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AGPC3 > Pain Management > Flashcards

Pain Management Flashcards

1
Q

What are the two main categories of chronic pain?

A

neuropathic and nociceptive

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2
Q

What is neuropathic pain?

A

pain arising from abnormal neural activity secondary to disease, injury, or dysfunction of the nervous system (described as burning or tingling)

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3
Q

What are the types of nociceptive pain?

A

musculoskeletal, inflammatory, mechanical/compressive

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4
Q

What is hyerpalgesia?

A

increased response to a stimulus that is normally painful

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5
Q

What is hypoalgesia?

A

diminished response to a normally painful stimulus

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6
Q

What is analgesia?

A

absence of pain in response to a stimulus that is normally painful

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7
Q

What is hyperesthesia?

A

increased sensitivity to stimulation, especially the skin (excluding the special senses - senses that have specialized organs devoted to them: vision [the eye] hearing and balance [the ear, which includes the auditory system and vestibular system] smell [the nose] taste [the tongue])

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8
Q

What is hypesthesia?

A

diminished sensitivity to stimulation, excluding the special senses

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9
Q

What is dysesthesia?

A

act of touching a part of the body causes some unpleasant sensation, such as pain, burning, or tingling - may be spontaneous or evoked

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10
Q

What is paresthesia?

A

an abnormal sensation, typically tingling or pricking (“pins and needles”), caused chiefly by pressure on or damage to peripheral nerves - may be spontaneous or evoked

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11
Q

What is allodynia?

A

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

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12
Q

What is nerve convergence?

A

convergence of sensory nerves from the viscera and superficial areas onto the same neurons in the spinal cord

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13
Q

What is the spinothalamic pathway?

A

major route by which pain and temperature information ascend to the cerebral cortex

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14
Q

What are nociceptors?

A

highly specialized sub-set of primary sensory neurons preferentially sensitive to a noxious stimulus or to a stimulus that would become noxious if prolonged - categorized by the kind of stimulation they respond to and the nature of their response

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15
Q

What are myelinated nociceptors?

A

relatively fast-conducting A-delta fibers that are responsible for the first (immediate) sharp pain associated with a noxious stimulus

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16
Q

What is the pathway of the pain response from an external stimulus?

A

nociceptors on the skin pass signals through the sympathetic ganglion of the ANS - the signal then passes through the dorsal root ganglion of the spinal cord and then along to the brain, which perceives the pain in the somatosensory cerebral cortex

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17
Q

What is transduction?

A

conversion of a noxious stimulus into electrical activity in the peripheral terminals of nociceptor sensory fibers

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18
Q

What is transmission?

A

passage of action potentials from the peripheral terminal along axons to the central terminal of nociceptors in the CNS

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19
Q

What is conduction?

A

the synaptic transfer of input from one neuron to another

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20
Q

What is modulation?

A

alteration (i.e., augmentation or suppression) of sensory input

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21
Q

What is perception?

A

the decoding/interpretation of afferent input in the brain that gives rise to the indiviudal’s specific sensory expeirence (i.e., realization that something is painful)

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22
Q

What is the International Association for the Study of Pain’s Pain Taxonomy?

A

Axis I: anatomic regions; Axis II: organ systems; Axis III: temporal characteristics/patterns of occurrence; Axis IV: intensity/time since onset of pain; Axis V: etiology

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23
Q

What are the six major categories of treatment options for chronic pain?

A

(1) pharmacologic, (2) physical medicine, (3) behavioral medicine, (4) neuromodulation, (5) interventional (neural blockade, spinal cord stimulation), (6) surgical

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24
Q

What is included in Step 1 for management of chronic (mild) pain?

A

aspirin, acetaminophen (analgesic, not anti-inflammatory), NSAIDs, COX-2 inhibitors, adjuvants

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25
Q

What is included in Step 2 for management of chronic (moderate) pain?

A

acetaminophen or aspirin, codeine, hydrocodone, oxycodone, dihydrocodeine, tramadol, adjuvants

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26
Q

What is included in Step 3 for management of chronic (severe) pain?

A

morphine, hydromorphone, methadone, levorphanol, fentanyl, oxycodone, nonopioid analgesics, adjuvants

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27
Q

What is adaptive pain?

A

contributes to survival by protecting the organism from injury and/or promoting healing after injury

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28
Q

What is maladaptive pain?

A

represents pathologic functioning of the nervous system

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29
Q

What are the two components of the nervous system?

A

CNS and peripheral nervous system

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30
Q

What are the two components of the peripheral nervous system?

A

somatic (voluntary) and autonomic (involuntary)

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31
Q

What are the two components of the autonomic nervous system?

A

sympathetic (action and stress) and parasympathetic (calm and relaxed)

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32
Q

What is sympathetically mediated pain?

A

pain arising from a peripheral nerve lesion and associated with autonomic change (e.g., complex regional pain syndrome)

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33
Q

What is peripheral neuropathic pain?

