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Primary Care 3 > Pain Management > Flashcards

Pain Management Flashcards

1
Q

Chronic Pain can be one of these two categories

A

Neuropathic or Nociceptive

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2
Q

Neuropathic pain

A

Seconday to a disease or a dysfunction of the nervous system. Either peripheral like PHN, Diabetic neuropathy or central like post stroke pain or MS.

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3
Q

Nocicpetive pain

A

Musculoskeletal (back, ankle) , Inflammatory (arthropathies, infection) or Mechanical/Compressive (kidney stone, tumor) Caveat – multifactorial causes of chronic pain are not uncommon

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4
Q

Hyperalgesia

A

increased response to a stimulus that is normally painful

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5
Q

Hypoalgeisa

A

Diminished response to a normally painful stimulus

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6
Q

Analgesia

A

Absence of pain in response to stimulation that normally is painful

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7
Q

Hyperesthesia

A

Increased sensitivity to stimulation, excluding the special senses

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8
Q

Hypoesthesia

A

Diminished sensitivity to stimulation, excluding the special senses

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9
Q

Dysesthesia

A

An unpleasant abnormal sensation, whether spontaneous or evoked

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10
Q

Paresthesia

A

An abnormal sensation, whether spontaneous or evoked

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11
Q

Allodynia

A

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

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12
Q

Myelinated nociceptors

A

relatively fast- conducting A-delta fibers

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13
Q

Nociceptors

A

highly- specialized subset of primary sensory neurons that respond only to pain stimuli. Their signals sum to produce the nociceptive input, leading to the subjective sense of pain.

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14
Q

Sciatica pain

A

Pain typically found in posterior part of lower extremity and follows dermatomal pattern.

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15
Q

Digital Gangrene

A

Arterial ulcers are intensely painful and occur on the distal portions of the extremities. They may result in tissue necrosis.

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16
Q

Herpes Simplex Infection in HIV Infection

A

In patients with HIV disease, herpes simplex may appear as painful, nonhealing shallow ulcers.

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17
Q

Transduction

A

conversion of a noxious stimulus (thermal, mechanical, or chemical) into electrical activity in the peripheral terminals of nociceptor sensory fibers

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18
Q

Transmission

A

he passage of action potentials from the peripheral terminal along axons to the central terminal of nociceptors in the central nervous system

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19
Q

Conduction

A

is the synaptic transfer of input from one neuron to another

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20
Q

Modulation

A

alteration (eg, augmentation or suppression) of sensory input

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21
Q

Perception

A

the “decoding”/interpretation of afferent input in the brain that gives rise to the individual’s specific sensory experience- the ouch experience

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22
Q

The International Association for the Study of Pain (IASP)

A

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
Caveat Number #2: compatible with the International Classification of Diseases (ICD 9 and ICD 10) but provides for more detailed identification of various chronic pain syndromes and major acute pain syndromes

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23
Q

Axis I: Anatomic regions

A

Need Specifics to Accurately bill ex R10.1 pain localized to upper abdomen

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24
Q

Treatment options for chronic pain generally fall into six major categories

A
  1. pharmacologic;
  2. physical medicine;
  3. behavioral medicine; 4. neuromodulation;
  4. interventional, and 6. surgical approaches.
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25
Q

Opioids in chronic pain mgmt

A

Opioids should not be considered first- line or routine therapy for chronic pain. This does not mean that patients should be required to sequentially “fail” nonpharmacologic and nonopioid pharmacologic therapy before proceeding to opioid therapy - benefits should be weighed against the risk

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26
Q

Adaptive pain

A

Adaptive pain contributes to survival by protecting the organism from injury and/or promoting healing when injury has occurred.

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27
Q

Maladaptive pain

A

Chronic pain- aka – maladaptive - is pain as disease itself, and represents pathologic functioning of the nervous system.

