Pharm2 7 Pain pt1

Question 1

the complaint of Pain is split into 2 categories:

Answer 1

Acute Pain

Chronic Pain

Question 2

What kind of pain?
Short duration
Identifiable pathology
Predictable prognosis
Treatment of underlying pathology eliminates or mediates pain

And how it is treated?

Answer 2

Acute pain

Tx with analgesics

Question 3

What kind of pain?
Long duration (usu > 3 mos)
Pathology may be unclear
Potential lack of physical findings
Unpredictable prognosis

And how is it treated?

Answer 3

Chronic pain

Treatment often requires multidisciplinary approach (or a multimodal approach – multiple medications to to control he pain)

Question 4

Ankle fracture is an example of ___ pain. How is it managed?

Answer 4

Acute pain

Reduced, casted, use an analgesic, elevate and ice the area.

Question 5

What type of pain does not qualify as ‘acute’ or ‘chronic’?

Answer 5

Pain from cancer

Question 6

6 categories of drug treatments for pain

Answer 6

NSAIDS (ASA, Ibuprofen, etc.)
COX-2
Opioids
Tricyclic antidepressants (amitriptyline)
Centrally-acting agents (that are non-narcotic)
Muscle relaxants
Glucocorticosteroids

Question 7

Describe the WHO 3-Step Ladder for Pain

A patient rarely explicitly falls into one of these categories, nor do the drugs work consistently in each patient

Answer 7

1: Mild - nonopiod +/- adjuvant
2: Moderate - Opiod for mild to moderate pain +/- nonopiod +/- adjuvant
3: Severe - Opiod for moderate to severe pain +/- nonopiod +/-adjuvant

Question 8

COX-2 vs COX-1

Answer 8

COX-2 is selective, lower incidence of bleeding.

Question 9

Why is aspirin not always just given at a higher dose such as 325 (instead of 81)?
Who is it used for?

Answer 9

325 deaggregates more platelets. Causes more bleeding. It’d kill ppl at risk for bleeding. So it’s only used for very serious cases unless they are aspirin insensitive.

Question 10

3 types of drugs for Acute & Chronic pain

Answer 10

Acetaminophen, NSAIDs, Opioids

Question 11

4 drugs used for Neuropathic pain, neuralgias. These drugs are ____ drugs, but they also work for neuralgias.

Answer 11

Carbamazepine, phenytoin, tricyclics, gabapentin, others

These are antiepileptic drugs, but work for neuralgias

Question 12

Top 2 most common types of Neuropathic Pain

Answer 12

diabetic peripheral neuropathy

post-herpetic neuralgia.

Question 13

Acetaminophen.
What is it used for?
What property does it not have?
What 2 things must you keep in mind about this drug?

Answer 13

Analgesic
Low effect on peripheral COX
Few drug-drug interactions
*Not antiinflammatory - not for inflamm’n, used specifically for the pain.
Analgesic ceiling (if you give a higher dose it won’t do anything)
Liver toxicity (really horrible way to die! Acetylcysteine only helps so much)

Question 14

__ is why FDA limited the daily dosing for acetaminophen.

What’s the max dose of Acetaminophen per day?

Answer 14

Liver toxicity

Max dose: FDA has lowered it so you can only take 4g in one day ONCE, the subsequent days must be <4g.

Question 15

What’s a concern about Acetominophen-containing products?

Answer 15

Patients may take products other than Tylenol, not knowing it contains Acetominophen and may become acetominophen toxicitiy. Must warn them that it contains Acetominophen.

Question 16

Vicodin (Hydrocodone/Acetaminophen) is about to be reclassified from sched _ to a sched _ drug. Why?

Answer 16

From schedule 3 to schedule 2. this reclassifying of schedules will make no difference in NY. But there are 10 states where PA’s cannot prescribe Schedule II drugs in the outpatient setting.

B/c it is most commonly the drug ppl are prescribed that gets them addicted to narcotics”

Question 17

NY state requirement for prescribing Sched 2 drug:

Answer 17

requires you to log online in outpatient setting before prescribing controlled substance meds istop website: updates prescription in real time for patients.
Just started this year b/c of overdoses, deaths. So if a patient needs a Sched 2 pain med, you check istop before you write the prescription to see if they are addicted and seeing prescribers to get their fix. ISTOP Dramatically stops “doc-shopping”

Question 18

Aspirin
Effects (3)
Additional benefits (2)

Answer 18

Analgesic, Antiinflammatory, Antipyretic

Inhibits COX
Irreversibly inhibits platelet aggregation
Irreversible inhibitor of COX

Question 19

Aspirin
Side effects (3)

what’s another important note about aspirin for pain?

Answer 19

Nonselective inhibitor of COX (adverse effects)
Drug-drug interactions (with anything else that may increase bleeding)
Reye’s syndrome ( this is why you don’t give Aspirin to kids with fevers)

Aspirin has an Analgesic ceiling

Question 20

“there is an additional benefit of 22% reduction if you combine with ___”. Aspirin is cheap, but ___ ain’t cheap. Wouldn’t be used if not necessary.

Answer 20

clopidogrel

Question 21

Aspirin Dosing & Effects

Answer 21

80-160mg: Antiplatelet
325-1000 - Antipyretic, analgesic
325-6000 - Antiinflammatory, tinnitus
6-10g - Resp alkalosis
10-20g - Fever, dehydration, acidosis
>20g - Shock, coma

Question 22

Any aspirin dose over ___ has antiplatelet effects
over __ adds on antipyretic & analgesic effect
over __ adds on inflammatory and tinnits (adverse)

Answer 22

> 75mg
325 mg
1 g

Question 23

If aspirin follows by bleeding, it’s reversed how?

Answer 23

FFP (platelets)

Question 24

*when should you stop aspirin?

Answer 24

5 days if applying pressure can get bleeding to stop.
Otherwise 7 days.

cardiologist would never want a patient to stop aspirin if they’re on stent thrombosis.
Also won’t stop it for Orthopedics doing total knee replacement, a bloody surgery. Tourniquet can control bleeding in this patient