Pharm Pain Management & CDS Flashcards
What are some red flags for chronic pain?
Major trauma or minor trauma in the context of osteoporosis
Age > 50 or < 20
Constitutional symptoms (infection/inflammatory conditions/malignancies)
IVDU or recent bacterial infection
Immunosuppression
Pain worse at night or when supine
Severe or progressive sensory alteration or weakness
Bladder or bowel dysfucntion
What are chronic pain yellow flags?
Belief that pain and activity are harmful "Sickness behaviours" Low mood Belief that passive treatment > active treatment will be most beneficial Hx back pain, timef off work, other Job dissatisfaction Overprotective family Heavy work or unsociable hours
What medication class might you consider for mild to moderate pain?
NSAIDS/tylenol
What medication classes might you consider for mild to moderate pain with sleep disturbance?
NSAIDS/tylenol (general analgesics) and broad spectrum analgesic antidepressant (duloxetine)
What medications might you consider for moderate to severe nociceptive pain ?
Broad spectrum analgesic antidepressant (nortriptyline, duloxetine), and/or opioids (stronger than codeine, continuous release)
What medication might you consider for moderate to severe mixed or neuropathic pain?
Anticonvulsant or broad spectrum analgesic antidepressant (duloxetine, nortriptyline) & opioid (stronger than codeine, continuous release)
What are topical options for pain management? What might this be used for?
Topical NSAIDS or rubifacients (capsaicin)
MSK or OA
What cannabinoids might be considered for neuropathic pain?
synthetic THC (nabilone)
nabiximols
dried cannabis
Opioids should be reserved for patients that meet the following criteria:
Non-opioids have been trialled
Pain impacts daily fntn
Pts with low risk for OUD. If high risk for OUD, consider consultation with addiction’s specialist
Guidelines recommend reassessing the benefit/risk of opioid doses > or equal to _____/day and to justify/avoid doses > or equal to _____ mme/day
50, 90
What are some risk factors for opioid use disorder?
current anxiety/depression, PTSD, hx SUD (ETOH, cannabis, opioids)
What is considered effective or efficacious opioid dose?
Improvement of 2 pts on 10 pt scale
What are complications from prescribed opioids?
overdose, falls, MVA, sleep apnea, hypogonadism
Opioids have a _____ effect on pain, reduction of ______%.
Improvement of function is < _____%
medium, 10-20%
< 10 % improvement function
When Rx opioids for chronic pain, what is the frequency of reassessment (risk/benefit)?
Q3months
Renal and liver function for NSAID use
avoid if CrCl < 30, caution if 30-59.
Avoid in severe hepatic impairment
What are some CI and precautions to NSAIDS
pregnancy (3rd trimester) BF head failure allergy Cerebrovascular disease IBD hyperkalemia active PUD *best avoided in older adults CVS risks (MI/CVA)
How long does it take for full effect of NSAIDS?
1-2 weeks
How long is it okay to take tylenol 4gm/day?
5 days
How long do you taper gabapentin/pregabalin over?
1 week
What is carbamazepine first-line for? How often do you consider discontinuation or reduction? How long do you taper over?
TN
Q3mo
20%/week (so 5 weeks?)
What drug class is duloxetine and what non-neuropathic pain condition is it approved for?
SNRI
OA
duloxetine S/E? CI?
H/A, GI, insomnia, drowsiness, constipation, fatigue, dizziness… CI in hepatic/renal failure.
How do you taper duloxetine?
decrease to 30 mg daily or take on alternate days for 2 weeks
How do you taper TCAs?
- Taper over 4 weeks to 3 mo or more (reduce dose by 25% Q4weeks). - If patient has been on the drug for > 6 weeks, tapering is very important!
- Decrease slowly towards the end of the taper
What are some S/E and precautions for TCAs?
may cause:
prolonged QT!
dry mouth, confusion, constipation, urinary retention (anticholinergic)
caution w/ older adults (nortiptyline preferred)
What antidepressant should be considered for fibromyalgia?
fluoxetine
According to BCCNM CDS prescribing standards, when is it okay not to assess the patient prior to prescribing?
1) patient is known to provider & 2) patient is being assessed by another provider
According to BCCNM CDS prescribing standards, what are the steps (a to g) to be carried out prior to CDS prescribing?
a) assessment
b) pharmanet
c) indication & duration, goals, rationale
d) lowest dose and minimum quantity dispensed
e) limit co-prescriptions of sedating medications
f) advise clients about s/e and risks (discuss tolerance, psychological dependence, addiction, diversion)
g) implement evidence-informed strategies for minimizing risk
NPs are responsible for their Rx pad. NPs must: (standard # 15 a to d)
a. store pads in locked area
b. report loss or theft of pads to BCCNM, pharmanet, police, and BC privary commissioner (the latter if pt ID on pad)
c. return pad to BCCNM if no longer practicing
d. store duplicate cope with the client health record, not on the pad
What are the 9 BCCNM limits and conditions to prescribing CDS?
1) register for pharmanet
2) complete further education
3) complete BCCNM CDS prescribing module
4) meet the competencies
5) additional ed for: chronic non-cancer pain, methadone for analgesia (+ preceptorship), OAT for OUD, MAiD
6) Amphetamine, benzphetamine, methamphetamine, etc… only for certain dx (for not adults with ADHD, but kids are fine)
7) anabolic steroids are NOT in NP scope (except testosterone)
8) coca leaves are not in NP scope
9) opium is not in NP scope
What are NP CDS competencies?
ethical practice, knowledge of legislation, assessment, identifies and manages risk of aberrant drug-related behaviours, diagnosis, knowledge of therapeutic management, education, decision-making in prescribing, documentation
WHO Pain ladder: 4 bidirectional steps
Step One: Mild Pain
• Non-opioids (eg NSAIDs or tylenol) +/- adjuvants
Step Two: Moderate Pain
• Weak opioids (hydrocodone, codeine, tramadol) PLUS step one
Step Three: Severe and Persistent Pain
• Potent opioids (morphine, methadone, fentanyl, oxycodone, buprenorphine, hydromorphone) PLUS step one
Step Four: Invasive and minimally invasive treatment for Persistent Pain
Eg epidural, intrathecal analgesia, neurosurgery, neuromodulation (stimulators), nerve blocks, ablation, cementoplasty, palliation radiotherapy
What does bidirectional mean for acute vs chronic pain?
acute top down (strongest indicated, then step down)… chronic bottom up (lowest strength, then step up as needed, or down if pain improves)…
Explain expanded receptive fields after sensitization (like in the video)
peripheral nerves (nociceptive) have nociceptive fields… they carries nociceptive stimuli to second order neurons which receives info from multiple peripheral nerves… it corresponds with a specific region or field, making it possible to localize pain. Adjacent afferent neurons often give signals to neighbouring 2nd order neurons, but they only really respond to significant stimuli from their own peripheral/nociceptive nerves. with sensitization, they respond to these adjacent stimuli… and their fields are expanded.
