Pain Management Flashcards
Oxycodone is available w/ and w/o …
Acetaminophen
W/ = Percocet
Ultram = ______
Tramadol
Nucynta = ______
Tapendatol
Tramadol and Tapendatol are unique amongst the opioids for being…
Partial µ-agonists so not as strong as other opioids (and not Schedule 2)
Vicodin, Norco, and Lortab are all…
Hydrocodone with acetaminophen
Opana is …
Oxymorphone immediate release
No longer available as ER
Dilaudid is ….
Hydromorphone
Also available ER
ER indicates…
Extended release (long acting)
Possible side effects of opioids
N/V Constipation*** Pruritis Dry mouth Altered mental status*** Respiratory depression*** Tolerance Dependence
The take away from Ms. Sears’ weird examples of patients presenting with pain and asking for opioids when they really are sick
Take your own complete history (don’t rely upon nurses/others to relate info)
Watch for personal bias
Acute on chronic pain meds, ask about increased use of pain meds at home
Look at vitals, they often reflect pain
What are some vital signs that indicate pain?
Tachycardia
Tachypnea
Elevated BP
Undertreated pain resulting in red flag behaviors
Pseudo-addiction
Withdrawal symptoms with abrupt d/c or decrease in opioids (usually chronic pain)
Physical dependence
Need for increased dose for pain relief or reduced effect of constant dose over time
Tolerance
Impaired control over drug use/craving and compulsive/continued use despite harm
Addiction characteristics
What are the three types of pain
Nociceptive
Neuropathic
Psychogenic
Etiology of the pain dictates treatment
Nociceptive pain is caused by…
Injury to tissues —> activation of peripheral pain receptors, either somatic or visceral
Examples of nociceptive pain
Laceration or other skin injury Fractures, strains, sprains Surgery Tumors/cancer Internal organ injury
How do you manage nociceptive pain?
Short term NSAIDs (ibuprofen, toradol)
Tylenol (can give up to 1g IV in-patient)
Corticosteroids
Oral/topical opioid pain management
Parenteral pain meds/PCA
PT
TENs unit
+/- muscle relaxants vs trigger point injections for spasm
Neuropathic pain results from…
Damage to or dysfunction of nerves, the spinal cord, or the brain
Examples of neuropathic pain
Post-hermetic neuralgia
Cervical/thoracic/lumbar radiculopathy
Trigeminal neuralgia
Diabetic neuropathy
Phantom limb pain
Central pain syndrome (CVA, traumatic cord injury)
What are the first line pain management options for neuropathic pain?
NOT OPIOIDS
Neurontin (Gabapentin)
Lyrics (Pregabalin)
Elavil (Amitriptyline)
Cymbalta (duloxetine)
Other options: Tramadol and Nucynta (partial µ antagonists) Lidoderm patch Spinal cord stimulations Epidural steroid injections
How should lidoderm patch’s or creams be used?
Can wear for up to 12 hours then must take them off for 12 hours
What are some non-pharmacological intervention pain management techniques for neuropathic pain?
Epidural steroid injections Joint injections Intrathecal pump implants Spinal cord stimulator implants Peripheral nerve blocks Sympathetic nerve blocks and neurolysis
Which sympathetic nerve blocks are used more for palliative management of terminal cancer patients?
Superior hypogastric
Ganglion of Impar
Patient with persistent pain typically w/ evidence of psychologic disturbance but no evidence of disorder that could account for the pain or its severity
Psychogenic pain
Goals for treating psychogenic pain?
Improving comfort and psychologic function
Techniques:
• Biofeedback/distraction
• Encourage exercise
• Psychologic/psychiatric eval and therapy
What are your management options for nociceptive low back pain?
NSAIDs, oral or topical
Probably not muscle relaxant if they have an active job
Trigger point injections
Medrol dose back
Ice/heat
Consider short course of short-acting opioid (at bed time only, but this is very risky)
Patient considerations when considering whether to prescribe opioids for low back pain
Employment (will it cause them to need to miss work)
Hx of addictive behavior (EtOH, tobacco)
Caring for small children at home
Teenagers in the home
If you decide on conservative treatment for your patient with low back pain, how/when should you follow up?
