Pain Mgmt 2 Flashcards
What is the opioid antagonist?
- Synthetic
- No histamine release
- IV route
- If no response within __ mins, repeat dose
- Onset is slightly longer if given IM
Naloxone (Narcan)
- 5
- Is a chronic pain
- Treatment options
–Anticonvulsants
–Tricyclic antidepressants
–Serotonin–norepinephrine reuptake inhibitors
–Opioids
–Topical analgesics
Neuropathic Pain
Which drug?
- Chronic Pain - Anticonvulsants
- Mechanism: May decrease neuronal excitatory neurotransmitters & nociception through voltage gated Ca channels specifically possessing the alpha-2-delta-1 subunit
Gabapentin (Neurontin)
Which drug for chronic pain?
-
ADE:
- fatigue
- headache
- abnormality in thinking
- amnesia
Chronic Pain Anticonvulsants
Gabapentin
Which drug for chronic pain-anticonvulsants?
- Binds to alpha2-delta subunit of voltage-gated calcium channels within the CNS, inhibiting excitatory neurotransmitter release
- Although structurally related to GABA, it does not bind to GABA or benzodiazepine receptors
•Exerts antinociceptive and anticonvulsant activity*
- Decreases symptoms of painful peripheral neuropathies
- May also affect descending noradrenergic and serotonergic pain transmission pathways from the brainstem to the spinal cord
Prebgabalin (Lyrica)
Which drug for chronic pain-anticonvulsants?
–Peripheral edema
–Weight gain
–Tremor
–Dizziness, ataxia
(no amnesia, no fatigue, no HA)
Prebgabalin (Lyrica)
Serotonin/Norepinephrine reuptake inhibitor antidepressants and _____
- Block the reuptake of serotonin and norepinephrine enhancing pain inhibition
Tricyclic antidepressants
(for chronic pain)
What med decreases nerve stimulation?
Topically applied local analgesic / anesthetics
- Lidocaine patches
- NSAIDs patches: flector, voltarin
- OTC-Salonpas, Tiger balm
(for chronic pain)
Which drug for chronic pain?
–Potent inhibitor of neuronal serotonin and norepinephrine reuptake**
–Weak inhibitor of dopamine reuptake
–No significant activity for muscarinic cholinergic, H-1 histaminergic, alpha-2 adrenergic receptors, or MAO-inhibitory activity
Duloxetine (Cymbalta)
What are 3 ADE’s of Duloxetine?
- Xerostomia (dry mouth)
- Insomnia
- Agitation
(AID)
- Treatment for mild pain?
- Always consider what?
- Acetaminophen and/or NSAID
- Around the clock regiments
- Treatment for moderate pain?
- Always consider what?
- Combination opioid & acetaminophen or NSAID
- Around the clock regimens
- Treatment for severe pain?
- Always consider what?
- Opioid analgesics
- Around the clock regimens
Use what route for analgesics whenever possible?
PO
What 4 opioids should you avoid/exercise caution?
- Codeine
- Meperidine
- Agonist / Antagonist agents
- Tramadol
Regional Analgesia
- Administered local anesthetics can provide relief of _____
- Positioned by ____ or ______
- _____ in the form of a patch has proven effective in treating focal neuropathic pain
- Regional application of local anesthetics relieve pain by blocking ______
- both acute & chronic pain
- injection or topically
- Lidocaine
- nerve impulses
ADEs of Regional Analgesia
- High plasma concentrations lead to what?
Signs of CNS excitation & CNS depression
- dizziness
- tinnitus
- drowsiness
- disorientation
- muscle twitching
- seizures
- respiratory arrest
(DDD MRTS)
Regional Analgesia
- What are the CV effects? (7)
- Myocardial depression
- Hypotension
- Decrease CO
- Heart block
- Bradycardia
- Arrhythmias
- Cardiac arrest
What are the 3 disadvantages of Regional Analgesia?
- need for skillful technical application
- need for frequent administration
- highly specialized follow up procedures
Local Anesthetics
- What are the names of 3 Esters?
- Procaine
- Chloroprocaine
- Tetracaine
(1 i)
Local Anesthetics
- Name the 5 amides
- Mepivacaine
- Bupivacaine
- Lidocaine
- Prilocaine
- Ropivacaine
(2 I’s)
Intraspinal Opioids
- What are the 4 opioids for the Epidural Route?