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28
Q

Sympathetically Mediated Pain

A

pain arising from a peripheral nerve lesion and associated with autonomic chances (e.g. complex regional pain syndrome I and II)

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29
Q

Peripheral Neuropathic Pain

A

is due to damage to a peripheral nerve without autonomic change (e.g. post-herpetic neuralgia)

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30
Q

Central Pain

A

arises from abnormal CNS activity (e.g. phantom limb pain)

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31
Q

Nociceptive Pain

A

A nociceptor is a nerve fiber sensitive to a noxious stimulus or a stimulus that would become noxious if prolonged (e.g. operative incisions) Nociceptive pain is the perception of nociceptor input arising from tissue injury, inflammation or mechanical deformation.

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32
Q

Somatic Pain

A

arises from injury to body tissues, well localized, variable in description and experience

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33
Q

Visceral Pain

A

arises from the viscera mediated by stretch receptor, poorly localized, deep, dull and cramping.

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34
Q

Examples of Nocioceptive pain

A

Examples: trauma, burns, infections, arthritis, ischemia and tissue distortion

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35
Q

Examples of neuropathic pain

A

diabetic neuralgia, trigeminal neuralgia, thalamic pain syndrome

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36
Q

Nociceptive Somatic pain described as

A

“ache”, “throb”, “sharp” May worsens with movement

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37
Q

Nociceptive Visceral described as

A

“colickly”, “vague”, “diffuse” May worsen with meals

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38
Q

Neuropathic described as

A

“burning”, “sharp”, “tingling” May worsen with touch

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39
Q

Chronic neck pain

A

Constant dull pain, occasionally shooting pain, pain does not follow nerve distribution. No trigger points, poor ROM in involved muscle

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40
Q

Fibromyalgia

A

Diffuse muscular pain, stiffness, fatigue, sleep disturbance, Diffuse muscle tenderness, >11 trigger points

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41
Q

Chronic back pain

A

Constant dull pain, occasionally shooting pain, pain does not follow nerve distribution, NO trigger points, poor ROM in involved muscle

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42
Q

Myofascial back pain syndrome

A

Constant dull pain, occasionally shooting pain, pain does not typically follow nerve distribution, TRIGGER points in area of pain, usually no muscle atrophy, poor ROM in involved muscle

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43
Q

When to use opiods

A

Opioids are generally recommended to reduce the level of moderate to severe pain, Opioids should be considered if reasonable, conservative therapy has failed

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44
Q

Nonopiod analgesics

A

acetaminophen and nonsteroidal anti- inflammatory drugs (nonselective agents and selective COX-2 inhibitors).

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45
Q

Adjuvants

A

specific medications for neuropathic pain (antidepressants, anticonvulsants, miscellaneous agents), specific medications for cancer-related pain (bisphosphonates, radioisotopes, steroids), and medications for bowel spasms

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46
Q

fibromyalgia cardinal symptom

A

Chronic widespread pain

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47
Q

Documentation with opiod treatment

A

Documentation is critical and should include the initial evaluation, substance abuse history, psychosocial issues, pain/pain relief, side effects, functional outcomes, and continuing monitoring- with each visit. The medical record should document the nature and intensity of the pain, current and past treatments for pain, underlying or coexisting diseases or conditions, the effect of the pain on physical and psychological function, and history of substance abuse- WITH EACH VISIT- Now Being Done Monthly.

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48
Q

When to refer

A
  • Previous failure with opioids or other analgesics • Significant psychosocial issues
  • Conviction of a drug-related crime
  • Current use of illicit drugs
  • Regular contact with drug high-risk groups
  • History of substance abuse
  • Be careful- you cannot quickly abandon the patient
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49
Q

Bio/Physical Approaches

A
  • pharmacologic and/or nonpharmacologic therapies
  • physical rehabilitation
  • physical/ occupational therapy
  • homeexercise program
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50
Q

Psychological Intervention

A
  • mood disturbances • coping skills

* sleep disturbance

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51
Q

Social Issues

A
  • family/social relations

* work issues

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52
Q

Psychologicalintervention

A

integralpartoftheroutinemanagement→improvespatients’coping skills and their ability to relax and sleep without interruption

