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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
Q

Morphine

A

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
Q

Hydromorphone (Dilaudid)

A

more potent than morphine, otherwise no advantages

27
Q

Oxymorphone (Opana)

A

Most potent Phenanthrene

  • can use immediate + controlled release for cancer pt.
  • ER reformulated to deter misuse
28
Q

Codeine (methylmorphine) General

A
  • 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
Q

Phenylpiperidines: General

A
  1. Meperidine (Demerol)

Histamine: +++
Strength: 100x weaker
-DON’T use, toxic metabolite accumulation can cause seizures

  1. Fentanyl (sublimaze, Duragesic Actiq)

Histamine: +
Strength: 0.1x weaker**

30
Q

Phenylpiperdines: Meperidine (Demerol)

A

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
Q

Phenylpiperdines: Fentanyl

A
  • Don’t use the transdermal patch for acute pain (dose too low)
  • Transmucosal, intranasal, sublingual
32
Q

Diphenylheptanes: General

A

Methadone

histamine: +
Dose: variable!!**

ADE: QT prolongation*****
avoid titrations more frequently than every 2 weeks

33
Q

Agonist-Antagonist (these contain Naloxone)

A
  1. Pentazocine (historical, not used today)
    - 3rd line agent

These are 2nd line:

  1. Buprenorphine
    dose: 0.3x weaker than oxymorphone
    - may not be effecting in reversing respiratory depression
  2. Nalbuphine
  3. Butorphanol

**May precipitate withrdrawal in opiate-dependent patients

34
Q

Opioid Analgesics: Central analgesics

A
  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
Q

Analgesic Drug monitoring

A
  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
Q

Opioids: ADEs

A

Sedation, Nausea, vomiting: will decrease over time

Hypogonadism: fatigue, depression, sexual dysfunction, amenorrhea

Sphincter: monitor for biliary spasm, urinary retention

37
Q

Opioid antagonist: Naloxone

A
  • synthetic
  • IV
  • duration is shorter than opioid so need to repeat dose*
38
Q

Neuropathic pain

A 
-Chronic type of pain
Treatments:
1. Anticonvulsants
2. TCA
3. SNRI
4. Opioid
5. Topical analgesics
39
Q

Chronic Pain: Anticonvulsants: Gabapentin [neurontin]

A

-decreases neuronal excitatory neurotransmitters by affecting voltage-gated calcium channels

ADE: Dizziness, fatigue, peripheral edema, tremor, headache, amnesia, ataxia, weight gain

40
Q

Chronic Pain: Anticonvulsants: Pregabalin [lyrica]

A

-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
Q

Chronic pain-Adjunctive therapy: TCA, SNRI, Duloxetine

A

block reuptake of serotonin and norepinephrine enhancing pain inhibition

42
Q

Mild pain treatment

A

Acetaminophen +/- NSAID

43
Q

Moderate pain treatment

A

Opioid + acetaminophen or NSAID

44
Q

Severe Pain treatment

A

Opioid

45
Q

which 2 opioid analgesic drugs are prodrugs

A
  1. Codeine

2. Tramadol

46
Q

What is the caution with using agonist/antagonist agents?

A

can produce opioid withdrawal in patients chronically taking opioid

47
Q

Why should you avoid Meperidine?

A

short duration so frequent dosing

-toxic metabolite normeperidine (seizures)

48
Q

What is the drug of choice for focal neuropathic pain?

A

Lidocaine

49
Q

Intrathecal

A

injected into the spinal column subarachnoid space

-indicated for cancer-related pain

Ex. Morphine or Fentanyl

50
Q

Epidural route

A

Ex. Morphine
Hydromorphone
Fentanyl
Sufentanil

-can do continual infusion with this route*

51
Q

Ziconotide

A

MOA: unique mechanism, no action on the mu receptor

First line therapy for localized and nociceptive pain

52
Q

What is the treatment algorhythm for low back pain

A
  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
Q

Neuropathic pain: treatment

A

1st line: TCA, SNRI, AED, lidocaine patch

2nd line: central analgesics, opioids

3rd line: capsaicins

–NSAID and acetaminophen - rarely effective

54
Q

Heroine

A
  • Diacetylmorphine (give the euphoric feeling, helps cross the BBB)
  • metabolized to morphine
55
Q

Opioids: What is thought to represent true allergy only

A

Bronchospasm
and sometimes angioedema

  • severe angioedema
  • severe hypotension
56
Q

Pseudoallergy

A
  • mast cell degranulation
  • itching, flushing, sweating, mild hypotension

**depends on the concentration of the opioid at the mast cell

57
Q

Which opioids are most commonly associated with pseudoallergy?

A
  • codeine
  • morphine
  • meperidine

more potent opioid, less likely to release histamine

Pharmacology II (31 decks)

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