- Morphine
- Hydromorphone
- Fentanyl
- Sufentanil
Intraspinal Opioids
- What are the 2 opioids for Subarachnoid/Intrathecal route
- Morphine
- Fentanyl
Which intraspinal opioid has the quickest onset of pain relief?
Fentanyl (5 mins)
Which intraspinal opioid has the longest duration of pain relief?
Morphine
Which drug for Intrathecal/Subarachnoid Therapy?
MOA:
- Selectively binds to N-type voltage-sensitive calcium channels located on the nociceptive afferent nerves of the dorsal horn in the spinal cord
- Blocks the excitatory neurotransmitter release and reduces sensitivity to painful stimuli
- No action on the mu receptor
Ziconotide
What are the “more serious” ADEs of Ziconotide for Intrathecal Therapy (4)
Neurocognitive:
- Confusion
- Dizziness
- Hallucinations
- Urinary retention
What are the “less serious” of Ziconotide for Intrathecal therapy? (4)
- Sedation
- Somnolence
- Nausea
- HA
- What is 1st line therapy for both localized & diffuse neuropathic and nociceptive pain
- Is used in place of an opioid for those pts intolerant to opioid
- ONLY administered intrathecally
- 1st line for treating intractable cancer pain (localized & diffuse)
Ziconotide for Intrathecal therapy
How should Acute, Subacute, and Chronic low back pain be treated initially?
Nonpharm therapy
- heat
- massage
- acupuncture
- CBT
- mindfulness based stress reducations to physical therapy
2 treatments for acute low back pain
- NSAIDs
- Skeletal muscle relaxants
What is 1st and 2nd line for chronic low back pain?
1st: NSAIDs
2nd: Duloxetine & Tramadol
Which med is NOT recommended in Fibromyalgia?
Opioids
Acetaminophen & NSAIDs are rarely effective in which type of pain?
Neuropathic Pain
1st line for Neuropathic pain? (4)
- TCAs (tricyclic antidepressants)
- SNRIs (duloxetine)
- AEDs (pregab, gaba)
- 5% lidocaine patch
2nd line tx for neuropathic pain (2)
- Central analgesics
- Opioids
3rd line tx for neuropathic pain?
- Capsaicins
2 resources for prescribing opioids
- www.agencymeddirectors.wa.gov
- www.ncbi.nlm.nih
Heroin
- Derived from ____
- ***Name for it?***
- Acetyl group facilitates what?
- Metabolized to what?
- Urine Drug Screen for Heroin can be positive for ___ and ____
- 3 contaminants?
- poppy
- Diacetylmorphine
- crossing BBB (blood brain barrier)
- Morphine
- UDS: Morphine & Codeine
- quinine, scopolamine, strychnine
True or Pseudo opioid allergy?
- IgE mediated
- T-cell mediated
- Bronchospasm
- Angioedema
True
True or Pseudo opioid allergy?
- histamine release from cutaneous mast cells
- non-immunologic effect
- Sxs: itching, flushing, sweating
Pseudoallergy
True or Pseudo opioid allergy?
- Hives
- Tachycardia
- Hypotension
Pseudo, but are also seen w/ true
(so both?)
Pseudoallergy depends on what?
the concentration of the opioid at the mast cell
- potency
- dose
- route of administration
Choosing an Analgesic (A or B)?
- Flushing, itching, hives, sweating, mild hypotension
A
Choosing an Analgesic. (A or B)
- Severe hypotension
- Rash
- Breathing, speaking, swallowing difficulties
- Swelling of face, lips, mouth, pharynx, or larynx
B
A
- Sxs due to:_____
- Result of histamine release
- Give the patient _____ (____, ____)
- Avoidance of what 3 meds?
- What is the high potency drug least likley to release histamine?
- What is the lowest potency drug which would cause histamine release?
- If needed, concurrent administration of _____.
- pseudoallergy
- non-opioid analgesics (acetaminophen, NSAIDs)
- codeine, morphine, meperidine
- Fentanyl = highest
- Meperidine = lowest
- Antihistamine
B
- This pt may have experienced _____
- Give non-opioid: acet / NSAIDs
- Give an opioid in a different chemical class, ____ or ____
- a true allergy
- Phenylpiperidines (meperidine, fentanyl, sufentanil, remifentanil
- Diphenylheptanes (methadone, propoxyphene)
What group?
- Hydrocodone
- Oxycodone
- Nalbuphine
- Butorphanol
- Levorphanol
- Pentazocine
Morphine
