Pain Management Flashcards
1
Q
Inpt pain management?
A
- controlled enviro: need for pain control over at least 12 hrs
- PCA: usually written on pre-printed order sets - usually have loading dose, PCA dose, lockout interval, 4 hr limit
- choice of morphine, fentanyl, deluded, demerol
- need coherent pt, attentive staff, Narcan taped to pump and bowel program
2
Q
Pain management - inpt for sporadic pain control?
A
- need to be able to adjust: Toradol IM/IV morphine IM/IV Dilaudid IM/IV Demerol/Phenergan IM: most pts however can usually be controlled w/ oral meds
3
Q
Management for acute pain?
A
- usually in ambulatory setting following injury or post op recovery
- mix of narcotic and non-narcotic meds
- don’t forget importance of splinting/bracing/immobilization in ortho pain management
4
Q
How is chronic pain managed?
A
- ground rules need to be est early
- most cases are better dealt w/ through chronic pain providers
- pain contracts:
pain med - amt - time period
drug testing
providers
ancillary services: behavior health, biofeedback, PT, OT, hypnosis, osteopathic medicine
5
Q
Most common narcotics used in ortho pain?
A
- most in combo w/ APAP
- codeine
- hydrocodone
- oxycodone
- tramadol
- hydromorphone
- meperidine
- fentanyl
6
Q
Schedule I drugs?
A
- use: illegal/restricted to research. No accepted medical use
- drug or other substance has high potential for abuse
- lack of accepted safety for use
- ex:
hallucinogens, heroin, peyote, coca, psilocybin mushrooms
7
Q
Schedule II drugs?
A
- reqr Rx
- high abuse potential: psych of physical dependence (No refills or verbal orders)
- ex:
codeine
hydrocodone
hydromorphone
morphine
cocaine
fentanyl
methadone
meperidine
8
Q
Schedule III drugs?
A
- reqr a Rx
- moderate abuse potential
- max 5 refills/6 mos
- verbal orders allowed
- ex: some opioid combos
- stimulants:
benzphetamine
clortemine - depressants:
ketamine
pentobarbital
secobarbital
sulfomethane
9
Q
Schedule IV drugs?
A
- reqr Rx
- low abuse potential
- max 5 refills/6 mos
- verbal orders allowed
- benzos, sedatives/hypnotics and now tramadol
- ex:
alprazolam
barbital
clonazepam
lorazepam
midazolam
phenobarbital
diazepam
tramadol
10
Q
Schedule V drugs?
A
- reqr Rx or may be OTC w/ restrictions in some states
- low abuse potential
- currently accepted medical use in tx
-ex:
Robitussin AC
lyrica
lomotil
potiga (anticonvulsant)
11
Q
Combo of codeine/APAP?
A
- opioid agonist (binds to opioid receptors)
- used as antitussive as well
- schedule III
- good choice for peds
- cost approx $15 for 30 tabs
12
Q
What is hydrocodone? Combos?
A
- opioid agonist
- many combo formulations w/ APAP
lorcet
Vicodin
norco
lortab
price: 30 tabs for $55 - schedule II
13
Q
Oxycodone use? Combo?
A
- can be combo or not
- percocet = oxycodone + APAP
- oxycontin = no APAP: MS-contin, oral morphine sulfat - for chonic pain
- Opioid agonist: bind APAP to opioid receptors
- Schedule II
- Percodan has aspirin instead of APAP
- cose $100 for 30 tabs
14
Q
Tramadol (ultram) MOI? combo?
A
- APAP combo called Ultracet
- MOA unknown, binds to opioid receptors and inhibits NE/serotonin reuptake: caution w/ seizure hx and cause cause serotonin syndrome
- schedule IV
- cost: 30 tabs for $60
15
Q
Hydromorphone MOA, Schedule?
A
- Dilaudid
- MOA - opioid agonist
- high abuse potential and highly sedative
- taper dose to D/C
- schedule II
- cost 20 tabs/$30
16
Q
Meperidine MOA, caution, schedule?
A
- Demerol
- opioid agonist
- very sedative
- seizure risk over time and dose
- oral route least effective
- avoid abrupt cessation
- Schedule II
- 20 tabs for $30
- often causes N/V so give Phenergan
17
Q
Use of Fentanyl? Schedule?
A
- Duragesic
- for chronic pain
- for opioid tolerant pts only
- major abuse potential
- need responsible pts and/or caregiver to administer
- schedule II
- cost $100 for 5 patches, 1 patch= 3 days dose
18
Q
Use of NSAIDs in ortho
A
- anti-inflammatory
- caution w/ concomitant anticoagulation
- some studies have suggested NSAIDs may slow down fracture healing
- all have warnings pertaining to CV risk, GI bleeding, kidney risk
19
Q
Acetic acid group of NSAIDs?
