Review 2

Question 1

Chronic pain

Answer 1

Hyperalgesia

Allodynia

Question 2

Hyperalgesia

Answer 2

Sensitized perfiery
Ad/C fiber
abnormally heightened sensitivity to pain.

Question 3

Allodynia

Answer 3

AB fibers
refers to central pain sensitization (increased response of neurons) following painful, often repetitive, stimulation. Allodynia can lead to the triggering of a pain response from stimuli which do not normally provoke pain

Question 4

NSAIDs

Answer 4

Work on sensitizing agents

PGs

Question 5

Mechanisms of Neuropathic PainCentral Sensitization

Answer 5

NMDA receptor antagonists

α2δ ligands- VSCC (gabapentin)

Question 6

Ectopic Activity

Mechanisms of Neuropathic Pain

Answer 6

Increased excitability of injured sensory neurons can generate pacemaker-like ectopic discharges that result in sensory inflow that is independent of any peripheral stimuli.

Question 7

Peripheral
Sensitization
RX

Answer 7

VSSC
Carbamazepine
Oxcarbazepine
Lidocaine

Prostaglandins
NSAIDs

Question 8

Central
Sensitization
RX

Answer 8

VSCC (α2δ ligands)
Gabapentin
Pregabalin

NMDA Receptors
Ketamine*

Prostaglandins
NSAIDs

Question 9

Descending Inhibition

RX

Answer 9

NE
Opioid Receptors

TCADs*
SNRIs*
Tramadol
Opioids

Inhibitors of monoamine reuptake (TCADs-SNRIs) are NOT effective for ACUTE pain

Question 10

Chronic Pain Management - Mechanistic Approach

Answer 10

↑ Descending inhibition

↓ Central/ perf sense

Question 11

Activation of opioid receptors

Answer 11

opioid analgesics, tramadol

Enhancement of Descending Inhibitory pathway

Question 12

Block of NE-5HT reuptake

Answer 12

• antidepressants-TCAD*-SNRI-SSRI
• First line

Enhancement of Descending Inhibitory pathway-

Question 13

Principles of Chronic Pain Management

Answer 13

Non-opioid and adjuvant medications are emphasized

Adjuvants (useful for pain but not classified as analgesics)

Question 14

Block of VSCC

Decrease in Central Sensitization

Answer 14

↓ excess NT release: anticonvulsants (α2δ ligands)

Question 15

Block of NMDA-Glu receptors

Answer 15

ketamine

Decrease in Central Sensitization

Question 16

Block of Cyclooxygenase-2

Answer 16

NSAID, celecoxib, acetaminophen

Decrease in Central Sensitization

Question 17

Block of VSSC

Decrease in Peripheral Sensitization

Answer 17

inhibit excess neurotransmission: local anesthetics, anticonvulsants

Question 18

No good evidence for long-term benefits of opioids – avoid in: _________, headaches-migraines, TMD, IBS

Answer 18

low back pain, fibromyalgia

Question 19

Anticonvulsants - Gabapentin and Pregabalin

Answer 19

Binds to α2δ subunit of VSCC - may act to ↓ release of excitatory NT glutamate in pain pathways

Question 20

Adverse Reactions

Anticonvulsants - Gabapentin and Pregabalin

Answer 20

better tolerated than other AEDs

Sedation - ataxia - dizziness

Generally free from drug-drug interactions

Risk of abuse with pregabalin - C-V controlled substance

Adjuvant Use in Selected Chronic Pain Syndromes

Question 21

NSAIDs, acetaminophen, COX-2 selective, aspirin

Answer 21

Nonopioid analgesics

Question 22

Opioid analgesics may be used for:

Answer 22

Acute neuropathic pain

Neuropathic cancer pain

Episodic exacerbations of severe pain

Should generally be reserved for moderate to severe pain that adversely impacts function or quality of life

Question 23

Controlled substances with high abuse potential –

Answer 23

CII-III

Question 24

neuropathic pain- Adjuvant Analgesics

Answer 24

Anticonvulsants

Antidepressants

Local anesthetics

Question 25

``` Mild pain (rated 1-3) Acute Pain Management ```

Answer 25

Non-opioid (e.g., NSAID or acetaminophen) ± Adjuvant analgesics* *Generally more useful in chronic pain syndromes - discussed later

Question 26

``` Moderate pain (rated 4-6) Acute Pain Management ```

Answer 26

Immediate-release, short-acting opioids with slow titration + Non-opioid (NSAIDs more effective) ± adjuvant analgesics* *Generally more useful in chronic pain syndromes - discussed later

Question 27

``` Severe pain (rated 7-10) Acute Pain Management ```

Answer 27

Immediate-release, short-acting opioids with rapid titration + Non-opioid ± adjuvant analgesics* (most commonly LAs) Commonly managed with multimodal analgesia approach *Generally more useful in chronic pain syndromes - discussed later