1-2 weeks
If no improvement:
• Consider PT
• Consider imaging
• May repeat trigger point injection if they were effective short term
• Transcutaneous electrical nerve stimulator (TENS) for ongoing myofascial pain
Should you give opioids to a patient with RA for their pain management?
Probably not
If they’re already on them though, work with rheumatologist to optimize dose
Tolerance increases faster on high dose, short acting opioids, consider switching them to long-acting med
Possible long acting meds you could consider for a patient with long history of RA who is compliant with their meds but still having pain
OxyContin (oxycodone ER) q12 hrs
MS Contin q12hrs
DURAGESIC PATCH (fentanyl) q72 hours** Safe and steady state opioid w/o risk of OD
How do you switch from a short acting to a long acting opioid in chronic pain patients?
Typically start by reducing total daily dose by 50-75%, with a lower dose opioid for breakthrough pain while converting
Breakthrough med no more than 20-25% of daily long-acting dose
Recommend patient follow up in 1-2 weeks for further titration as needed
Good adjuncts for pain management in RA patients
Topical compound cream (lidocaine, ibuprofen, diclofenac)
TENS unit for myofascial pain
Aqua therapy
Good meds for diabetic neuropathic pain
Gabapentin - titrate slowly 100mg-300mg starting qd, then BID, then TID over weeks-months
Pregabalin - titrate slowly 25-50mg qd then BID, then TID over weeks-months
Cymbalta
Topical compounded cream
TENs unit
What recommendations should you give for pain management in fibromyalgia patients?
Encourage physical activity** Esp aqua therapy
Support - consider referral for counseling
Pregabalin or Gabapentin
Cymbalta
AVOID OPIOIDS - not recommended (tramadol if you must but not together with Cymbalta)
Cancer pain is both…
Nociceptive and neuropathic
When are PCAs used?
For severe post-op pain and intractable cancer pain
Can be used short term for patients on chronic, high dose opioids outpatient that are suddenly NPO to avoid withdrawal
Who will follow a patient who is on a PCA?
Managed by surgeon or anesthesiologist (they will round on them daily)
What are the different settings for PCAs?
“On demand” dose, ie 0.4mg morphine every 15 min
On continuous dose, ie 1 mg of IV morphine over one hour (used more for cancer pain)
Both continuous and on demand (basal rate plus available on demand amount)
Benefits of PCAs
Patient psychologically feels that they have some control over their pain and are not “waiting for the nurse”
Patients typically do not use while they are sleeping so typically less opioid use overall
Can help get severe, debilitating pain under control fairly quickly
Risks of PCAs
Family members pushing button for demand dose for the patient (ie while they are asleep)
OD risk if patient is not properly monitored and titrated - educate the family!!!
What orders do you need to include when putting a patient on PCA?
Continuous pulse oximetry
Orders for naloxone prn
Discuss with RN, make note that she/he is to monitor for mental status changes, resp distress
Patient should be seen again within 12 hours, and every 12-24hrs thereafter
What is the ratio of PO to IV morphine when converted a patient to oral therapy (ie for discharge)?
3:1
If patient was on 20 mg IV morphine/24 hours, they should get 60 mg PO morphine/24 hours
Can then convert to long acting pain meds plus something for breakthrough pain
Helpful to convert while they are still inpatient
Fast facts about the fentanyl patch
Not great for acute pain
Can take up to 12 hours to reach therapeutic levels
When converting IV opioids to fentanyl patch do a two-step taper
• Reduce IV opioids by 50%, add patch, then d/c opioids 12 hours later
Less effective in cachectic patients
Warn patients about exposure to heat - can increase absorption —> death
Fast facts about methadone
Can decrease neuropathic pain (good and cheap)
Can cause QT prolongation —> TdP
• Always do baseline EKG/check renal/hepatic function and EKG yearly
1/2 life up to 55 hours so very slow titration every 3-5 days
Many drug interactions, so need thorough history
Fast facts about tramadol
Consider for neuropathic pain
Can consider in patients with fibromyalgia if absolutely necessary (but not recommended)
Caution with patients on antidepressants, possible serotonin syndrome
Fast facts about the Buprenorphine patch
Can cause QT prolongation
Is NOT for use with opioids
Drug of choice for pain in ESRD
Fentanyl (either patch or parenteral)
Methadone
What pain meds should be avoided in patients with ESRD?
