Pain Management Flashcards
Drug Choices for PCA Pumps
Morphine
Fentanyl
Dilaudid
Other Pain Management Options for Inpatients
Toradol IM/IV
Morphine IM/IV
Dilaudid IM/IV
Demerol/Phenergen IM
Acute Pain Management of Post-Operative Pain
Narcotic + non-narcotic medication
Points of Pain Contracts
Pain med- amount- time period
Drug testing
Providers (primary & secondary)
Ancillary Services
Ancillary Services for Chronic Pain
Behavioral health Biofeedback PT OT Hypnosis Osteopathic manipulation
Most Commonly Prescribed Narcotics
Codeine Hydrocodone Oxycodone Tramadol Hydromorphone (Dilaudid) Meperidine (Demerol) Fentanyl
What are narcotics commonly in combination with?
Acetaminophen (APAP)
Use of Schedule I Drugs
Illegal
Restricted to research
No accepted medical use
Examples of Schedule I Drugs
Hallucinogens Heroin Peyote Coca Psilocybin mushrooms Marijuana
Schedule II Regulations
Requires prescription
30 days of medication with no refills
Psychological or physical dependence
Verbal orders not allowed
Examples of Schedule II Drugs
Codeine Hydrocodone Hydromorphone Morphine Cocaine Fentanyl Methadone Meperidine
Schedule III Regulations
Requires a prescription
Moderate abuse potential
Max: 5 refills
Verbal orders allowed
Examples of Schedule III Drugs
Benzphetamine Clortemine Ketamine Pentobarbital Secobarbital Sulfomethane
Schedule IV Regulationss
Requires a prescription
Low abuse potential
Max of 5 refills
Verbal orders allowed
Examples of Schedule IV Drugs
Alprazolam Barbital Clonazepam Lorazepam Midazolam Phenobarbital Diazepam Tramadol
Schedule V Drug Regulations
OTC with restrictions or requires a prescription
Low abuse potential
Examples of Schedule V Drugs
Robitussin AC
Lyrica
Lomotil
Potiga
Codeine/APAP
Opioid agonist Used as antitussive as well Schedule II Good for pediatric patients Cost: $15 for 30 tabs
Hydrocodone
Opioid agonist
Many combo formulations (with APAP)
Schedule II
Cost: $55 for 30 tabs
Examples of Hydrocodone Variations
Lorcet (10/650)
Vicodin (5/500)
Norco (5/325, 7.5/325, 10/325)
Lortab (5/500, 7.5/500, 10/500)
Oxycodone
Combo drug or not
Opioid agonist
Schedule II
Cost: $100 for 30 tabs
Examples of Oxycodone
Percocet (combo)
OxyContin
Tramadol (Ultram)
Binds to opioid receptors & inhibits norepinephrine/serotonin reuptake
Schedule IV
Cost: $60 for 30 tabs
APAP Combo of Tramadol
Ultracet
Hydromorphone (Dilaudid)
Opioid agonist High abuse potential Highly sedative Taper to D/C Schedule II Cost: $30 for 20 tabs
Meperidine (Demerol)
Opioid agonist Very sedative Seizure risk over time & dose Avoid abrupt cessation Schedule II Cost: $30 for 20 tabs
SE of Meperidine (Demerol)
N/V
Fentanyl (Duragesic)
Chronic pain Opioid tolerant patients Major abuse potential Responsible patients or caregiver to administer Schedule II Cost: $100 for 5 patches
How long does a fentanyl patch last?
3 days
NSAIDS
Good for orthopedics
Anti-inflammatory
Caution: concomitant anti-coagulation
Slow fracture healing
Warnings of NSAIDs
CV risk
GI bleeding
Kidney risk
MOA of Acetic Acid Group
Inhibit cyclooxygenase, reducing prostaglandin & thromboxane synthesis
Examples of Medications in Acetic Acid Group
Diclofenac
Etodolac
Indomethacin
Ketorolac
What is the acetic acid group of medications effective of treating?
Arthritis associated pain
Examples of Propionic Acids
Naproxen
Ibuprofen
MOA of Propionic Acids
COX 1 and COX 2 inhibitor
Mess with prostaglandins
SE of Propionic Acids
GI issues
Kidney issues
COX2 Inhibitor
Celebrex
Contraindication of COX2 Inhibitors
Sulfa allergy
Oral Steroids
Medrol-dose pack
Injectable Steroids
Triamcinalone (Kenalog)
Celestone (betamethasone)
Depo-medrol (methylprenisolone)
Aim of Muscle Relaxants
Produce a decrease in muscle tone and involuntary movement without loss of voluntary motor function or consciousness
MOA of Muscle Relaxants
Alters the balance of synaptic excitation and inhibition of motor neuron receives
Indications of Muscle Relaxants
Acute, painful musculoskeletal conditions of local origin
Adjunct to rest and PT
Relief of acute painful musculoskeletal conditions which include muscle spasm secondary to trauma, radiculopathy, musculoskeletal strain or sprain, herniated intervertebral disc & muscle spasm of OA
Muscle Relaxant Effects
CNS depressants
Well absorbed with quick effects
When should you be cautious when prescribing muscle relaxants?
Renal insufficiency
Hepatic insufficiency
Elderly
SE of Long Term Use of Muscle Relaxants
Leukopenia Thrombocytopenia Hemolytic anemia Bleeding agranulocytosis Withdrawal
How are muscle relaxants commonly used with for abusive purposes?