A
- Diclofenac, Etodolac, Indomethacin, Ketorolac
- thought to inhibit cox, reducing prostaglandin and thromboxane synthesis
- usually fairly cheap and this class is effective for management of arthritis assoc pain (rheum., osteo, ankylosing spondylitis)
20
Q
Propionic acid groups of NSAIDs?
A
- Naproxen, Ibuprofen
- MC OTC grouping
- still has BBWs
- Cox 1 and Cox 2 inhibitor, mess w/ prostaglandins
- can cause GI issues, kidney issues
21
Q
Cox 2 inhibitor group of NSAIDs?
A
- Celebrex
- many ortho surgeons use in adjunct w/ narcotics following total jt
- may not interfere w/ anticoag as bad as others, or delay fx repair
- CI in person w/ sulfa alelrgy
- less of GI profile
22
Q
Diff steroid formulations?
A
- oral: medrol dose pack
rheum: longer duration, mostly use prednisone, need to taper - injectable:
Triamcinalone-kenalog
celestone-betamethasone
depo-medrol-methylprednisolone
23
Q
Why are oral muscle relaxants used?
A
- aim of centrally acting skeletal muscle relaxants is to produce a decrease in muscle tone and involuntary movement w/o loss of voluntary motor fxn or consciousness
- alters the balance of synaptic excitation and inhibition the motor neuron receives
- primarily to elicit varying degrees of skeletal muscle relaxation
24
Q
Indications for muscle relaxants?
A
- for relief of acute painful MSK conditions of local origin
- as an adjunct to rest and PT
- for the relief of acute painful MSK conditions which include muscle spasm secondary to trauma, radiculopathy, MSK strain or sprain, herniated intervertebral disc and muscle spasm of OA
25
Q
Muscle relaxants are all ____ depressants?
A
- CNS depressants
so caution w/ elderly - all are well absorbed orally w/ quick effects
26
Q
Caution use of muscle relaxants w/?
A
- renal and hepatic insufficiency
- leukopenia, thrombocytopenia, hemolytic anemia, bleeding agranulocytosis w/ long term use primarily so no initial or F/u labs unless sxs occur
- freq. used w/ EToH or opioids for abusive purposes
- can have withdrawl from muscle relaxants
- taper off to avoid withdrawls
27
Q
When should muscle relaxants not be used?
A
- in pregnancy
- in kids
- shouldn’t be mixed w/ EToH or other CNS depressants, this will potentiate effects
- should only be taken 10-14 days optimally, must revaluate need
28
Q
Guidelines for muscle relaxants use?
A
- combo muscle relaxant and analgesic agent appear to be preferred
- most effective therapy should consider drugs in conjunction w/ various modes of PT
- all agents have potential to cause drowsiness, HA, dizziness, and blurred vision, dry mouth
- pts shouldn’t be tx for protracted periods:
initial: 10-14 days
eval after to determine need for further therapy - NSAIDs may be useful where pain predominates
- for pts w/ anxiety in whom sedation is desireable - Diazepam (valium) should be considered
- combo muscle relaxant and analgesics are available, equally effective and less costly: norgesic (asa/caffeine/orphenadrine)
29
Q
What is Carisoprodol (Soma)?
MOA?
A
- centrally acting skeletal muscle relaxant that doesn’t directly relax tense skeletal muscles
- MOA: relieving acute muscle spasm of local origin has not been clearly ID, but may be related to its sedative properties
- in animals: been shown to produce muscle relaxation by blocking interneuronal activity and depressing transmission of polysynaptic neurons in spinal cord and in descending reticular formation of the brain
- one of products of metabolism, meprobamate, is active as an anxiolytic. Its contributing efficacy is unknown
30
Q
Adverse effects of Carisoprodol (soma)?
A
- shouldn’t be used for periods longer than 10-14 days, eval need for further tx
- Adverse effects:
drowsiness, dizziness
vertigo, ataxia
N/V
hiccups
epigastric distress
tremor, agitation
HA, insomnia
tachycardia
postural hypotension
facial flushing
31
Q
CIs to Soma? Precautions?
A
CI:
- porphyria: inherited porphobilinogen deaminase mutation -
abdominal and urinary sxs, periph. neuropathy, systemic and CNS involvement
precautions:
seizures
32
Q
MOA of cyclobebenzaprine (flexeril)?
A
- structurally similar to TCAS
- relieves skeletal muscle spasm of local origin w/o interfering w/ muscle fxn:
onset of action: 1 hr, effects last up to 12 hours, has an anticholinergic effect - shouldn’t be used for periods longer than 10-14 days, eval needed for further tx
33
Q
CIs, adverse effects of Flexeril?
A
CI:
- w/ concurrent use of MAOIs
- acute phase of MI
- arrhythmias
- heart block
MC adverse effects:
- drowsiness**
- dry mouth
- fatigue
- HA
less common adverse effects:
- constipation
- abdominal pain
- acid regurg
- dizziness
- nausea
34
Q
Use of diazepam (valium) as muscle relaxant?