53
Q

Alternatives to Opioid Therapy

A
  • adjuvant analgesics
  • nonpharmacologic modalities
  • CAM (e.g. Acupuncture/massage)
  • Anticonvulsants
  • Tricyclic antidepressants
  • Topical medications
54
Q

Interventional treatments

A
  • Neuralblockade

* Stimulatory techniques (spinal cord stimulation; peripheral nerve stimulation)

55
Q

Nonpharmacological therapies

A
  • Biofeedback
  • Relaxation therapy
  • Cognitive/behavioralstrategies • Acupuncture
56
Q

Antispasmodics

A

can be useful in treating this aspect of the patient’s symptoms, but their action may be more the result of sedation rather than muscle relaxation.

57
Q

Benefits of high-dose opioids for chronic pain

A

these are not established

58
Q

ER/LA opioids

A

methadone, transdermal fentanyl, and extended-release versions of opioids such as oxycodone, oxymorphone, hydrocodone, and morphine. reserved for “management of pain severe enough to require daily, around-the-clock, long-term opioid treatment” when “alternative treatment options (e.g., nonopioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain” and not used as “as needed” pain relievers

59
Q

limiting days of opioids

A

Because physical dependence on opioids is an expected physiologic response in patients exposed to opioids for more than a few days (contextual evidence review), limiting days of opioids prescribed also should minimize the need to taper opioids. Each day of unnecessary opioid use increases likelihood of physical dependence without adding benefit

60
Q

Initiating Opioid Therapy

A
  • Consider cost, tolerability, ease of administration, compliance
  • Develop and document an Exit Strategy
  • Should regularly reassess all patients receiving long-term opioid therapy, including patients who are new to the clinician but on long- term opioid therapy, at least every 3 months.
61
Q

Moderate to Severe pain

A

Morphine, Fentanyl, oxycodone, hydromorphone

62
Q

Mild to Moderate

A

Codeine, Tramadol, hydrocodone, propoxyphene

63
Q

Mild pain

A

nonopiod, Tylenol, Asa, Nsaids, Corticosteroids Tricyclic antidepressants Anticonvulsants Topical Preparations

64
Q

Factors That Influence Analgesic Selection

A
  • Type of pain
  • Severity
  • Duration
  • Patient-specific factors:::
  • age
  • pain and analgesic history
  • concomitant diseases, organ function
  • psychosocial issues
65
Q

Create an Exit Strategy

A

Upon initiating opioid therapy, agree with patient on criteria for failure of the trial. Common failure criteria include: • lack of significant pain reduction
• lack of improvement in function • persistent side effects
• persistent noncompliance

66
Q

The “Four A’s of Pain”

A 
Analgesia
Activities of daily living Adverse effects
Aberrant drug-taking behaviors
Important to remember two other “A’s”
Assessment
Action (treatment plan)
67
Q

Prescribe naloxone when factors that increase risk for opioid overdose, such as:

A
  • History of overdose

* history of substance use disorder, higher opioid dosages

68
Q

Review the patient’s history of controlled substance prescriptions

A

the state prescription drug monitoring program

69
Q

Urine drug testing

A

–before starting opioid therapy –consider urine drug testing at least annually to assess –Recommend 3 negative test per 12 months for prescribed medications as well as other controlled prescription drugs and illicit drugs

70
Q

Nausea and vomiting s/e

A

Switch opioids; anti-emetics

71
Q

Sedation s/e

A 
Lower dose (if possible); add co-analgesics;
add stimulants
72
Q

Constipation s/e

A

Treat prophylactically with stool softeners, bowel stimulants; non-pharmacological measures; switch opioids

73
Q

Itching s/e

A

Switch opioids; antihistamines

74
Q

Endocrine dysfunction/reduced libido s/e

A

Endocrine monitoring; testosterone replacement; endocrine consultation

75
Q

Edema and sweating s/e

A

switch opioids

76
Q

Dizziness s/e

A

Antivertiginous agents (eg, scopolamine)

