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Pain Management Flashcards

1
Q

Define acute pain.

A

Usually <3 months
Primarily a symptom of a pathological process or injury; treating illness or injury typically will reduce or eliminate symptoms

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2
Q

Define chronic pain.

A

Typically lasts >3-6 months

Pain which lasts beyond the ordinary duration of time that an insult or injury to the body requires to heal

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3
Q

Acute pain evolves into chronic pain in ___% of patients.

A

20

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4
Q

What are the 2 types of nociceptive pain?

A

Somatic

Visceral

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5
Q

Define somatic pain.

A

Localized, sharp pain involving body surface tissue or musculoskeletal tissue

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6
Q

Define visceral pain.

A

Poorly localized pain that results from compression, obstruction, infiltration, ischemia, stretching, or inflammation of the thoracic, abdominal, or pelvic viscera

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7
Q

Define neuropathic pain.

A

Burning, lancinating, shooting pain caused by damage to or dysfunction of peripheral or central nervous system, rather than stimulation of pain receptors

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8
Q

How do patients describe somatic pain?

A

Sharp, dull, often aching
Familiar
May be exacerbated by movement
Well-localized and consistent with underlying lesion

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9
Q

List 4 examples of somatic pain.

A
  1. Metastatic bone pain
    2 Post-surgical pain
  2. MSK pain
  3. Arthritis pain
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10
Q

How do patients describe visceral pain?

A

Arises from distention of a hollow organ
Poorly localized, deep, squeezing, crampy
Often associated with autonomic sensations (N/V, diaphoresis)
May be referred

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11
Q

List 3 examples of visceral pain.

A
  1. Pancreatitic cancer
  2. Intestinal obstruction
  3. Intraperitoneal metastases
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12
Q

How do patients describe neuropathic pain?

A

Patients may struggle to describe it
Unfamiliar
Burning, electrical, numb
Innocuous stimuli may bring on pain (allodynia)
May have paroxysms of electrical sensation

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13
Q

List 3 examples of neuropathic pain.

A
  1. Trigeminal neuralgia
  2. Post-herpetic neuralgia
  3. Diabetic neuropathy
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14
Q

Describe the nociceptive pain pathway, beginning with trauma.

A

Trauma -> activates peripheral nervous system -> transmission via fibers to dorsal root ganglion -> activation of CNS at spinal cord (spinothalamic tract) -> transmission of pain signal to brain

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15
Q

Important elements of a pain history?

A

PQRSTU

Precipitating, palliating, previous treatment
Quality
Region, radiation
Severity
Temporal
U (you) - impact on ADLs, quality, enjoyment

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16
Q

List 4 general principles of pain management.

A
  1. Assess pain thoroughly.
  2. Know pharmacologic and non-pharmacologic options.
  3. Dose to reduce pain by at least 50%.
  4. Reassess frequently.
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17
Q

What are the 3 steps of the WHO ladder and what medications are used at each step?

A
  1. Mild - aspirin, acetaminophen, NSAIDs
  2. Moderate - codeine/…, hydrocodone/…, oxycodone/…, …/acetaminophen or NSAID, tramadol
  3. Morphine, hydromorphone, methadone, oxycodone, fentanyl

Always consider adding adjunctive treatment

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18
Q

List 8 adjuvant analgesics (drugs whose primary indication is other than pain management).

A
  1. Antidepressants.
  2. Corticosteroids
  3. Anticonvulsants
  4. Local anesthetics
  5. Osteoclast inhibitors
  6. Radiopharmaceuticals
  7. Muscle relaxants
  8. Benzodiazepines
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19
Q

List 13 options for non-pharmacological management of pain.

A
  1. Heat
  2. Cold
  3. Massage therapy
  4. Physical therapy
  5. TENS (trancutaneous electrical nerve stimulation)
  6. SCS (spinal cord stimulation)
  7. Aromatherapy
  8. Guided imagery
  9. Laughter
  10. Music
  11. Biofeedback
  12. Self-hypnosis
  13. Acupuncture
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20
Q

Routes of opioid administration?

A

Oral, IV, subcutaneous, transdermal, transmucosal, rectal, spinal

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21
Q

What are the 2 types of oral opioid formulations?

A

Immediate release

Extended release

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22
Q

Discuss the following regarding immediate release oral opioids:

  • Form of administration
  • Peak analgesic effect
  • Expected total duration of analgesia
  • Frequency of dosing
A
  • Administered as single agents or combination products
  • Peak analgesic effect in 60-90 minutes
  • Expected total duration 3-4 hours
  • Single agent generally given Q4hrs; may be scheduled for continuous pain or PRN for episodic pain
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23
Q

What are combination opioid/non-opioid medications typically used for?

