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Advanced Pharma > Pain: textbook > Flashcards

Pain: textbook Flashcards

1
Q

nociceptive pain

A

transient pain in response to a noxious stimulus at nociceptors

explained by ongoing tissue injury

classified as thermal, mechanical & chemical

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2
Q

functional pain

A

sustained by abnormal processing or functioning in the peripheral or central nervous system in response to normal stimuli

-fibromyalgia, IBS

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3
Q

neuropathic pain

A

spontaneous pain and hypersensitivity to pain associated with damage or pathological changes in the peripheral or central nervous system

-diabetic peripheral neuropathy, post-herpetic neuralgia, fibromyalgia, IBS

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4
Q

treatment for neuropathic pain

A

heavily relies on “adjunctive” therapies (transdermal lidocaine, antidepressants, anticonvulsants, etc)

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5
Q

treatment goals

A

-decrease pain
-improve functioning, mood & sleep

pt s/b involve in setting goals; it assures that outcomes are important to the patient

eg. pain score 3 or less at rest
pain score 5 or less w/ movement
able to have 6 hrs of uninterrupted sleep

chronic pain: cant be eliminated but should be managed

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6
Q

non-pharmacological interventions

A

s/b part of ongoing therapy

-PT, heat, ice, acupuncture, etc

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7
Q

WHO’s pain relief ladder: step 1

A

mild pain (1-3)

-non-opioid analgesics
-adjuvant drugs
-management of side effects

(NSAIDs):
ibuprofen 600mg q6h, APAP 1000mg q6h
naproxene
diclofenac

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8
Q

WHO’s pain relief ladder: step 2

A

moderate pain (4-6)

weak-opioid analgesic
non-opioid analgesic
adjuvant analgesics

APAP 325mg + oxycodone 5mg q4h

APAP 325mg + cod 60mg q4h

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9
Q

WHO’s pain relief ladder: step 3

A

severe pain (7-10)
strong opioids

hydromorphone 4mg q4h
morphine 10mg q4h
fentanyl

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10
Q

when starting on pain meds start with

A

PRN then switch to scheduled dosing if patient uses more than occasionally

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11
Q

adjust the scheduled dose depending on the

A

frequency or severity of breakthrough pain

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12
Q

monitor “four As”

A

-analgesia: pain relief?
-adverse events: tolerable?
-activities - functioning improved?
-aberrant drug-related behavior

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13
Q

when prescribing NSAIDs and/or tylenol consider

A

-renal fn
-platelet count
-risk of GI bleed (NSAIDs)
-transaminases (liver disease)
-current EtOH use (tylenol)

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14
Q

opioids side effects

A

-resp depression
-sedation
-N
-pruritus
-constipation
-urinary retention

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15
Q

when prescribing opioids high risk for respiratory depression occurs when

A

obstruction or central sleep apnea

concurrent benzodiazepine use

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16
Q

acute pain: sxs

A

physiologic responses are:
-tachypnea
-tachycardia
- inc sympathetic nervous system activity (pallor, diaphoresis, pupil dilation[mydriasis])

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17
Q

poorly treated pain causes psychological stress and

A

compromise the immune system due to the release of endogenous corticosteroids

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18
Q

somatic acute pain

A

arises from injury to skin, bone, joint, muscle, and connective tissue

usually localized to the site of injury

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19
Q

visceral pain

A

referred pain

injury to nerves on internal organs (intestines, liver) and can present as diffuse, poorly differentiated

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20
Q

4 main effects of chronic pain

A
  1. effects on physical fn (impaired activities of daily living & sleep disturbances)
  2. psychological changes (depression, anxiety, anger, loss of self-esteem)
  3. social & societal consequences (isolation, changes in relationships w/ fam/friends, intimacy)
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21
Q

management of chronic pain

A

-multimodal
-cognitive interventions
-physical manipulations
-pharma agents
-surgical interventions
-regional/spinal anesthesia

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22
Q

chronic malignant pain

A

associated w/ progressive disease (cancer, AIDS, dementia, etc)

tolerance, dependence & addiction NOT concern

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23
Q

chronic nonmalignant pain

A

not life-threatening; lasting more than 6mo

-associated w/ low back pain, osteoarthritis, previous bone fractures, peripheral vascular disease, genitourinary infection, RA, coronary heart disease

