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Pharmacology II > Pain Management > Flashcards

Pain Management Flashcards

1
Q

What are the steps of processing pain?

A
  1. Transduction (stimulation of the nociceptors)
  2. Conduction
  3. Transmission (Pain traveling up spinal cord)
  4. Perception
  5. Modulation
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2
Q

What is the cause of sharp, well-localized pain?

A
  • large diameter

- sparsely myelinated fibers

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3
Q

What fibers are involved with aching, poorly localized pain?

A
  • small-diameter

- unmyelinated

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4
Q

Somatic Pain

A
  • from skin, bone, joint, muscle, connective tissue

- throbbing, well localized

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5
Q

Type of pain from large-diameter sparsely myelinated Alpha and Delta

A

sharp, well-localized pain

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6
Q

Type of pain from unmyelinated, small-diameter C fibers

A

dull, aching, poorly localized

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7
Q

Where is the blockade of N-methyl-D-aspartate (NMDA) receptors found

A

dorsal horn

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8
Q

Central sensitization

A
  • increase in excitability or responsiveness of neuron within the CNS
  • Associated with inflammatory pain after injury
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9
Q

Neuropathic pain

A

nerve damage

ex. post-herpetic neuralgia, diabetic neuropathy

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10
Q

Functional pain

A

abnormal operation of nervous system

ex. Fibromyalgia, IBS, tension-type headache

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11
Q

Non-pharmacologic therapy for pain

A
  • physical manipulation
  • heat or cold
  • massage
  • exercise
  • TENS (transcutaneous electrical nerve stimulation)
  • cognitive and behavioral
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12
Q

Pain - PPQRST

A 
Palliative
Provocative factors
Quality
Radiation
Severity
Temporal
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13
Q

Treatment goal difference between acute and chronic pain?

A

acute - pain reduction

chronic - functionality

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14
Q

Salicylates

A
  1. Acetysalicylic acid (ASA)
    - irreversibly binds to platelets for 7-10 days
  2. Choline and magnesium trisalicylate
    - no acetyl group, doesn’t alter platelets
  3. Diflunisal
    - no acetyl group, doesn’t alter platelets
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15
Q

Non-opioid analgesics

A
  1. Salicylates
  2. Acetaminophen
  3. anthranilic acid (ex. Mefenamic acid)
  4. Indolacetic Acid ( ex. Etodolac)
  5. Phenylacetic acids (ex. Diclofenac)
  6. Propionic Acids (ex. Ibuprofen, Naproxen)
  7. Pyrrolacetic acids (ex. Ketorolac (toradol))
  8. Cox-2 selective (ex. Celecoxib)
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16
Q

Acetaminophen max dosing

A

Elderly: max of 2gm/day

-Normal adults: max of 3gm/day

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17
Q

Phenylacetic Acids

A

Diclofenac potassium

Diclofenac epolamine, (patch)

Diclofenac sodium (topical gel, for osteoarthritis)

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18
Q

Propionic acids

A
  1. Ibuprofen (max daily dose for inflammation: 3200mg, max dose of fever/dysmenorrhea: 1200mg)
  2. Naproxen - osteoarthritis; Naproxen sodium for acute pain
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19
Q

Pyrrolacetic Acids

A
  1. Ketorolac (Toradol) Parenteral max of 5 days
  2. Oral ketorolac - max of 5 days
  3. Nasalspray ketorolac: one spray, in one nostril. Max of 5 days
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20
Q

Celecoxib and ASA

A

If using low dose ASA in a patient, give it before the Celecoxib

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21
Q

NSAIDS: adverse reactions and monitoring

A
  1. Upper GI bleed
    - monitor with CBC, stool guaiac
  2. Acute Renal Failure
    - monitor serum creatinine (esp. if CHF, hypovolemia)
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22
Q

Acetaminophen: adverse reactions and monitoring

A
  1. Hepatotoxicity
    - ALT/AST
    - Liver synthesis tests
    - PT/INR, albumin
    - Acetaminophen concentration
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23
Q

Opioids: Phenanthrenes - Potency

A

Greatest to least potency:

Oxymorphone
Hydromorphone (Dilaudid) (1.5 x weaker than oxymorphone)
Morphine (10x weaker than oxymorphone)
-morphine PO has the greatest first pass effect (ex. have to give 3x the dose orally)
-Codeine 15-30x weaker than Oxymorphone
-Hydrocodone 30x weaker
-Oxycodone 30x weaker

