Pain Notes Week 5 Flashcards
Non-pharmacological options for pain
Acupuncture Massage Exercise therapy Physical therapy Cognitive behavioral therapy TENS/ External Stimuli Biofeedback/ Behavioral Therapy
What is neuropathic pain and what are some drug classes/meds discussed in class?
Alternatives for people who are opioid resistant to relieve pain
EX: antidepressants (TCAs, SNRIs) - Gabaptentin, Pregablin
Anticonvulsants - Carbamazepine, lamotrigine
What drug class is considered a complementary agent to manage pain and what are some drug examples?
Muscle relaxants: Cyclobenzaprine (Flexeril) Methocarbamol (Robaxin) Tizanidine (Zanaflex) Carisoprodol (Soma)
Acute Pain examples from class (what’s causing the acute pain)
Injury
Post-operative
Flare
T/F CDC guidelines can be used as a guide for both acute and chronic pain management
True
T/F opioids are considered to be a first line of therapy for mild to moderate pain according to the CDC
False, they should not be considered
Do muscle relaxants act on skeletal muscle for relaxation?
No
WHO’s Pain Relief Ladder (the 4 steps)
Step 1: non-opioid agent (NSAIDS, acetaminophen)
Step 2: Opioid for mild to moderate pain + non-opioids
Step 3: opioids for moderate to severe pain + non-opioids
Step 4: invasive and minimally invasive treatments
Two non-opioid pharmacological options for mild to moderate localized pain
Local anesthetic
Capsaicin
Local Anesthetics
Action, therapeutic use, safety
Action: blocks neuronal sodium channels resulting in loss of neuronal excitability
Therapeutic use: causes anesthesia- can be topical to injection for nerve blocks
Safety: possible CNS or cardiovascular side-effects with excessive use, hypersensitivity
Capsaicin
Actions
Therapeutic use
Safety
Actions:
TRVP1 receptor agonist
Inc release and depletion of substance P
Chronic stimulation to disrupt neuronal function
Therapeutic use:
topical analgesic for moderate pain
Requires repeated application that can take several days for max effect
Used for joint pain, osteoarthritis, shingles, diabetic neuropathic pain
Safety:
rash or burning sensation
Wash hands after applying
NSAIDs/aspirin
Actions
Therapeutic use
Safety
Actions: NSAIDs compete on the cyclooxygenase enzyme inhibiting production of prostaglandins
Therapeutic use:
- analgesia
- antipyresis (reduce fever due to inhibiting prostaglandins)
- anti-inflammatory (in higher doses)
- anti-platelet: prostaglandins involved in platelet generation in individuals who have already had a cardiac event
Safety: GI (common effects) Cardiovascular (inc cardiac work, risk of vascular/platelet effects) Renal (potential acute renal failure) Neurologic (headache, dizziness) Hematologic (vascular/platelet effects Hypersensitivity (common with salicylates - aspirin) Hypersensitivity
Commonly used NSAIDs/Aspiring from lecture
Aspirin Ibuprofen Naproxen Diclofenac (top) Celecoxib Meloxicam Ketorolac
Acetaminophen Action Therapeutic use Safety Max recommended daily dose
Action:
A poor inhibitor of COX
Therapeutic use:
Analgesia
Antipyretic: reduce fever
Safety:
Safer than NSAIDs
Acutely hepatotoxic at high doses
3200mg max recommended daily dose
Opioids Actions Therapeutic use Safety *what other drug class should not be used with opioids?
Actions:
analgesics
Therapeutic use:
pain relief
Safety: Nausea Constipation (should use stool softeners) Sedation Respiratory depression (cause of death in overdose) Allergic response (not common) Tolerance (uncommon with short term use) Addiction *benzodiazepines
Most common full opioid agonists (full cellular response when they bind to receptor)
Are all fully effective?
Is immediate release preferred?
How should dosing start?
Morphine Hydromorphone Oxycodone Hydrocodone Fentanyl
Yes
Yes
Start low
Fentanyl notes
Very high potency, used for well informed patients
Don’t disrupt dosage or apply heat
Buprenorphine notes
Not a full agonist, very potent partial agonist
Why combine acetaminophen with oxy/hydrocodone
To decrease dose of opioid required for pain
Codeine
Actions
Therapeutic use
Safety
Actions:
Weak opioid agonist
Must be activated to morphine by CYP2D6 enzyme
If processed by CYP3A4 becomes inactive
Therapeutic:
antitussive: relieve cough
Safety:
GI upset common
Rapid CYP2D6 metabolizes have inc risk of respiratory depression
Tramadol
Actions
Therapeutic use
Safety
Actions:
Alternative to full opioid agonists
One isomer is metabolized to an opioid receptor agonist by CYP2D6
Activation required for full efficacy
Therapeutic:
Treat pain
Safety:
GI upset common
Rapid CYP2D6 metabolizes have inc risk of respiratory depression