Avoid morphine, Demerol, hydrocodone, codeine
Extreme caution with hydromorphone, oxycodone
If concomitant hepatic disease, avoid opioids all together
Can you give opioids to a patient with increased intracranial pressure?
NOPE
Considering opioids?
Only give them if you can answer yes to all of these questions?
Does the patient have a definitive diagnosis?
Has there been a documented workup with abnormal findings?
Is the patient experiencing impairment of function?
Have you evaluated for contraindications to opioid management?
Has teh patient tried adjunct treatments and failed?
Prescriptions for controlled substances must include…
Date of issue
Patient’s name and address
Practitioner’s name, address, telephone, and DEA number
Drug name, strength, form and quantity
Don’t use short hand, write out # of pills per day, quantity, and refills in long hand
Directions for use
Manual signature
Possible sources of pediatric pain
Developmental impairment
Procedural and post op somatic pain
Sickle cell disease
Trauma
Chronic pain
Cancer
Self-reporting of pain by peds patients relies on…
Child’s cognitive ability
May need to use pain rating scales and location tools
What is the name of the pain rating scale we use for peds patients?
Wong-Baker FACES
How do we evaluate pain in infants and children who are not able to self-report?
Revised FLACC pain score
What are the categories that make up the FLACC score?
Face Legs Activity Cry Consolability
When using the FLACC score, what is the difference between evaluating sleeping or awake patients?
If awake, observe for at least 1-2 min with legs and body uncovered
If asleep, observe for at least 2 min or longer with body and legs uncovered
What should be your initial choice for pain management in a febrile 4 year old with a URI?
Tylenol 10-15 mg/kg q4-6 hours prn
Ibuprofen 4-10mg/kg q6-8hours prn
Opioids - HELL NO
What do you need to give the poor kid with testicular torsion for pain control prior to his detorsion surgery?
IV analgesics
IV antiemetic
Are opioid analgesics indicated pre-operatively for appendicitis?
YES - give that kid some morphine
Also give them an antiemetic
• Promethazine if >2 years
• Metoclopramide
Should you give opioid pain meds to a kid with burns over 19% of body?
YES - IV morphine to start, and with wound treatment
Which pain meds should be avoided in patient <12 years
Codeine and tramadol - variability in metabolism can alter the level of active drug in system —> fatal overdose in extreme cases
What’s the most important thing to take into account when treating geriatric pain?
Polypharmacy - 87% of patients aged 62-85 are on at least one prescription med
Don’t forget about herbal/dietary supplements
Herbal supplements that can have disasterous adverse effects
Ginkgo biloba extract with warfarin —> increased risk of bleeding
St. John’s Wort with a SSRI —> increased risk of serotonin syndrome
Stepwise approach to prescribing in the elderly
Review current meds D/c unnecessary meds Consider adverse drug events for any new symptoms Consider non-pharmacological options Care in the use of commonly prescribed drugs Reduce dosing when able Simplify the dosing schedule Prescribe beneficial therapy
How is the Beers Criteria used?
To help avoid concurrent use of opioids with benzos or gabapentinoids —> OD and severe ADE including respiratory depression and death
To avoid use of SNRIs in patients with a history of falls or fractures
What is the STOPP criteria?
Screening Tool of Older Person’s Prescriptions
Considers drug-drug interactions and duplications of drugs within a class
