Pain management - mahoney

Question 1

Oral-sustained release forms

Answer 1

preferable for chronic pain

Question 2

PCA pump-patient controlled analgesia

Answer 2

• acceptable for alert patients
• need IV site
• provides quick relief
• morphine or hydromorphone are first line agents

Question 3

IV infusion

Answer 3

• avoids peaks and valleys, but may see mroe sedation
  
  • Use PCA pump instead if able

Question 4

rectal dosing

Answer 4

• equals oral dose
• morphine and oxycodone available as suppositories
  
  • morphine works faster than oxycodone

Question 5

Step one drugs

Answer 5

• Mild to moderate pain (1-3 on VAS)
• non-opioid +/- adjucant
  
  • acetaminophen or tylenol (do NOT exceed 3000mg)
  • NSAID (can add)
• Adjuvants (all the “aunties”)
  
  • antidepressants, antihistamines, anticonvulsants, anti anxiety agents

Question 6

Bone pain

Answer 6

• NSAID are the drug of choice for bone pain
  
  • useful first line for all forms of cancer, arthritis, neuropathies
  • Have CEILING EFFECT
  • consider using cytoprotective agent (misoprostol or PPI)

Question 7

Adjuvants

Answer 7

• antidepressants –> use with neuralgias
• anti-anxiety agents –> anxious patients
• anticonvulsants –> use in neuropathic pain
• antihistamines –> useful for agitation, may minimize pruritus associated with narcotics

Question 8

why are adjuvants used for pain

Answer 8

• lots of receptors for pain other than mu receptor
• NMDA and AMPA receptors when stimulated by glutamate cause pain
• GABA and mu receptors (opioids) when stimulated cause analagesia

Question 9

Step two

Answer 9

• patients who fail step one or with moderate pain (4-6 VAS)
• steo two opioid (codeine, oxycodone, hydrocodone)
  
  • +/- nonsteroidal +/- adjuvant
• consider increasing the dose of the scheduled therapy if patients receives mroe than two extra doses per day
• ADD SCHEDULED LAXATIVE (senokot S)

Question 10

Codeine**

Answer 10

• 10% of population are UNABLE to convert codeine to morphine
  
  • SLOW METABOLIZERS
    
    • won’t provide ANY pain relief

Question 11

step three

Answer 11

• Patients who fail step two or with severe pain (7-10 VAS)
• step three opioid (morphine) +/- nonsteroidal +/- adjuvants
• administer around the clock or on schedules basis
• _NO CEILING EFFECT TO OPIOIDS***********_
• DON”T USE METHADONE to reduce pain –> result in respiratory depression