A

Moderate pain that is episodic (typically Q4hrs PRN)

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24
Q

What is the dose-limiting property of all combination products?

A

Aspirin/acetaminophen/NSAID

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25
List opioids that come as extended release (with brand names).
1. Morphine (Morphine ER, MS Contin, Kadian, Avinza) 2. Oxycodone (Oxycodone ER, Oxycontin) 3. Fentanyl (transdermal patch) 4. Hydrocodone, hydromorphone
26
Discuss the following regarding extended release oral opioids: - Dosing - Frequency of dose adjustment - Dosing of transdermal fentanyl patch
Dose Q8, 12, or 24 hours (product-specific) Adjust dose Q2-4 days (once steady state reached) Fentanyl transdermal Q72 hrs (adjust Q6 days once steady state is reached)
27
What should be used for breakthrough pain (IR or ER)?
IR
28
List the equianalgesic dosing of opioids (oral).
``` Codeine (200 mg) Hydrocodone (30 mg) Morphine (30 mg) Oxycodone (20) Hydromorphone (7.5) ```
29
List the equianalgesic dosing of opioids (parenteral).
``` Codeine (100 mg) Hydrocodone (N/A) Morphine (10 mg) Oxycodone (N/A) Hydromorphone (1.5) ```
30
List 13 side effects of opioids.
1. Constipation 2. N/V 3. Urinary retention 4. Pruritis 5. Lethargy/fatigue/mental clouding/memory deficits 6. Somnolence/sedation 7. Respiratory depression 8. Dry mouth 9. Loss of appetite 10. Dizziness 11. Hypogonadism 12. Secondary adrenal insufficiency 13. Risk of overdose and addiction
31
When are long-acting opioids indicated?
For chronic, around the clock pain. Begin when pain is controlled with short-acting agents. Use short-acting agents for breakthrough pain.
32
Routes of administration of morphine?
Oral (IR, ER) IM IV Rectal suppositories
33
Routes of administration of hydromorphone (dilaudid)?
Oral | IV
34
Routes of administration of NSAIDs?
``` Oral Ketorolac (toradol) - IV ```
35
Routes of administration of aspirin?
Oral
36
Routes of administration of oxycodone?
``` Oral (IR, ER) Rectal suppositories (ER) ```
37
Routes of administration of codeine/acetaminophen?
Oral
38
Routes of administration of oxycodone/acetaminophen?
Oral
39
Routes of administration of fentanyl?
IV Transdermal patch Transmucodsal
40
Routes of administration of hydrocodone/acetaminophen?
Oral
41
Routes of administration of methadone?
Oral | IV
42
Routes of administration of tramadol?
Oral
43
What is the MOA of tramadol?
Synthetic partial mu receptor agonist that is also a weak inhibitor of serotonin and norepinephrine, enhancing inhibitory effects of pain transmission in the spinal cord
44
Routes of administration of acetaminophen?
Oral | Suppository
45
First line agent for constipation prophylaxis or recent mild constipation?
Senna (large bowel stimulant laxative); docusate is a stool softener that can be added to prevent constipation
46
What is preferred for acute moderate to severe pain?
IV opioid; if no IV, can give IM until getting IV started.
47
If total opioid dose is greater than or equal to ___ mg of morphine equivalent daily, reassess pain, function, etc. and consider offering naloxone.
50
48
Avoid doses of ___ mg of morphine equivalent daily.
90+
49
What are some risk factors for increased harms when using opioid therapy?
Moderate to severe OSA Pregnancy Renal, liver insufficient Age >65
50
List 5 common indications for PCA.
1. Post-operative pain 2. Severe acute pain 3. Acute exacerbations of chronic pain 4. Cancer pain 5. Patients unable to take oral medications
51
List 2 contraindications for PCA.
1. Poor understanding of PCA | 2. Poor health care support for PCA
52
Drugs commonly used in PCA?
1. Opioids: morphine, fentanyl, hydromorphone 2. Local anesthetics: bupivacaine, ropivacaine 3. Other - clonidine, baclofen, etc.
53
List the 7 settings of a PCA.
1. Concentration 2. Total amount 3. Loading dose 4. Patient dose (aka demand dose) 5. Lockout interval 6. Basal rate 7. Limit
54
Define the following PCA setting - concentration.
Amount of drug per mL of solution (eg, morphine concentration is 1 or 5 mg/mL)
55
Define the following PCA setting - total amount.
