocks voltage gated sodium channels.
Carbamazapine AE:
Drowsiness dizziness nausea vomiting Carbamazepine-induced leukopenia is not uncommon Aplastic anemia is a rare side effet
Glucocorticoids
DOC
commonly used in advanced illness
- useful for acute nerve compression; increased intracranial pressure; Bone pain; viseral pain; anorexia; nausea and depressed mood
- Dexamethasone is the DOC
- Prednisone and methylprednisolone can also be used.
Glucocorticoids indications
Improve appetite; nausea; malaise and overal quality of life.
Hydroxyzine adds to what kind of effect?
May add to the analgesic effect of opioids
Clonidine can be administered in what forms?
Available as oral or transdermal patch formulations. May improve pain and hyperalgesia in sympathetically maintained pain.
Lidocaine Patch or capsaicin patch
are approved for postherpetic neuralgia
Caffeine can enhance analgesic effect of
Acetaminophen and NSAIDs.
OPOID management of adverse effects:
Pruritus
Due to histamine release from mast cells Can be managed
with hydroxyzine or diphenhydramine.
OPOID management of adverse effects:
Nausea/vomiting managed by?
It can be treated with hydroxyzine, metoclopramide or prochlorperazine.
ANTIDEPRESSANTS AND ANTICONVULSANTS
Mainstay of treatment for several neuropathic pain syndromes
ANTIDEPRESSANTS MOA of serotonin and norepinephrine?
- Serotonin and norepinephrine mediate descending inhibition of ascending pain pathways in the brain and spinal cord
- Antidepressants that enhance both serotonergic and noradrenergic transmission display significant analgesic effects
• Tricyclic antidepressants (TCAs)
•Serotonin and norepinephrine reuptake inhibitors (SNRIs).
