Pain Palliation Flashcards
1
Q
Somatic Nociceptive Pain
A
- Dull
- Aching
- Well-localized
- Skin, bone, joint, soft tissues
EX:
-Mets to bone or fractures
2
Q
Visceral Nociceptive Pain
A
- Diffuse
- Deep
- Aching
- Gnawing
- Poorly localized
EX:
- Bladder distension/cramping
- Intestinal distention
- Constipation
- Angina
3
Q
Neuropathic Pain
A
- Burning
- Shooting
- Pricking
- Parasthesias
EX:
- Phantom limb pain
- SCI Pain
- Stroke
- Diabetic Neuropathy
- Post-herpetic neuralgia
4
Q
Pain + Cancer
A
- One of the most common and feared symptoms
- Negative impact on several life factors and overall QoL
5
Q
Acute Pain + Cancer
A
- Diagnose via biopsy or lumbar puncture
- Intervene with stent placement paracentesis, or chest tube insertion
6
Q
Chronic Pain + Cancer
A
- Tumor-related
- Somatic, visceral, or neuropathic
7
Q
Durations of Pains
A
- Acute: seconds to less than 3 months
- Peripheral nociceptors activated and COX enzymes/prostaglandins are released
- Chronic: >= 3 mo
- Sensitization at the level of spinal neurons via multiple mechanisms
- Breakthrough: Seconds to hours
- Due to movement, spontaneous, or from weaning off drugs or effect of drug in a well-treated patient
8
Q
Chemo-Related Pains
A
- Oral mucositis**
- Neuropathy**
- Arthralgia/myalgia
- Hand-foot syndrome
- Chemo-induced headaches
9
Q
Opioid Indications
A
- Treating moderate to severe pain that doesn’t respond to non-opioids alone
- Used for acute and breakthrough pain, cancer pain, visceral/somatic pain, opioid sparing regimens, and treating addiction
- Possible AE: Cough, diarrhea, dyspnea, opioid dependence
10
Q
Opioid MoA
A
- Bind to receptors in CNS
- Inhibits transmission of nociceptive input from periphery to spinal cord
- Alters limbic system activity
- Modifies sensory and affective aspects of pain
11
Q
Opioids + Renal Failures
A
Caution with:
- Meperidine
- Morphine
- Codeine
- Tramadol
12
Q
Opioids + Liver Failure
A
- Codeine
- Meperidine
- Methadone
13
Q
Opioid Escalation Strategies
A
- For moderate to severe pain increase opioid TDD by 50-100% regardless of starting dose
- For mild to moderate pain, increase by 25-50% of TDD regardless of starting dose
- Increase short-acting opioids safely every 2 hours
- Long acting opioids can be safely increased every 24 hours (excluding methadone and patches)
14
Q
Fentanyl Patches
A
- Good for chronic, stable pain
- DON’T give to opioid naive patients
- NOT good for rapid escalations
- > 12 hour onset of action and 3 days to steady state
- Unusual conversion to MME
15
Q
Transmucosal Fentanyl
A
- Required REMS training for providers
- Buccal tabs, film, oral lozenge, nasal or SL spray, SL tablet
- Starting dose: 100 mcg with duration of axn 1-2 hours (opioid TOLERANT)
- Only use in failed standard IR therapies
16
Q
Methadone
A
- Treat opioid dependent patients
- Long duration of action, efficacious, cheap
- Good for chronic pain
- Comparative efficacy to morphine for cancer pain
- Mu agonist and NMDA antagonist
- May help overcome tolerance and toxicities
- Extensively metabolized hepatically (avoid in liver failure)
17
Q
Cardiac Concerns + Opioids
A
- Caution in combination with other QT prolonging agents
- EX: antipsychotics, antidepressants, antibiotics, antiemetics
- Low potassium/magnesium can increase risk
18
Q
Good Methadone Patients
A
- True morphine allergies
- Significant renal impairment
- Neuropathic pain
- High pill burdens
- Difficulty swallowing or PEG tube
- Benefit from long-acting opioids
19
Q
Bad Methadone Candidates
A
- Many DDI in regimen with methadone
- History of syncope or arrhythmias
- Live alone
20
Q
Cannabis + Cancer Pain
A
- Elevated levels of CB1 found in brain areas that modulate nociceptive processing
- Agonists of CB1 and 2 have peripheral analgesic axns and possibly anti-inflammatory
- Doesn’t work at same sites at opioids
- Opioid-sparing effects
- Used in peripheral neuropathy
- Also helps with anxiety, sleep, and N/V in cancer patients
21
Q
Reasons to Change Opioids
A
- Lack of response
- AE
- Change in patient status
- Drug/Formulation availability
- Formulary issues
- Health care beliefs
22
Q
Hyperalgesia
A
- Paradoxical reaction where patient becomes more sensitive to certain stimuli and could experience pain from normal stimuli
- Accompanied by neuroexcitatory signs/symptoms (confusion, hallucinations, myoclonus)
- Usually high dose opioids >1000 mg OME
- Treat by reducing dose, rotating opioid to synthetics, supportive measures
23
Q
Incomplete Cross-Tolerance
A
- Profound response in untolerated receptors when switching opioids
- Decreased new opioid dose by 25-50% of patients current MME
24
Q
Chronic Opioid AE
A
- Constipation
- No tolerance develops
- Treat with stimulant (senna +/- osmotic agent)
25
Q
Acute Opioid AE
A
- N/V
- Sedation
- Confusion/hallucinations
- Pruritis/itching
- Lasts a week or less
- Treat by lowering doses, changing agents, or adding other supportive drugs (antihistamines, steroids, antipsychotics, dopamine antagonists, Zofran)
26
Q
Neuropathic Pain Options
A
- TCAs: amitriptyline, nortriptyline, desipramine (effective at 50-150 mg)
- SNRIs: duloxetine (<60 mg BID), venlafaxine
- Topicals?
- Calcium Channel Alpha-2 ligands: Gabapentin, pregabalin (inhibits calcium influx and diminishes neuronal hyperactivity)
27
Q
Ketamine
A
- Anesthetic with analgesic, dissociative, sedative, and amnestic properties
- Subanesthetic dosing to treat intractable pain (severe neuropathic pain not responding to opioids)
- May reduce opioid tolerance
- Antagonizes NMDA receptors on dorsal horn of spinal cord
28
Q
Bone Metastases Care
A
- Corticosteroids
- NSAIDs
- Calcitonin
- Bisphosphonates
- Denosumab
- External beam radiation therapy
- Radiopharmaceuticals
29
Q
Patient Perspective + Opioids
A
- Identify fears/concerns about opioid use and cancer pain
- Address potential self management
- Educate about appropriate use and SE
- Maintain good provider/patient communication