Total amount in the pump (30 mL for IV, 250 mL for epidural)
56
Define the following PCA setting - loading dose.
The dose given in frequent intervals to load the receptors and decrease severe pain (eg, morphine 2 mg q5 minutes to a maximum of 20 mg)
57
Define the following PCA setting - patient dose (aka demand dose)
The dose provided by the pump when the patient presses the button (eg, morphine 2 mg)
58
Define the following PCA setting - lockout interval.
The time interval before the pump can provide the next dose; it is a safety features (eg, morphine 2 mg every 10 minutes)
59
Define the following PCA setting - basal rate.
Amount of drug given as a continuous infusion; set per hour (eg, morphine 2 mg/hr)
60
PCA basal rate is useful in what types of patients?
Opioid-tolerant patients Patients with severe rest pain Nighttime Do NOT use in opiate naive patients
61
Define the following PCA setting - 1 or 4 hour limit
The pump can provide only the amount set within the time frame, including both the basal rate and demand dose 4-hour limit with IV 1-hour limit with epidural
62
How is a patient transitioned from PCA to oral medications?
# Translate the last 12- or 24-hour requirements Provide 10-15% of the 24-hour dose as breakthrough
63
Summarize the opioid MOA.
Opioids act on mu, kappa, and delta receptors. All opioids in common clinical use act predominantly through the mu receptor. - Activation of opioid receptors in the midbrain to "turn on" the descending systems (through disinhibition) - Activation of opioid receptors on the second-order pain transmission cels to prevent ascending transmission of the pain signal - Activation of opioid receptors at the central terminals of C-fibers in the SC, preventing the release of pain neurotransmitters - Activation of opioid receptors in the periphery to inhibit the activation of the nociceptors as well as inhibit cells that may release inflammatory mediators
64
Maximum dose of acetaminophen per 24-hour period? For those with underlying liver disease?
3-4 g; 1.5-2 g (ideally none)
65
List the combo opioids/non-opioids in order of potency?
1. Oxycodone/acetaminophen (Percocet) 2. Hydrocodone/acetaminophen (Norco-325/Vicodin-500/Lortab) 3. Tramadol (Ultram) 4. Codeine/Acetaminophen (T3 -> 30 mg codeine), T4 -> 60 mg codeine, T2 -> 15 mg codeine
66
Tramadol is contraindicated with what medications?
SSRIs, MAOIs, etc., due to concern for 5-HT syndrome
67
Safest opioid in liver and kidney failure?
Fentanyl (?)
68
AE of methadone?
QT prolongation -> Torsades
69
Gold standard morphine dose?
10 mg IV
70
What is meperidine (demoral) used for?
Rigors
71
AE meperidine?
Can increase CNS excitability -> seizures Renally excreted, cannot use in renal insufficiency Causes tachycardia (atropine derivative)
72
In general, patients will feel relief in ___, peak effect in ___, effect wears off in ___ with PO opioids.
30 minutes 1.5-2 hours 3-4 hours
73
In general, patients will feel relief in ___, peak effect in ___, effect wears off in ___ with IV opioids.
5-10 minutes 30 minutes 2-3 hours
74
Dosing for ER?
Q12 hours + breakthrough dose (10-15% of 24-hour dose)
75
Dosing for a patient who is opiate tolerant?
Sustained opiate for at least 5 days on equivalent 50 mg morphine for 24-hour period?
76
TD fentanyl dosing?
Relief in 18-24 hours Dose Q72 hrs Size of patches: 12, 25, 50, 75, or 100 mcg/hr
77
Describe how to start a PCA with PO morphine dose.
1PO morphine dose of 660 mg PO Q24hrs Basal dose -> patient's 24 hr morphine equivalent -> 660/3 -> 220 mg morphine (IV) -> divide by 24 -> 10 mg/hr for basal infusion Demand dose/lockout ?5 mg Q 10 min
78
Convert from IV morphine to PO.
PO 3x higher than IV 2/3 of 24 hours dose given via ER and 1/3 for breakthrough If 24 hour IV dose was 15 mg -> 45 mg PO Give morphine XR 15 mg BID with morphine IR 15 mg PO PRN Q4hrs
79
Convert from PO morphine to fentanyl patch
PO morphine 24 hour total dose/2 -> mcg/hr fentanyl patch dose (patients need to have tolerated 50 mg/day morphine for 5 days before starting patch)

Sub-I Wards (2 decks)

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