Alcohol
Opioids
What populations are muscle relaxants not recommended in?
Pregnancy
Children
Guidelines for Muscle Relaxants
Muscle relaxant + analgesic agent preferred
Most effective therapy: drugs + PT
SE: drowsiness, HA, dizziness, blurred vision, dry mouth
NSAIDs where pain predominates
Diazepam should be considered in anxiety ridden patients
Possible Mode of Action of Carisoprodol (Soma)
Doesn’t directly relax muscles
MOA may be related to sedative properties
Length of Time to Use Carisoprodol (Soma)
Not longer than 10-14 days
SE of Carisoprodol (Soma)
Drowsiness, dizziness Vertigo, ataxia N/V Hiccups Epigastric distress Tremor, agitation Headache, insomnia Tachycardia Postural hypotension Facial flushing
Contraindications of Carisoprodol (Soma)
Porphyria: inherited porphobilinogen deaminase mutation
Precautions with Carisoprodol (Soma)
Seizures
MOA of Cyclobenzaprine (Flexeril)
Relieves skeletal muscle spasm of local origin without interfering with muscle function
Contraindications of Cyclobenzaprine (Flexeril)
Concurrent use with MAOIs
Acute phase of MI
Arrhythmias
Heart block
SE of Cyclobenzaprine (Flexeril)
Drowsiness Dry mouth Fatigue Headache Constipation Abdominal pain Acid regard Dizziness Nausea
Use of Diazepam (Valium)
Centrally acting skeletal muscle relaxant
MOA of Diazepam (Valium)
Depresses muscle excitability indirectly by potentiating the effects of synaptic inhibition medication by GABA
MOA of Methocarbamol (Robaxin)
CNS depression
No direct action on contractile mechanism of striated muscle
What medication is good for the elderly, fall risk individuals, or individuals with mental status issues?
Methocarbamol (Robaxin)
Other Muscle Relaxant Medications
Metaxalone (Skelaxin)
Tizanidine (Zanaflex)
Baclofen (Lioresal)
What is the most common use for Tizanidine (Zanaflex)?
Chronic muscle issues
What is Baclofen (Lioresal) used for?
Treat spasms associated with spinal cord injuries
Order off Pharmacologic Medications for Ortho Pain
NSAIDs Muscle relaxants Narcotics Steroids TCA's GABA analog (gabapentin, valproic acid) OTC: glucosamine, omega 3's
Non-Pharmacologic Treatment of Ortho Pain
Ice/heat Patient handouts on stretches/exercises Consider PT/OT Consider plain films then MRI Osteopathic manipulation or chiropractor Behavioral health for chronic pain Biofeedback, hypnosis, or anti-inflammatory diet Splint, bracing, or immobilization
Treatment of Grade I Ankle Sprains
NSAIDS
Treatment of Grade II-III Ankle Sprains
NSAIDs during the day
Narcotic at night to sleep
SE of Vicodin
Constipation Shallow breathing, slow heartbeat Feeling light-headed, fainting Confusion, fear, unusual thoughts or behavior Seizure (convulsions) Problems with urination Nausea Epigastric pain Itching Loss of appetite Dark urine Clay colored stools Jaundice
Define Fibromyalgia
Widespread musculoskeletal pain accompanied by fatigue, sleep, memory & mood issues
Risk Factors for Fibromyalgia
Genetics
Rheumatic diseases
Physical, emotional, or sexual trauma
Classes of Medications to Treat Fibromyalgia
Pain relievers
Antidepressants
Anti-seizure drugs
Pain Relievers in Fibromyalgia
OTC Acetaminophen (Tylenol) Ibuprofen (Motrin, Advil) Naproxen (Aleve) Tramadol (Ultram)
Antidepressants in Fibromyalgia
Amitriptyline (noc for sleeping)
Duloxetine (Cymbalta)
Alternative to Amitriptyline for Fibromyalgia
Cyclobenzaprine (Flexeril)
Anticonvulsants in Fibromyalgia
Gabapentin
Pregabalin
What is combination treatment in fibromyalgia directed at reducing?
Chronic widespread pain
Fatigue
Insomnia
Cognitive dysfunction
What is reflex sympathetic dystrophy characterized by?
Severe pain
Swelling
Limited ROM
Skin changes
Inciting Events for Reflex Sympathetic Dystrophy
Soft tissue injury
Fractures
MI
CVA
Medications for Reflex Sympathetic Dystrophy
Capsaicin cream Prednisone NSAIDs Propranolol Terzosin Prazosin Opioids: severe pain
Characteristics of Drug Seeking Behavior
Requests for early refills
Multisourcing
Intoxicated behaviors
Pressuring behaviors
“Reasons” for Requesting for Early Refills
"I took too many" "Lost the prescription" "Washed it with the laundry" "Spilled it in the toilet" "Pharmacist shorted the count" "My sorry ass brother-in-law stole them"
Multi sourcing and Drug Seeking Behavior
Visiting multiple physicians
Recruiting surrogates to obtain meds
Purchasing drugs from illicit drug dealers or over the internet
Intoxicated Behaviors and Drug Seeking Behavior
Slurred or disinhibited calls to the office
Presenting to pharmacies under the influence
ED visits for repeated falls, other traumatic injuries, accidental overdose
Pressuring Behaviors and Drug Seeking Behavior
Begging or pleading
Excessive compliments
Breaching boundaries
Threats of harm to self or others