A
- used as centrally acting skeletal muscle relaxant
- diazepam depresses muscle excitability indirectly by potentiating the effects of synaptic inhibition med by GABA
- among benzos, diazepam is only agent in this class to be approved for tx of muscle spasm or MSK disorders
35
Q
Use of methocarbamol (robaxin)?
A
- MOA hasn’t been established, may be due to CNS depression
- has no direct action on contractile mechanism of striated muscle, the motor end plate or nerve fiber
- less sedating than some other muscle relaxants
- rx to pts w/ dizziness, risk of falling - can dial down dose as well
- start w/ 6 gms/day for first 48-72 hrs and then can reduce down to 4 grams/day
- should not be used longer than 10-14 days: eval need for further tx
36
Q
Other muscle relaxants used?
A
- Metaxalone (skelaxin)
- Tizanidine (Zanaflex): indicated for more chronic pain in conjuction w/ other meds
- baclofen (Lioresal): for spinal cord injuries
37
Q
How can ortho pain be managed?
A
- NSAIDs
- muscle relaxants
- narcotics
- steroids
- TCAs
- GABA analog: gabapentin, valproic acid
- OTC: glucosamine, Omega 3s
- ice/heat
- stretches/exercises
- PT/OT
- plain films then MRI
- osteopathic manipulation/chiropractor
- behavioral health for chronic pain
- biofeedback/hypnosis/anti-inflam diet
- splinting/bracing/immobilization
38
Q
Tx of Grade I ankle sprain?
A
- most likely inversion injury w/ immediate pain and then some swelling
- no sig past hx
- consider:
NSAIDs - ibuprofen 800 mg 1 po tid-qid
or
Naproxen 250mg 1-2po bid
39
Q
Tx of Grade 2-3 ankle sprain?
A
- NSAIDs - ibuprofen, naproxen, indocin 25mg 1 po tid
- at noc: vicodin #10 1-2 po q noc prn pain
- Percocet probably little too strong but can be considered
40
Q
SEs of vicodin?
A
- 5mg/325mg SEs: - constipation - shallow breathing, slow heartbeat - feeling light headed, fainting - confusion, fear, unusual thoughts or behavior - seizure - problems w/ urination - nausea, upper stomach pain, itching, loss of appetite, dark urine, clay colored stools, jaundice - diversion is a real problem!
41
Q
Pt was lifting heavy object when he had sudden sharp, non radiating LBP. No bowel, bladder fever or saddle parasthesia
- DTRs 2+ BL, neg SLR, no CVA tenderness
- what would you do for this pt?
A
- Start NSAID: ibuprofen for 3-5 days then prn
or
naproxen - start a muscle relaxer: Robaxin 500 mg 1-2 po qid x 3 days then prn (Can combine w/ NSAID)
42
Q
What is fibromyalgia? Rfs?
A
- widespread msk pain accompanied by fatigue, sleep, memory and mood issues
- researchers believe fibromyalgia amplifies painful sensations
- cause is unknown
- RFs:
genetics, rheum diseases, physical or emotional trauma
43
Q
Meds for fibromyalgia?
A
- pain relievers
- antidepressants
- anti-seizure drugs
44
Q
Pain relievers used for fibromyalgia?
A
- OTC meds
- tylenol
- ibuprofen
- naproxen
- tramadol
- narcotics not advised
45
Q
Antidepressants used to tx fibromyalgia?
A
- Amitriptyline: initial dose 10mg qhs (can icnrease to 150mg)
- duloxetine (cymbalta): 30 mg qdx 1 wk then increase to 60 mg qd as tolerated
- upon d/c of antidepressant therapy, gradually taper the dose
- an alt to amitriptyline is Flexeril - immediate release initial dose is 5 mg, may increase up to 10 mg tid prn - doesn’t tx depression
46
Q
Anticonvulsants used to tx fibromyalgia?
A
- Gabapentin: 300 mg starting dose
- pregabalin: 75 mg starting dose
47
Q
Combo tx for fibromyalgia?
A
- use if unresponsive to monotherapy
- get psych, PT involved
- directed at reducing major sxs:
chronic widespread pain, fatigue, insomnia, cognitive dysfxn
48
Q
What is reflex sympathetic dystrophy?
A
- disorder of body region: usually extremites
- characterized by severe pain, swelling, limited ROM, and skin changes
- inciting event:
soft tissue injury in 40%
fxs in 25%
MI 12%
Cerebrovascular accidents 3%
49
Q
Meds for reflex sympathetic dystrophy?
A
- topical tx: capsaicin cream
- glucocorticoids: prednisone 30-80mg/day may be effective
- NSAIDs: motrin or naproxen
- sympathetic blockers: propranolol
- alpha 1 adrenoceptor antagonist: Terazosin, prazosin
- opioids: for severe pain
50
Q
How do you ID drug seeking behavior?
A
- distinguish medical use from abuse, monitor response to tx
- know medical and nonmedical use
- characteristics:
request for early refills
multisourcing
intoxicated behaviors
pressuring behaviors