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24
Q

chronic pain management: initial tx

A

combination of non-pharmacologic and pharm modalities such as acetaminophen, oral and topical NSAIDs, adjunctive tx based on the cause of the pain

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25
Q

PHN abbr

A

postherpetic neuralgia associated w/ acute herpetic neuralgia or an acute shingles outbreak

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26
Q

peripheral or polyneuropathic pain

A

associated with the distal polyneuropathies of diabetes, human immunodeficiency virus (HIV), and chemotherapeutic agents

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27
Q

central pain includes

A

central stroke pain, trigeminal neuralgia, and a complex of syndromes known as complex regional pain syndrome (CRPS)

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28
Q

sxs of neuropathic pain are

A

tingling, burning, shooting, stabbing, electric shock-like quality, or radiating pain

-described as constant dull, throbbing or burning pain, or an intermittent pain that is stabbing or shooting

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29
Q

pain assessment includes

A

onset, duration, location, quality, severity, and intensity), pain relief efforts, and efficacy and side effects of current and past treatments for pain

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30
Q

VAS best used for children

A

older than 7 years

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31
Q

3 groups of analgesic drugs

A

-nonopioid
-opioid
-coanalgesic (adjuvants)

32
Q

non-pharmacological therapy

A

psychological interventions and physical therapy for acute & chronic pain

33
Q

Psychological interventions helpful in management of acute pain

A

imagery (picturing oneself in a safe, peaceful place) and distraction (listening to music or focusing on breathing)

34
Q

Chronic pain patients might benefit from

A

relaxation, biofeedback, cognitive behavioral therapy, psychotherapy, support groups, and spiritual counseling

35
Q

physical therapy: modalities are

A

heat, cold, water, ultrasound therapy, TENS, massage, and therapeutic exercise. Heat and cold therapy are utilized in a variety of musculoskeletal conditions (muscle spasms, low back pain, fibromyalgia, sprains, and strains)

36
Q

1st line therapy for mild-to-moderate pain

back pain & osteoarthritis

A

APAP

37
Q

APAP

A

pts on warfarin: max does is 2,000mg/day
-norm hepatic/renal pts: 4,000mg
-hepatotoxicity
-max dose w/ narcs: 325 mg per dosing
-for renal/hepatic pts: reduce by 50-75% dose

38
Q

aspirin

A

nonacetylated salicylates

inhibit cyclooxygenase (cox-1 and cox-2) enzymes thus preventing prostaglandin synthesis (dec nociceptor sensitization and increased pain threshold)

*mild-to-moderate pain
risk of GI irritation and bleeding

39
Q

aspirin hypersensitivity is seen in

A

asthma, nasal polyps, or chronic urticaria (hives)

40
Q

aspirin-sensitive pts rx…

A

nonacetylated salicylates (choline magnesium salicylate and sodium salicilate_

41
Q

NSAIDs are preferred agents for

A

mild-to-moderate pain mediated by prostaglandins (RA, menstrual cramps, postsurgical pain), bony metastasis

not helpful in neuropathic pain

42
Q

if NSAIDs are ineffective of 2-3 wk, it is reasonable to

A

switch to another member of the class

43
Q

ketorolac use limit to

A

5 days due to inc risk of serious GI s/e

44
Q

NSAID dosing

A

high is the same as medium dosing (flat-dose response curve)

-inc incidence of a/e (GI irritation, hepatic dysfunction, renal insuff, platelet inhibition, sodium retentions, CNS dysfn)

45
Q

NSAIDs

A

-nonselective (inhibit COX-1 and COX-2): inc GI & renal toxicity

-selective (inhibit only COX-2): anti-inflammatory effects

46
Q

black box warning for NSAIDs and

A

celecoxib

cardiovascular events and GI bleeding

47
Q

opioids are classified

A

by their activity at the receptor site, usual pain intensity treated, and duration of action (short vs long acting)

48
Q

opioids for moderate pain

A

-codeine
-hydrocodone
-tramadol
-partial agonists

49
Q

opioids for severe pain

A

morphine and hydromorphone

50
Q

pure agonists (morphine) divided into 3 classes

A

phenanthrenes or morphine-like

phenyl piperidine or meperidine-like

diphenyl heptane or methadone-like

51
Q

at low doses full and partial agonists

A

provide similar effects to their full agonists agents; however, partial agonists with increased doses will reach analgesic activity plateau (no additional relief; inc a/e)

52
Q

Agents with high affinity for κ-receptors

A

(pentazocine, nalbuphine, and butorphanol) are more likely to cause psychomimetic effects

53
Q

Hepatic impairment can decrease the

A

metabolism of most opioids, particularly methadone, meperidine, and pentazocine. Furthermore, the clearance of meperidine and morphine and their metabolites is reduced in renal dysfunction.