A

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

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34
Q

What is central pain?

A

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

35
Q

What is nociceptive pain?

A

pain due to the perception of nociceptor input arising from tissue injury, inflammation, or mechanical deformation

36
Q

What is somatic pain?

A

type of nociceptive pain arising from injury to body tissues, well localized, variable in description and experience (focal and described as achy, throbbing, sharp)

37
Q

What is visceral pain?

A

type of nociceptive pain arising from the viscera mediated by stretch receptors, poorly localized, deep, dull, cramping (viscous organ and described as colicky, vague, diffuse)

38
Q

When are opioids recommended for pain treatment?

A

persistent pain despite reasonable trial of non-opioid analgesics/adjuvants OR severe pain requiring rapid relief OR PT characteristics contraindicate use of other analgesics

39
Q

What are the first line treatments for neuropathic pain?

A

calcium channel alpha 2 delta ligands (pregabalin, gabapentin), SNRIs (duloxetine, venlafaxine), TCAs (amitriptyline, nortriptyline)

40
Q

What are the second line treatments for neuropathic pain?

A

antiepileptics (valproic acid), opioids, tramadol

41
Q

What are third line treatments for neuropathic pain?

A

NMDA antagonists (dextromethorpan), tizanidine, baclofen

42
Q

What are fourth line treatments for neuropathic pain?

A

botulinum toxin injection, intrathecal ziconotide

43
Q

What are alternatives to opioids for persistent pain?

A

anticonvulsants, TCAs, topical medications, acetaminophen, ketamine, neural blockade, stimulatory techniques, biofeedback, relaxation therapy, CBT, acupuncture

44
Q

What are the doses of muscle relaxants for chronic pain?

A

cyclobenzaprine (Amrix) 10 mg TID; carisoprodol (Soma) 350 mg TID; baclofen (Lioresal) 5-10 mg TID; methocarbamol (Robaxin) 1500 mg QID

45
Q

What is the mechanism of action for muscle relaxants with chronic pain?

A

most likely sedation, not muscle relaxation

46
Q

What are examples of extended release/long acting opioids?

A

oxycodone, oxymorphone, hydrocodone, morphine

47
Q

When is it recommended to use extended release/long acting opioids?

A

for pain severe enough to require daily, around-the-clock long-term opioid treatment when alternative Tx options are ineffective

48
Q

What should be the pattern of prescribing of opioids?

A

no more than 3 days in most cases (up to 7) with monitoring and reassessment every 3 months

49
Q

What are the four As of pain?

A

analgesia, ADLs, adverse effects, aberrant drug-taking behaviors

50
Q

When should urine drug testing be used with opioid prescribing?

A

before starting therapy and at least annually - test for prescribed medications and other controlled prescription/illicit drugs as well

51
Q

What is the purpose of the Opioid Use Disorder Treatment Expansion and Modernization Act (HR4981)?

A

amend the Controlled Substance Act to expand access to medication-assisted treatment for patients with substance use disorder (SUD) - qualified providers can administer buprenorphine in an office-based setting for the Tx of SUD (can initially treat 30 patients)

52
Q

What is recommendation #1 from the CDC Guidelines for Prescribing Opioid Therapy for Chronic Pain?

A

nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain - only consider opioids if expected benefits for pain and function outweigh risks

53
Q

What is recommendation #2 from the CDC Guidelines for Prescribing Opioid Therapy for Chronic Pain?

A

before starting opioid therapy, establish treatment goals and plans for discontinuation - continue only if there is clinical improvement in pain and function that outweighs risks

54
Q

What is recommendation #3 from the CDC Guidelines for Prescribing Opioid Therapy for Chronic Pain?

A

before starting opioid therapy, and periodically after, discuss risks and benefits with PT

55
Q

What is recommendation #4 from the CDC Guidelines for Prescribing Opioid Therapy for Chronic Pain?

A

prescribe immediate release opioid instead of extended release/long acting

56
Q

What is recommendation #5 from the CDC Guidelines for Prescribing Opioid Therapy for Chronic Pain?

A

prescribe the lowest effective dose - carefully assess risks and benefits when increasing dosage to > 50 morphine milligram equivalents per day and avoid dosages > 90 MME/day or carefully justify dosage > 90 MME/day

57
Q

What is recommendation #6 from the CDC Guidelines for Prescribing Opioid Therapy for Chronic Pain?

A

prescribe no greater quantity of opioid than needed for expected duration of pain severe enough to require opioids (generally <= 3 days)

58
Q

What is recommendation #7 from the CDC Guidelines for Prescribing Opioid Therapy for Chronic Pain?

A

evaluate benefits and harms with PT within 1-4 weeks and again at least every 3 months

59
Q

What is recommendation #8 from the CDC Guidelines for Prescribing Opioid Therapy for Chronic Pain?

