Pain Management - Chronic Flashcards
Signs and Sxs of Persistent Pain
- depression, anxiety, sleep disturbances
- frustration, anger
- decreased self esteem, social involvement, libido
- financial stresses, work issues, altered family dynamics, legal issues
Treatment Goals for Chronic Pain
- increase tolerance for physical activity
- decrease suffering and pain
- decrease reliance on healthcare system
- decrease reliance on medications
- return to work or other functional role in society
- develop appropriate strategies for self-management
General Strategies for Chronic Pain
- taper use of inappropriate meds
- provide education about chronic pain
- focus on increase in function and physical activity
- establish a time frame for achieving goals
Nonpharm Options for Persistent Pain
- TENS
- biofeedback
- PT if appropriate
List 3 pharm options for persistent pain.
- non-opioids: NSAIDs and APAP
- tramadol
- opioids
How Are Opioids Used in Treating Chronic Pain
- scheduled regular release product
- PRN regular release product for breakthrough pain
- consider changing to sustained release product when adequate scheduled dose is established
- start a bowel program
List Adjuvant Analgesics for Chronic Pain
- TCAs
- AEDs
- SNRIs
- local anesthetics, eg lidocaine
TCAs MOA
-inhibit NE and 5-HT reuptake
TCAs Generic Names
- amitriptyline
- nortriptyline
- desipramine
TCAs Onset
weeks
AEDs MOA
- decrease synaptic transmission (carbamazepine)
- inhibit neuronal activity and increase GABA (gabapentin)
- decrease release of glutamate, NE and substance P (pregabalin)
AEs of Carbamazepine
- CNS
- CYP450 induced
AEs of Gabapentin
- CNS
- GI
Valproic Acid AEs
- GI
- CNS
- increased LFTs
- decreased platelets
Pregabalin AEs
- dizziness
- sedation
- dry mouth
- peripheral edema
- weight gain
- blurred vision
SNRI MOA
-potent inhibition of NE and 5-HT3 reuptake
SNRI Generic and Trade Name
duloxetine/Cymbalta
What is the indication for duloxetine/Cymbalta?
-tx of pain assoc w/ diabetic neuropathy and chronic MS pain due to low back pain and OA
How should chronic low back pain be treated?
- APAP first
- tramadol or opioids in selected patients
- AEDs or TCAs if neuropathic sxs
How should fibromyalgia chronic pain be treated?
- APAP considered 1st (weak evidence)
- TCAs, AEDs, SNRIs have stronger evidence
- tramadol better alternative than opioids
- NSAIDs only with other agents
How should neuropathic pain (eg diabetic neuropathy or postherpetic neuralgia) be treated?
- TCAs, SNRIs, AEDs, 5% lido patch considered 1st line
- tramadol and opioids 2nd line
- capsaicins 3rd line tx