77
Q

Confusion s/e

A

Titrate dose; switch opioids

78
Q

Opioid treatment may lead to the development of

A
  • pharmacological tolerance
  • opioid-induced pain through similar cellular mechanisms Both may contribute to the clinical manifestation of apparent opioid tolerance with a demand of opioid dose escalation. Opioid dose escalation may feed back into the cellular mechanisms of pharmacological tolerance
79
Q

Opioid-induced pain sensitivity

A

further escalating the opioid demand

80
Q

Continue Opioid Therapy

A

An option if there is • effective pain relief
• improvement in ADLs
• improvement in psychosocial functioning • management of side effects

81
Q

Relevant regulations of the CDC include

A
  • federal (DEA)
  • state policies
  • Your scope of practice
  • Your prescribing habits
  • Your collaborative agreement
82
Q

Exit Strategy

A

Start on Day one. Documentation of lack of pain reduction and/or lack of functional improvement
• criteria for tapering emphasized in the initial patient agreement • This is Huge: Distinguish between abandoning opioid therapy, abandoning pain management, and abandoning patient • Taper off opioid therapy, with or without specialty assistance

83
Q

preferred treatment for chronic pain

A

Nonpharmacologic therapy and nonopioid

pharmacologic therapy

84
Q

Clinicians should consider opioid therapy only if

A

expected benefits for both pain and function are

anticipated to outweigh risks to the patient.

85
Q

If opioids are used you need to combine them with what?

A

nonpharmacologic therapy and nonopioid

pharmacologic therapy, as appropriate.

86
Q

Before starting opioid therapy for chronic pain,

clinicians should establish

A

treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks.

87
Q

Clinicians should continue opioid therapy only if there is

A

clinically meaningful improvement in pain and function that outweighs risks to patient safety.

88
Q

Before starting and periodically during opioid therapy, clinicians should discuss with patients

A

known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.

89
Q

When starting opioid therapy for chronic pain, clinicians should prescribe

A

immediate-release opioids instead of

extended-release/long-acting (ER/LA) opioids.

90
Q

When opioids are started, clinicians should prescribe

A

the lowest effective dosage.

91
Q

Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to

A

≥50 morphine milligram equivalents (MME)/day

92
Q

We should avoid increasing dosage to

A

≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.

93
Q

Long-term opioid use often begins with treatment of

A

acute pain

94
Q

When opioids are used for acute pain, clinicians should prescribe

A

the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.

95
Q

Clinicians should evaluate benefits and harms of continued therapy with patients every

A

3 months or more frequently (many places do this monthly)

96
Q

If benefits do not outweigh harms of continued opioid therapy, clinicians should

A

optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.

97
Q

Before starting and periodically during continuation of opioid therapy, clinicians should

A

evaluate risk factors for opioid-related harms.

98
Q

Clinicians should incorporate into the management plan strategies to mitigate risk, including

A

considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present.

99
Q

Clinicians should review the patient’s history of controlled substance prescriptions using

A

state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose.

100
Q

Clinicians should review PDMP data when

A

starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.

101
Q

When prescribing opioids for chronic pain, clinicians should use urine drug testing

A

before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.

102
Q

Clinicians should avoid prescribing opioid pain medication and

A

benzos

103
Q

Clinicians should offer or arrange evidence-based treatment for patients with opioid use disorder

A

usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies

104
Q

Can improve pain in diabetic

neuropathy and post-herpetic neuralgia

A

Lyrica and Neurontin

105
Q

FDA approved adjuvant therapy for fibromyalgia

A

Lyrica and Tricyclic and SNRI antidepressants

106
Q

Effective analgesia for neuropathic pain conditions

A

tricyclic antidepressants and SNRIs (Cymbalta) often at lower dosages and with a shorter time to onset of effect than for treatment of depression

