Pain Management - Block 4 Flashcards
What is the definition for pain?
An unpleasant sensory and emotional experience associated with potential tissue damage
What are the causes on cancer pain?
- Bone pain from CSF
- Surgery
- Phantom pain
- ADRs of chemo and radiation
- Procedures and testing
- Cancer itself:
* Tumor can press onf nerves, bones, organs
* Spinal compression
* Bone metasasis
What are the types of nociceptive pain?
Somatic: sharp, well-localized, throbbing
* Surgery, bone mets, fractures, cuts
Visceral: ill defined, aching, cramping
* Compression, infiltration
Describe the presentation of neuropathic pain?
Burning or shooting pain, numbness
* Diabetic neuropathy, chemo, radiation
What is breakthrough pain?
- Flare of pain that can happen at anytime
- Non-predicatable
- Quick onset
- Last as long as hours
Who is tx for breakthrough pain different from other pain?
Not controlled by regular pain meds
* Requires additional dose or alternative therapy
What are the goals for pain management?
- Analgesia (optimize)
- Activities (optimize)
- ADR (minimize)
- Aberrant drug taking (Avoid)
- Affect (relationship between pain and mood)
Screen patients at every contact
When should you consider hospitalization for pain?
Acute, severe pain or pain crisis
Tx for persistant cancer pain? Breakthrough?
Scheduled or long-acting analgesics
Breakthrough pain with supplemental doses of short-acting analgesics
What is steady state?
stable drug dose routinely administered for period -> 5 t1/2
What do you want to know when assessing your patient’s pain?
- Location
- Intensity
- Does it interfere with ADLs
- Timing
- Description
- Aggravating/alleviating factors
- Other symptoms?
- What is current pain regimen?
- Response to current regimen
- Breakthrough pain
- Prior history of pain meds?
- Special considerations
- Assess for abuse/misuse/diversion
- Psychosocial support
- Risk factors for undertreatment
- Medical History
What are patient-specific variables you need to consider when managing someone’s pain?
- Age
- Sex
- Pharmacogenomics
- Duration and history of opioid exposure
- Level/stability of pain control
- Interacting meds
- Comorbid conditions
- Liver and kidney function
All of these factors impact pharmacokinetics and pharmacodynamics
Recommended opioids for renal impairment?
Fentanyl and Methadone (safe with adjustment)
Hydrocodone/oxycodone, hydromorphone (Cautiously, adjust dosage)
Codeine, tramadol, meperidine, morphine (not recommended)
Opioids metabolized by CYP3A4?
Fentaly, oxycodone, tramadol
Opioids metabolized by CYP2D6?
Codeine, hydrocodone
Opioids metabolized by glucoronidation?
Hydromorphone, oxymorphone, morphine
Side effects of opioids?
GI: constipation, n/v
CNS: sedation, dz, respiratory depression
Allergies: hives, rash, difficulty breathing
Cutaneous: itching
Opioid for opioid naive patients with moderate/severe pain?
- Morphine
- Hydromorphone
- Oxycodone IR
- Hydrocodone
What is gold standard for opioids?
Morphine
How does cross tolerance differ in patients for stable or uncontrolled pain?
Stable: dose reduce by 25-50%
Uncontrolled: no dose reduction or slight dose increase
What is equianalgesic?
Two different opioids or different routes of the same opioid, that provide approximately the same degree of pain relief
Indications for fentanyl?
Only for opioid-tolerant patients. DO NOT use in opioid naïve patient
Counseling for fentanyl?
Apply 1 patch q72h, must remove old patch, discard appropriately
Indication for methadone?
Detox and maintenance treatment in opioid addicted patients: once daily dosing
BBW of methadone?
Life threatening QT prolongation and arhthmias
How do you convert one opioid to another?
Non-opioid tx for pain?
- Acetaminophen
- NSAIDs
- Antidepressants
- Steroids
- Antihistamines
- Anti-anxiety
- Stimulants and amphetamines
- Anticonvulsants
- Cannabinoids/marijuana
Indication and CP for APAP?
Mild to moderate pain
CP: hepatic metabolism
* maximum daily dose ≤ 4g
* consider decreasing to < 3g daily
Indication and CP for NSAIDs?
Indication:Nociceptive pain, low back, mild to moderate pain
CP: renal metabolism, GI and cardiac ADRs
* Risk increases with age and dose
* If one NSAID ineffective for patient, consider using a different NSAID.
Indication and CP for muscle relaxers?
Indication: pain from spasticity
CP: sedating
Indication and CP for Anticonvulsants?
Indication: Neuropathic pain conditions
CP: cognitive slowing, weight gain, and edema
Indication and CP for TCAs and SNRIs?
Indication: Neuropathic pain conditions ± anxiety/depression
CP: Confusion, uririnary retention, QTc prolongation
Indication and CP for topical agents?
Indication: Minor arthritis, backache, muscle and joint pain
CP: stinging, burning, itching
* Make sure to wash hands and avoid eye contact
Key consideration for pain management?
- If higher doses of opioids needed, switch combination products to single products
- Opioid rotation can be considered if pain not adequately treated
- Prescription monitoring program (PMP)
- Route of administration
- Onset and duration of action
Non pharm for pain?
- Physical therapy/manipulation
- Distraction/relaxation training
- Massage
- Heat/ice
- Transcutaneous electrical nerve stimulation (TENS)
- Acupuncture/acupressure
- Aromatherapy