54
Q

Normeperidine

A

the active metabolite of meperidine, can produce tremors, myoclonus, delirium, and seizures

55
Q

meperidine

A

should not be used in the elderly, those with renal impairment, in patients using patient-controlled analgesia (PCA) devices, or for more than 1 to 2 days of intermittent dosing

56
Q

Methadone

A

several mechanisms (μ-agonist, NMDA-receptor antagonist, and inhibition of reuptake of serotonin and norepinephrine)

long half-life: 30 hours permits extended dosing intervals

concern: resp depression, arrhythmias (QT prolongation)

57
Q

tramadol

A

synthetic opioid w/ a dual mechanism of action (μ-agonist & inhibition of serotonin and norepinephrine reuptake)

efficacy & safety similar to codeine/APAP

neuropathic pain & chrnoc pain

58
Q

tramadol is associated wtih

A

risk of seizures in pts w/ a seizure disorder, those at risk for seizures, and those taking meds that can lower the seizure threshold

59
Q

tramadol and serotonergic drugs

A

such as SSRIs can lead to serotonin syndrome

dependence can occur

60
Q

for severe pain in opiate-naive pts, starting dose for IV morphone is

A

5 to 10mg q4h

rescue doses for breakthrough pain are 10% to 20% of the total daily opioid requirements and administered q 2-6hrs if needed

61
Q

long-term opioid use

A

3 days or less will often be sufficient; more than 7 days will rarely be needed

eval q3m

62
Q

reverses opioid

A

naloxone

(think benzo)
relieves itching that accompanies intermittent bolus or con’t infusion

63
Q

opioids should not be prescribed with

A

benzos

64
Q

patients with opioid use disorder

A

Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies)

65
Q

onset for opioids

A

oral: 45m

IV/SC is more rapid relief
IM: not recommended

66
Q

morphine equivalnets

A

10 mg of IV morphine is equivalent to 1-mg epidural morphine and 0.1 mg of intrathecally administered morphine

67
Q

combination products

A

are short acting and often not suitable for chronic therapy. Single agents offer greater dosing flexibility than combination products

68
Q

opioid allergy

A

when an individual is allergic to one drug in a chemical class of opioids, it is reasonable to select an agent in another chemical class. For the purpose of drug selection in patients with allergies, mixed agonists/antagonists should be treated as morphine-like agents

69
Q

tapering opioids

A

dose should be reduced by 10% per week to avoid withdrawal symptoms

70
Q

s/e of opioids

A

-sedation
-hallucinations
-constipation
-nausea and vomiting
-urinary retention
-myoclonus
-respiratory depression

71
Q

methadone is a substrate of CYP3A4 and its metabolism is

A

increased by phenytoin and decreased by cimetidine

-CNS depressants might potentiate the sedative effects of opiates

72
Q

adjuvant analgesics

A

drugs that have indications other than pain but are useful as monotherapy or in combination with nonopioids and opioids

73
Q

examples of adjuvant analgesics

A

-antiepileptic drugs (AEDs)
-antidepressants
-antiarrhythmic drugs
-local anesthetics
-topical agents (eg, capsaicin)
-variety of other drugs (eg, NMDA antagonists, clonidine, and muscle relaxants)

74
Q

1st line therapy for neuropathic pain

A

-gabapentin or pregabalin
-transdermal lidocaine
-tricyclic antidepressants (TCAs)

SSRIs NOT as effective as TCAs

75
Q

SNRI drugs used for painful diabetic peripheral neuropathy (DNP)

A

-duloxetine
-venlafaxine

76
Q

chronic pain: medication regimen

A

instead of “as-needed” dosing should be used when treating chronic pain, and the effectiveness of therapy should be reassessed regularly

add topical agents (capsaicin)

77
Q

CAM abbr. and examples w/ dosing

A

complementary and alternative medicine

-acupuncture
-chiropractic
-botanical
-nonbotanical dietary supplements
-homeopathy

glucosamine (1500 mg/day):OA
chondroitin

Advanced Pharma (27 decks)

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