24
Q

Opioids: Phenanthrenes - Relative histamine release

A

Morphine (naturally occuring) +++

Hydromorphone (semi-synthetic) +

Oxymorphone (semi-synthetic) +

Codeine +++

Levophanol (semi synthetic) +

Hydrocodone (Vicodin) N/A

Oxycodone (OxyContin) (semi-synthetic) +

25
Morphine
**drug of choice in severe pain** For cancer patients: can use immediate-release product with controlled release product to control breakthrough pain -can cause sphincters to close more tightly, sometimes causing more pain
26
Hydromorphone (Dilaudid)
more potent than morphine, otherwise no advantages
27
Oxymorphone (Opana)
Most potent Phenanthrene - can use immediate + controlled release for cancer pt. - ER reformulated to deter misuse
28
Codeine (methylmorphine) General
- Mild to moderate pain and cough suppression - Needs CYP450, 2D6 to metabolize to morphine (prodrug metabolize to morphine)** DON'T use in children or with breastfeeding
29
Phenylpiperidines: General
1. Meperidine (Demerol) Histamine: +++ Strength: 100x weaker -DON'T use, toxic metabolite accumulation can cause seizures 2. Fentanyl (sublimaze, Duragesic Actiq) Histamine: + Strength: 0.1x weaker**
30
Phenylpiperdines: Meperidine (Demerol)
DON'T USE: - oral form - in renal failure **May precipitate tremors, myoclonus, seizures*** **Dilates eye (mydriasis) not constriction (miosis) *can cause serotonin syndrome with MOAIs
31
Phenylpiperdines: Fentanyl
- Don't use the transdermal patch for acute pain (dose too low) - Transmucosal, intranasal, sublingual
32
Diphenylheptanes: General
Methadone histamine: + Dose: variable!!** ADE: QT prolongation***** avoid titrations more frequently than every 2 weeks
33
Agonist-Antagonist (these contain Naloxone)
1. Pentazocine (historical, not used today) - 3rd line agent These are 2nd line: 2. Buprenorphine dose: 0.3x weaker than oxymorphone - may not be effecting in reversing respiratory depression 3. Nalbuphine 4. Butorphanol **May precipitate withrdrawal in opiate-dependent patients
34
Opioid Analgesics: Central analgesics
1. Tramadol dose: 120x weaker than oxymorphone - can be helpful for neuropathic pain - Pro-drug, must be converted to produce analgesia -Risk of seizure, serotonin syndrome, hypoglycemia ***Decrease dose in elderly (75+) and renal impairment**
35
Analgesic Drug monitoring
1. Respiratory depression - respiratory rate, end-tidal capnography* - The newer a patient is to opioids more likely they are to have this - Sleep apnea, COPD at higher risk 2. Constipation - use Bristol scale to assess
36
Opioids: ADEs
Sedation, Nausea, vomiting: will decrease over time Hypogonadism: fatigue, depression, sexual dysfunction, amenorrhea Sphincter: monitor for biliary spasm, urinary retention
37
Opioid antagonist: Naloxone
- synthetic - IV - duration is shorter than opioid so need to repeat dose*
38
Neuropathic pain
``` -Chronic type of pain Treatments: 1. Anticonvulsants 2. TCA 3. SNRI 4. Opioid 5. Topical analgesics ```
39
Chronic Pain: Anticonvulsants: Gabapentin [neurontin]
-decreases neuronal excitatory neurotransmitters by affecting voltage-gated calcium channels ADE: Dizziness, fatigue, peripheral edema, tremor, headache, amnesia, ataxia, weight gain
40
Chronic Pain: Anticonvulsants: Pregabalin [lyrica]
-structurally related to GABA, but doesn't bind to GABA receptors - Antinociceptive and anticonvulsant activity * *peripheral neuropathy** ADE: peripheral edema**, weight gain, tremor, dizziness
41
Chronic pain-Adjunctive therapy: TCA, SNRI, Duloxetine
block reuptake of serotonin and norepinephrine enhancing pain inhibition
42
Mild pain treatment
Acetaminophen +/- NSAID
43
Moderate pain treatment
Opioid + acetaminophen or NSAID
44
Severe Pain treatment
Opioid
45
which 2 opioid analgesic drugs are prodrugs
1. Codeine | 2. Tramadol
46
What is the caution with using agonist/antagonist agents?
can produce opioid withdrawal in patients chronically taking opioid
47
Why should you avoid Meperidine?
short duration so frequent dosing | -toxic metabolite normeperidine (seizures)
48
What is the drug of choice for focal neuropathic pain?
Lidocaine
49
Intrathecal
injected into the spinal column subarachnoid space -indicated for cancer-related pain Ex. Morphine or Fentanyl
50
Epidural route
Ex. Morphine Hydromorphone Fentanyl Sufentanil -can do continual infusion with this route*
51
Ziconotide
MOA: unique mechanism, no action on the mu receptor First line therapy for localized and nociceptive pain
52
What is the treatment algorhythm for low back pain
1. heat, massage, acupuncture, CBT 2. NSAIDs and skeletal muscle relaxants (acute <4 weeks) 3. Chronic low back pain (>12 wks) NSAIDs are 1st line. Duloxetine, Tramadol are 2nd line
53
Neuropathic pain: treatment
1st line: TCA, SNRI, AED, lidocaine patch 2nd line: central analgesics, opioids 3rd line: capsaicins --NSAID and acetaminophen - rarely effective
54
Heroine
- Diacetylmorphine (give the euphoric feeling, helps cross the BBB) - metabolized to morphine
55
Opioids: What is thought to represent true allergy only
Bronchospasm and sometimes angioedema - severe angioedema - severe hypotension
56
Pseudoallergy
- mast cell degranulation - itching, flushing, sweating, mild hypotension **depends on the concentration of the opioid at the mast cell
57
Which opioids are most commonly associated with pseudoallergy?
- codeine - morphine - meperidine **more potent opioid, less likely to release histamine**

Pharmacology II (31 decks)

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