A

evaluate risk factors for opioid-related harm and incorporate into the management plan strategies to mitigate risk

60
Q

What is recommendation #9 from the CDC Guidelines for Prescribing Opioid Therapy for Chronic Pain?

A

review PT’s Hx of controlled substance prescriptions using state prescription drug monitoring program data

61
Q

What is recommendation #10 from the CDC Guidelines for Prescribing Opioid Therapy for Chronic Pain?

A

use urine drug testing before starting opioid therapy and consider using at least annually

62
Q

What is recommendation #11 from the CDC Guidelines for Prescribing Opioid Therapy for Chronic Pain?

A

avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible

63
Q

What is recommendation #12 from the CDC Guidelines for Prescribing Opioid Therapy for Chronic Pain?

A

offer or arrange evidence-based treatment for PTs with opioid use disorder

64
Q

What is pain?

A

a somatic perception containing (1) bodily sensation with qualities like those reported during tissue-damaging stimulation, (2) an experienced threat associated with this sensation, and (3) a feeling of unpleasantness or other negative emotion based on this experienced threat

65
Q

How is chronic pain defined?

A

pain which lasts beyond the ordinary duration of time that an insult or injury to the body needs to heal (usually 3 months)

66
Q

What are unmylenated nociceptors?

A

majority of nociceptors - slow conducting primary afferents that respond to thermal, mechanical, and chemical stimuli - mediate delayed and longer-lasting pain, typically characterized as dull

67
Q

What are the major causes of pain hypersensitivity that lead to persistent pain?

A

(1) peripheral sensitization - tissue inflammation results in changes in the chemical environment of peripheral nociceptors and (2) central sensitization - amplifies the synaptic transfer from the nociceptor terminal to dorsal horn neurons

68
Q

What are associated symptoms that should be assessed when taking a PT’s history of pain?

A

restriction of ROM, stiffness, swelling, muscle aches/cramps/spasms, color/temp change, sweating, skin/hair/nail growth, muscle strength, sensation

69
Q

What are some of the specific instruments used to assess neuropathic pain?

A

neuropathic pain scale, S-LANSS (Leeds Assessment of Neuropathic Symptoms and Signs), DN4

70
Q

When are blood tests appropriate in pain assessment?

A

when specific causes of pain (e.g., rheumatologic, infectious, oncologic) are suggested by the patient’s history or physical exam

71
Q

When should you refer to a pain specialist?

A

pain is debilitating, pain is located at multiple sites, symptoms do not respond to initial therapies, there is an escalating need for pain medication

72
Q

What is first line treatment for trigeminal neuralgia?

A

carbamazepine or oxcarbazepine

73
Q

What is the mechanism of action of antiepileptic drugs that makes them effective for neuropathic pain?

A

gabapentin and pregabalin bind to the voltage-gated calcium channels at the alpha 2-delta subunit and inhibit neurotransmitter release - both can cause dizziness and sedation

74
Q

What are some common adjuvants used in the treatment of pain?

A

topical lidocaine (well-localized neuropathic pain), capsaicin cream (post perpetic neuralgia, diabetic neuropathy), topical NSAIDs, anstispasmodics, botulinum toxin, benzodiazepines, cannabis

75
Q

What are some nonpharmacologic therapies for pain?

A

CBT, biofeedback, relaxation therapy, psychotherapy, aerobic exercise, acupuncture, PT, chiropractics, ultrasonic stimulation, electrical modulation, heat/cold, ablation, nerve block, surgery

76
Q

What are the different modalities of transcutaneous electrical stimulation (TENS)?

A

(1) conventional - high frequency, short pulse duration, low intensity - produces paraesthesia; (2) acupuncture-like - low frequency, long pulse duration, high intensity; (3) burst - high frequency and low intensity; (4) intense - high frequency, long pulse duration, high intensity

77
Q

What are possible treatment of diabetic neuropathy and post-herpetic neuralgia?

A

pregabalin (Lyrica) and gabapentin (Neurontin)

78
Q

What is the PEG scale?

A

tracks patient outcomes (pain and function) for pain management: Pain assessment, Enjoyment of life, and General activity

79
Q

What is the definition of clinically meaningful improvement in pain management?

A

30% improvement in pain and function (according to PEG scale)

80
Q

How long should you wait before increasing the dosage of an opioid medication?

A

at least 5 half-lives (around 1 week)

81
Q

What is the recommendation for tapering opioids?

A

10-50% of the original dosage over 2-3 weeks - if PT has been on meds for years, need to go slow (10% per month)

82
Q

What are common signs of opioid withdrawal?

A

drug craving, anxiety, insomnia, abdominal pain, vomiting, diarrhea, diaphoresis, mydriasis, tremor, tachycardia, piloerection

83
Q

What are common side effects of opioids?

A

constipation, dry mouth, N/V, drowsiness, confusion, tolerance, physical dependence, withdrawal symptoms

AGPC3 (19 decks)

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