107
Q

Situations in which opioids will be discontinued or doses tapered

A

if treatment goals are not met, opioids are no longer needed, or adverse events put the patient at risk

108
Q

Scale to track patient oucomes

A

PEG - Pain assessment, Enjoyment of life, interfere with General activity

109
Q

Clinically meaningful improvement has been defined as a

A

30% improvement in scores for both pain and function

110
Q

assessment of functional improvement

A

assess functional goals like walking around the block

111
Q

If they do not receive benefit in both pain and function

A

taper of stop the opiod and use nonpharm and nonopiod forms of pain management (NSAIDS, SNRI, pt/ot, etc)

112
Q

common effects of opioids,

A

constipation, dry mouth, nausea, vomiting, drowsiness, confusion, tolerance, physical dependence, and withdrawal symptoms when stopping opioids.

113
Q

ER/LA opioids

A

methadone, transdermal fentanyl,extended-release versions of opioids such as oxycodone, oxymorphone, hydrocodone, and morphine – higher risk of overdose

114
Q

ER/LA opioids be reserved for

A

management of pain severe enough to require daily, around-the-clock, long-term opioid treatment” when “alternative treatment options (e.g., nonopioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain” and not used as “as needed” pain relievers

115
Q

opioid-tolerant patients

A

patients who have received certain dosages of opioids (e.g., 60 mg daily of oral morphine, 30 mg daily of oral oxycodone, or equianalgesic dosages of other opioids) for at least 1 week. ER/LA opioids should be reserved for severe, continuous pain and should be considered only for patients who have received immediate-release opioids daily for at least 1 week

116
Q

Methadone risk

A

Prolonged respiratory despression, QT prolonged

117
Q

transdermal fentanyl risk

A

absorption properties differ widely from patient to patient

118
Q

higher opioid dosages areassociated with increased risks for

A

motor vehicle injury, opioiduse disorder, and overdose

119
Q

although there is not a single dosage threshold below which overdose risk is eliminated, holding dosages < This Dose of MME/day would likely reduce risk among a large proportion of patients who would experience fatal overdose at higher prescribed dosages

A

50 MME/Day, increasing dosages to 50 or more MME/day increases overdose risk without necessarily adding benefits for pain control or function and that clinicians should carefully reassess evidence of individual benefits and risks when considering increasing opioid dosages to ≥50 MME/day. If > 50 need increased follow up monitoring and narcan education

120
Q

opioid dosages should not be increased to ≥ this dose MME/day without careful justification based on diagnosis and on individualized assessment of benefits and risks

A

90 MME/day

121
Q

Wait how long before increasing a dosage

A

5 half lives or usually one week - especially with methadone

122
Q

Consult pain mgmt if

A

do not experience improvement in pain and function at ≥90 MME/day, or if there are escalating dosage requirements

123
Q

early warning signs of serious adverse events, signs of opioid use disorder

A

difficulty controlling use, work or family problems related to opioid use

124
Q

exposed to greater risk of opioid use disorder or overdose

A

patients with depression or other mental health conditions, a history of substance use disorder, a histor of overdose, taking ≥50 MME/day, or taking other central nervous system depressants with opioids

125
Q

Tapering opiods

A

10-50% of original dose over 2-3 weeks. If taking for years it may need to be done by 10 percent per month.

126
Q

signs of opioid withdrawal

A

drug craving, anxiety, insomnia, abdominal pain, vomiting, diarrhea, diaphoresis, mydriasis, tremor, tachycardia, or piloerection – need to taper slow enough to avoid these symptoms

127
Q

factors that increase risk for harm

A

history of overdose, history of substance use disorder, higher dosages of opioids (≥50 MME/day), and concurrent use of benzodiazepines with opioids

128
Q

If clinicians suspect their patient might be sharing or selling opioids and not taking them, clinicians should

A

consider urine drug testing to assist in determining whether opioids can be discontinued without causing withdrawal. A negative drug test for prescribed opioids might indicate the patient is not taking prescribed opioids,

Primary Care 3 (29 decks)

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